Check out these number from the Wall Street Journal (How to Make Surgery Safer, Feb 16).
A little disconcerting, eh? Now there are obviously a lot of surgeries taking place every day in the US, so on a percentage basis having just 20 procedure in which the surgeon operates on the wrong site is very low. Still, that is not very helpful t the person who has a stitches on the wrong side of their body.
So what can be done to make surgery safer and more reliable?
The article discusses several things that different hospitals are doing. Some are based on the classic premise that what gets measured, gets managed.
One such effort involves helping hospitals pinpoint their own problems. Many hospitals are participating in the National Surgical Quality Improvement Project, or NSQIP, overseen by the American College of Surgeons and adapted from an effort at Veterans Administration hospitals that helped decrease postoperative death rates by 47% from 1991 to 2006. “All too often, patients are being harmed by preventable complications,” says Clifford Ko, a colorectal surgeon at UCLA and director of NSQIP. Many hospitals don’t collect reliable data on their own adverse events, and “you can’t improve a hospital’s surgical quality if you can’t measure it.”
NSQIP works with about 600 hospitals to gather and analyze data on complications and provides resources to help them tackle safety gaps. Hospitals can review their own clinical data and compare it with that of other hospitals. If every U.S. hospital used the program, the surgeon’s group estimates, each year they could save 100,000 lives, prevent more than 2.5 million complications and reduce costs by more than $25 billion.
This makes a lot of sense. A given hospital may do a lot of, say, hip replacements every week but that will be a drop in the bucket relative to the number done across the nation. One hospital can track complications for its own surgeons and may even see different levels of performance. But that doesn’t mean that its “best” surgeon is in any sense top rate or that its “worst” surgeon is incompetent. Looking at national data provides a better way of evaluating performance and identifying opportunities for improvement.
There are opportunities for cooperation here that don’t really exist in other industries. Hospitals have limited abilities to have truly unique approaches for different procedures. The surgeons (who may not even be hospital employees) are often trained elsewhere and are using equipment or components (like artificial hips) that are available to everyone. Further, they have an ethical obligation to generally advance the care of patients — even if those patients are in a different state. This is very different than asking Intel for the specifics of how it makes its chips.
Another set of ideas discussed in the article turn on making sure that no sponge gets left behind.
Dr. Heniford says data analysis can also help prevent foreign bodies from being left in patients when they do undergo surgery. A 2006 study he co-authored found that over 10 years, 30 patients at the medical center had objects such as sponges and instruments left inside, with 25 requiring another operation. Now, if a count at the end of a procedure indicates sponges or instruments are missing, hospital policy requires an X-ray before the patient leaves the OR, which can’t be overruled by a surgeon as happened occasionally in the past.
Technology can also help avoid leaving surgical objects in patients, such as using sponges with radio-frequency identification tags. At Memorial Hermann Health System in Houston, after routine sponge counts, all open surgical patients are scanned before the incision is closed, which has led to the detection of sponges that might have been retained because the sponge count was thought to be correct, says M. Michael Shabot, chief clinical officer.
This is related to ideas in Lean Operations to make problems visible and to detect issues early on. It is certainly easier to remove a wayward sponge before a suture is closed up, hence steps to detect problems sooner rather than latter matter.
A final point, part of the difficulty here is cultural.On the one hand, it takes a certain amount of self-confidence to slice open another human being and think that they will be better because of that. On the other, self confidence can come with some other personality traits. My father, a mere pediatrician, spent many years as the medical director of a large clinic. Few of his better surgeon stories did not equate the surgeon to some body part.
There’s also a movement afoot to change how some surgeons behave. Often seen as the rock stars of medicine, surgeons can be hard to rein in, resisting efforts to conduct preoperative briefings and being dismissive and curt if not downright intimidating to underlings. According to a study in the American Journal of Surgery in January, they are the specialists most commonly identified as “disruptive physicians,” and their outbursts can shift the focus away from the patient and lead to increased mistakes during procedures and diminished respect from colleagues.
This seems a real challenge. All of these suggestions come down to process improvements. In many ways, these changes can be liberating in a way — routinize the mundane to so everyone can focus on the challenging. But that only happens if everyone is on board with routinizing. If a greater focus on process is seen as undercutting traditional authority, it can be a tough sell.
