Raising the Standard: Rescue Improvement Conference as a Place to Institute Change
by John Mihran Davis, MD, FACS; Briana Concannon, MHA, NSQIP CSCR; Steven Em, MD; and Dominick Gadaleta, MD, FACS, FASMBS
Dr. Davis is Professor of Surgery, Zucker School of Medicine in Hempstead, New York. Ms. Concannon is Clinical Quality Improvement Specialist, Department of Surgery, South Shore University Hospital in Manhasset, New York. Dr. Em is Surgery Resident, Department of Surgery, South Shore University Hospital in Manhasset, New York. Dr. Gadaleta is Vice Chair, Department of Surgery; Director, Metabolic and Bariatric Surgery, South Shore University Hospital, Northwell Health; and Professor of Surgery, Zucker School of Medicine at Hofstra/Northwell in Hempstead, New York.
Funding: No funding was provided for this article.
Disclosures: The authors report no conflicts of interest relevant to the content of this article.
Bariatric Times. 2023;20(5–6):28–29.
As our understanding of why surgical complications occur and how to prevent them evolves, the way we conduct morbidity and mortality (M&M) conferences has become a more sophisticated process than it was 50 years ago. The resident in the 1970s knew that, whatever went wrong in the case they were presenting at their M&M conference, they were guilty, whether they had any control of the mistakes or not. Additionally, residents would be chastised for unimportant things that had little to do with the major issue of the patient’s complication. All too often, opinions were given, rather than evidence-based data that supported a better way to manage the patient. In some M&M conferences, disagreements between attending surgeons would flare, resulting in heated verbal exchanges which, while entertaining to the group, did not add much value to the educational experience. Over the past two decades, publications using big data with studies showing how bundled orders improved outcomes have resulted in a rich body of evidence for developing guidelines.
One purpose of the M&M conference is to identify processes that can prevent the complication from recurring. Clearly, not all complications have a root cause that can lend itself to a process, but many do. In some cases, the solution requires further investigation to find a remedy for the problem. Lack of available data to answer the questions needed at conferences has led to several database studies to help define a problem. The National Surgical Quality Improvement Program (NSQIP) and Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) can be great resources not only to review one’s outcomes but to explore data from other institutions by accessing provider use files (PUF), which include all participating sites. By reviewing these data sources, trends in management may be readily identified and lead to the initiation or revision of protocols and guidelines for clinical management.
For the past four years, the M&M conference at South Shore University Hospital has followed a standard protocol for case selection, focusing on preventable complications, delay in discharge, unexpected return to the operating room (OR), death, or readmission. The discussion by the presenting resident and faculty is directed to determining opportunities for improvement, with a special focus on system issues encountered, regardless of whether the outcome would have been affected. A literature review is presented by the resident to address what is known about the specific complication, providing insight into the standard of care based on current published practice guidelines and consensus statements. The presentation is shared with department leadership and the faculty involved with the care of the patients being presented at least three days before the conference to allow substantive review and suggestions. The case is presented without the names of any patients, residents, or attendings to ensure an open and frank discussion. Included in the presentation is a process improvement disclaimer, the Clavien-Dindo score, the International Healthcare Improvement (IHI) score, as well as the type of potential bias that might have occurred in the diagnosis or management of the patient.1,2 Subsequent discussion is focused on what the healthcare team could have done better, rather than who is to blame.
One of the goals of the discussion is to promote engagement across medical specialties. To do this, it is important to set up a culture of psychological safety, which establishes an environment where all concerns, questions, errors, and ideas seeking feedback can be brought up without fear of humiliation or retribution. This atmosphere has been shown to promote knowledge-sharing and error-reporting, both of which are characteristics of a healthcare system that promotes quality care and patient safety.3 Oftentimes, members of other specialties are involved, and their input is extremely valuable. Problem solving across multiple disciplines brings about new insight into your colleague’s field and an appreciation of the concerns they might have in caring for your patient.
This effort has resulted in the addition of several hospital-wide practice management guidelines and protocols that have significantly improved patient care. For example, take the case of an ileostomy patient who was readmitted for a sudden rise in their serum creatinine level. Their readmission led to a discussion of methods for the prevention of high ileostomy output and the adoption of a practice guideline for all patients following a newly created ileostomy. Recurrent presentations of patients with groin infections and seromas in patients with complicated vascular procedures revealed the presence of unjustified variability, which led to a manuscript addressing groin infections and a protocol to prevent them. Because of excessive delays in patients admitted through the emergency department (ED) with cholecystitis and jaundice waiting for a preoperative magnetic resonance cholangiopancreatography (MRCP) and endoscopic retrograde cholangiopancreatography (ERCP), a new guideline was created based on the work of Manning et al.4 With this new protocol, patients with a bilirubin of less than 4.0mg/dL go directly to the OR. An intraoperative cholangiogram is done to clear the common duct, and an ERCP is performed immediately after surgery in patients who had positive studies. As a result, length of stay is shorter, with fewer MRCPs and ERCPs. Finally, multimodal pain therapy has been adopted by all services following the presentation of a complication after opioid administration in a nonbariatric patient.
Holding surgical M&M conferences as a way to identify and resolve system issues is a valuable use of the faculty’s and residents’ time. Identifying the problems at hand with the involved disciplines in attendance is invaluable. It starts a process to address the identified problems with all the stakeholders present. Detailed review and documentation for a guideline or protocol is required, which is outside the confines of the M&M conference; a recent study that codifies this process has been recently published.5 Following the identification of system issues, a separate meeting, named the Rescue Improvement Conference, was scheduled to develop data-driven guidelines. The use of protocol-driven medicine over the past two decades has clearly improved patient care, as evidenced by the enhanced recovery protocols (ERPs), which are now adopted worldwide. Having a culture that evaluates outcomes and creates system-based solutions to prevent future occurrence is a hallmark of continuous quality improvement.
References
- Antonacci AC, Dechario S, Husk G, et al. Analysis of surgical judgment and mortality utilizing a critique algorithm-based database and morbidity/mortality conference (MMC) review. Presented at the Academic Surgery Congress; Feb 2019; Houston, TX.
- Antonacci AC, Dechario SP, Rindskopf D, et al. Cognitive bias and severity of harm following surgery: plan for workflow debiasing strategy Am J Surg. 2021; 222(6):1172–1177.
- O’Donovan R, McAuliffe E. Exploring psychological safety in healthcare teams to inform the development of interventions: combining observational, survey and interview data. BMC Health Serv Res. 2020;20(1):810.
- Manning A, Frazee R, Abernathy S, et al. Protocol-driven management of suspected common duct stones. J Am Col Surg. 2017;224(4):645–648.
- Ervin JN, Vitous AV, Wells EE, et al. Rescue Improvement Conference: a novel tool for addressing failure to rescue. Ann Surg. 2023;277(2):233–237.
Category: Current Issue, Raising the Standard
Subscribe
If you enjoyed this article, subscribe to receive more just like it.
