1998-01-01 Quality assurance in cardiac surgery.pdf

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cardiac surgery were invited to prospectively submit clinical data on all cardiacsurgical patients, on a voluntary basis. The system is known as the CardiacSurgery Reporting System (CSRS). The main purposes of the registry are: a- toprovide information to hospitals that will assist them in assessing the quality ofcardiac surgical care at their own institution and allow to make improvements,where appropriate, b- to assist the Department of Health in its qualityimprovement activities, and c- to give consumers information that allows themto make an informed selection of their providers of cardiac surgery. The CSRShas predominantly focused on coronary artery bypass surgery.

Public

Health

Profession

Health Insurers

Accreditation

Organization

Patient

Health Care

organization

QUALITY

Fig. 1. - Quality has different meanings for the various sectors of health care.

For each cardiac surgical patient, the hospital submits a 2 pagequestionnaire (Fig. 2a & 2b) to the Department of Health with information onthe patients preoperative condition, procedural information including theoperating surgeons identity, and the patients outcome. Using this information,the CSRS has developed statistical models that determine the relation betweenpreoperative risk factors and morbidity and mortality, and predict theprobability of adverse outcomes given the presence of various risk factors. TheCSRS also compares the outcomes of the participating hospitals and surgeonsby comparing predicted mortality rates with actual mortality.

All hospitals that perform CABG surgery in New York State have elected

to participate in the program. They receive data from CSRS on a regular basisthat outline their actual and risk-adjusted mortality rates. Each hospital alsoreceives a list of preoperative risk factors for CABG surgery that aresignificantly related to inpatient mortality. For a given patient, surgeons cancheck which risk factors are present and calculate a predicted probability of in-hospital mortality on the basis of the New York State experience. CSRS alsoprovides hospitals with surgeon-specific information such as the number ofCABG procedures, the number of deaths, crude mortality rate, and risk-adjusted mortality rate.


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Fig. 2b. - The New York State Department of Health Cardiac Surgery Reporting form.


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Table I(Modified from reference [11])

Risk-adjusted mortalityYear

Low-volume surgeons High-volume surgeons

1989 7.94* 3.57

1990 5.72* 3.03

1991 3.56 2.57

1992 3.20 2.36

The authors attributed this dramatic improvement in results for low-volume surgeons on the out of state exodus of low-volume surgeons with highrisk-adjusted mortality, the better performance of surgeons who were new tothe system, and the performance of surgeons who were not consistently low-volume surgeons.

Hospital-specific responses

The St. Peters Hospital in Albany, N.Y., is a 447-bed community hospitalthat began a cardiac surgical program in 1989 [12]. In 1991, St. Peters had ahigh actual mortality (4.6%), but low expected mortality (2.1%) resulting in arisk-adjusted mortality of 6.6% while the New York State average was 3.08%.The surgeons initial response was an intense mortality and morbidity review.Repeated reviews, however, all yielded the same conclusion: almost all thedeaths had occurred in high-risk patients and no obvious errors could be foundin their care. Having agreed that this was not just a surgeons problem, acomprehensive review of the database was undertaken. It was found that themortality was largely concentrated in emergency cases, which represented 10%of the surgical volume (mortality of 26% versus statewide average of 7.7%).The mortality for elective cases was found to be 1.2%, slightly below thestatewide average. Further analysis revealed that death in emergency patientswere concentrated in those patients who had a myocardial infarction within 6hours before the operation, or who were in shock or hemodynamically unstablebefore entering the operating room. As a result of the review several changeswere made to the cardiac surgical care of the emergency patients such as morefrequent use of preoperative intra-aortic balloon pumping, standardized

cardioplegia administration, and others. Since then, overall mortality hasdecreased to 1.5% and has consistently remained below the expected mortalityrate.

Other hospital-specific consequences of the publication of the outcomeshave included the suspension of a cardiac surgery program until a new chief ofcardiac surgery could be recruited, retirement from cardiac surgery of surgeonswith unsatisfactory performance, reassignment of patients to surgeons withbetter performance and limitations of surgical activities to specific areas ofcardiothoracic surgery (e.g. pediatric or thoracic surgery).


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NY

Ohio

Other states

Other countries

1980-88 1989-93

MORTALITY

Referrals to Cleveland Clinic

Fig. 3. - Mortality of patients referred to the Cleveland Clinic before and after 1989. (Modifiedfrom reference [13]).

1989 1990 1991 1992 1993

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NY Referrals

USReferralsEXPECTED MORTALITY

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variables in 2149 patients undergoing coronary artery bypass surgery at 2 NewYork State institutions and have assessed the association betweenhemodynamics and postoperative outcomes. Their findings have demonstratedthe prognostic significance of intraoperative hemodynamic abnormalities,including data from pulmonary artery catheterization. The study did not allowone to determine, however, whether interventions to control these variables

Fig. 4. - Expected mortality for CABG patients operated in New York State and for patientsreferred to the Cleveland Clinic. (Modified from reference [13]).


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care on a yearly basis and every 3-years evaluates compliance with thestandards during site visits at the healthcare organizations. In 1990, JCAHOpublished a list of 13 anesthesia indicators that were considered useful forinternal hospital quality assurance activities.

Table II

JCAHO Anesthesia Care Indicators

1. CNS complication (within 24 hrs of anesthesia)

2. Peripheral neurologic (within 48 hrs of anesthesia)

3. Cardiac arrest (within 24 hrs of anesthesia)

4. Acute MI (within 48 hrs of anesthesia)

5. Respiratory arrest (within 24 hrs of anesthesia)

6. Unplanned admission

7. Unplanned ICU admission

8. Mortality (within 48 hrs of anesthesia)

9. Pulmonary edema (within 24 hrs of anesthesia)

10. Aspiration pneumonitis (within 48 hrs of anesthesia)

11. Postural headache (within 4 days of anesthesia)

12. Dental injury

13. Ocular injury

The occurrence of these complications must be tabulated and reported tothe hospital Quality Improvement committee on a monthly basis. The JCAHOexpects that these indicators be tracked for individual anesthesiologists andthat appropriate actions be taken if any particular anesthesiologist surfaces asan outlier. The problem with this approach is that, fortunately, most of theseevents occur infrequently and that, as a result, it s difficult to find deviationsfor individual anesthesiologists that are statistically significant.

Another limitation of the anesthesia indicators is that they provide noinformation on the patients perception of quality. While there are numerousproblems in the assessment of quality from the patients perspective, it appearsnonetheless essential to try to incorporate such a pespective [16].

In 1995, the Department of Anesthesiology of St Lukes Roosevelt HospitalCenter began a patient survey study to assess the patients satisfaction withseveral aspects of their anesthetic care. On a monthly basis, approximately 400patients (20% of total) are sent a survey card inquiring about their perception ofthe anesthesiologists time commitment, concern with patients worries, andcourtesy. A question is also included concerning pain management as it is well-established that patients are most concerned and often dissatisfied withpostoperative pain management (Fig. 6).

To date, the response rate has been approximately 25 % and the overall


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Your anesthesiology care is important to us

Wont you please take a few moments of your time to complete this survey and let us know we ve done?Return postage has been provided. (Su Cuidado Anesthesico es importante para nosotros

Por favor tome el tiempo para Ilenar este cuestionario. El jiro postal esta incluido).

On a scale from 1 - 10, please rate the following. (Del 1 al 10 por favor indique lo siguiente).

1) Amount of time your anesthesiologist spent with you (El tiempo su anesthesiologo compartio con usted).(Unsatisfactory) 1 2 3 4 5 6 7 8 9 10 (Excellent)(No Satisfecho) (Excellente)

2) Anesthesiologists concern for your questions/worries (El concierno acerca sus preguntas/preocupaciones).(Unsatisfactory) 1 2 3 4 5 6 7 8 9 10 (Excellent)

3) Courtesy and attentiveness of your anesthesiologist (Cortesia y attencion de su anesthesiologo).(Unsatisfactory) 1 2 3 4 5 6 7 8 9 10 (Excellent)

4) The effectiveness of your pain management after surgery (El manejo de su dolor depues de la cirujia).(Unsatisfactory) 1 2 3 4 5 6 7 8 9 10 (Excellent)

5) Your overall satisfaction with your anesthesia care (Su satisfaction, en si, del cuidado anesthesico).(Unsatisfactory) 1 2 3 4 5 6 7 8 9 10 (Excellent)

Comments about your anesthesia experience (good or bad) ____________________________________

___________________________________________________________________________________

Patient Name (Optional) ___________________ Phone Number (Optional) ____________________If you would like to speak with someone in the Department, please call us at (212)523-2865.

Fig. 6. - Survey instrument used by the Department of Anesthesiology of St. Luke s-RooseveltHospital Center to assess patient satisfaction with Anesthesia services.

Time Concern Courtesy Pain Mgmt Overall

10

8

6

4

2

0

Department of Anesthesiology

St. Luke's-Roosevelt Hospital Center

Patient Satisfaction 1997

1 Qrtr 2 Qrtr 3 Qrtr 4 Qrtr

Fig. 7. - Quarterly patient satisfaction scores for 1997.

satisfaction scores for the department have been high (Fig. 7). The mostinteresting aspect of this effort, however, are the specific comments that patientsconvey. They provide great insight in some of the process factors of care andallow one to intervene once specific problems are identified. The other benefit is


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0 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31Individual Anesthesiologists

Mean Score2 SD

Department of Anesthesiology St. Luke's-Roosevelt Hospital Center

Overall Satisfaction (> 25 Records/Anesthesiologist)

that with an increasing database, it becomes possible to identify anesthesiologistswho are statistical outliers (Fig. 8). Such individuals are given feedback andcounseled on techniques to improve their interactions with patients.

Special considerations in cardiac anesthesia

One of the aspects of cardiac anesthesia that is most amenable to qualityassurance, is intraoperative echocardiography [17]. When applying TQMconcepts to perioperative TEE, the terms products and customers need tobe employed in their broadest meaning. The major product of perioperativeTEE is information, which is provided to customers. These customers caninclude other anesthesiologists, surgeons, cardiologists, other physicians, thepatient or the manufacturers of echocardiographic equipment.

Which process of a TEE program is the current key process that maybenefit from improvement will vary from program to program. The followingoutline of processes was developed to assist in focusing on possible keyprocesses within echocardiography programs.

Table IIIKey processes of intraoperative echocardiography

1. Indications for performing TEE

2. Technical aspects of performing and recording the examination

3. Application of examination findings to physiologic condition

4. Documentation

5. Equipment

6. Professional communications

Fig. 8. - Overall satisfaction scores for individual anesthesiologists for whom more than 25surveys were returned. The dark bar represents the anesthesiologist who deviated more than

2 standard deviations from the mean.


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7. Education

8. Billing

The application of Quality Management to an echocardiographic serviceneed not be restricted to the areas mentioned above. Periodic updating of theQA program as the TEE service evolves will facilitate meeting the goalsoriginally set forth and defining new goals to meet clinical needs.

Conclusions

Quality assurance can focus on many aspects of cardiac care. Many

programs and studies have, however, limited their emphasis on mortality andmorbidity data. It is only through a better understanding of the processes thatlead to untoward outcomes that improvements can be made. Unfortunately, theprocesses associated with cardiac anesthesia have received very little attentionin the overall assessment of cardiac care. Anesthesiologists have begun toassume greater responsibilities in the determination of cardiac care throughtheir involvement in perioperative echocardiography. A program for qualityassurance in cardiac anesthesia should, therefore, include the key process ofperioperative echocardiography.

REFERENCES

[1] Berwick D.M., Godfrey A.B., Roessner J. - Curing Health Care: New Strategies forQuality Improvement. A Report on the National Demonstration Project onQuality Improvement in Health Care. Josie-Bass Publishers, San Francisco,1990.

[2] Berwick D.M. - Continuous improvement as an ideal in health care. N. Engl. J. Med.,1989, 320, 53-56.

[3] Deming W.E. - Out of the Crisis. Cambridge, MA: Massachusetts Institute ofTechnology, 1986.

[4] Feigenbaum A.V. - Total Quality Control. New York, McGraw Hill, 1983.

[5] Kritchevsky S.B., Simmons B.P. - Continuous quality improvement. Concepts andapplications for physician care.JAMA, 1991, 266, 1817-1823.

[6] Laffel G., Blumenthal D. - The case for using industrial quality management sciencein health care organizations.JAMA, 1989, 272, 2869-2873.

[7] Wenzel R.P. - Beyond total quality management. Clinical performance and qualityhealth care, 1993, 1, 43-48.

[8] Hannan E.L. et al. - Improving outcomes of coronary artery bypass surgery in NewYork State.JAMA, 1994, 271, 761-766.

[9] Chassin M. et al. - Benefits and hazards of reporting medical outcomes publicly. N.Engl. J. Med., 1996, 334, 394-398.

[10] Green J. et al. - Report cards on cardiac surgeons: Assessing New York States


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1998-01-01 Quality assurance in cardiac surgery.pdf

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