Thursday, 01 August 2013 13:39

American College of Surgeons

Written by  doc roxas
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First of all let me describe what the American College of Surgeons National Surgical Quality Improvement Program is all about. The ACS NSQIP is the first nationally validated, risk-adjusted, outcome-based program to measure and improve the quality of surgical care across the US. Named ‘Best in the Nation” by the Institute of Medicine, the ACS NSQIP provides a prospective, peer-controlled, validated data base of preoperative to 30-day postoperative surgical outcomes based on clinical data. A 2009 Annals of Surgery study shows that each hospital participating in ACS NSQIP on average per year prevented 200-250 complications, saved 12-36 lives, and reduced millions of dollars in cost. There are nearly 500 hospitals participating in the program, not only from the US, but also from Canada and some other countries like Australia, Saudi Arabia, and Ireland.

On the first day of the 2013 ACS NSQIP convention, as I walked around the scientific poster exhibits, and attended the workshops and lectures, I was amazed at how large and well-organized the whole activity was. I got to see how comprehensive and seamless the database functioned; and how it was easily utilized to analyze various surgical outcomes within participating hospitals. It certainly required a lot of funding, personnel and effort; and I wondered whether we in the Philippines were ready to embark on a similar project.

It was also very evident to us participants that the ACS NSQIP model was indeed the future of surgery - where surgical outcomes are measured, monitored and analyzed, utilizing scientifically validated processes that are both transparent and formative. Pretty soon prospective patients will be able to check on the performance of hospitals and individual surgeons, comparing their results to national standards. There was, in the conference, a very palpable air of excitement and commitment to this vision.

The morning workshop focused on change management. Dr. Nestor Esnaola, MD, MPH,MBA,FACS and Beth Turrentine, PhD, RN handled the sessions quite effectively. They emphasized how each of us had to become surgeon champions for effective change within our respective institutions; - even as outmoded, inconsistent surgical practices persist, with their attendant risk for complications.

One activity that was quite interesting and enjoyable was the Paper Plane Game. We were grouped into 10 members each, with 1 assigned as pilot, 1 as recorder, and the rest as builders of paper planes. The objectives were to build as many paper planes as we could within 5 minutes, after which the pilot would try to fly each one accurately into a designated corner. The number of accurately flown planes over the total number made was then computed. We analyzed how communication, leadership and planning affected production processes. Quite an effective teaching model, I must say, and I am excited to try it out with my trainees.

The sessions also talked about the Six Sigma and LEAN methods to affect change, concepts I had encountered during my Leadership and Management Development Program at the Ateneo last year. Other phrases and concepts that stuck in my mind today included the following:

1. Use the “Unfreeze-Change-Refreeze” model for more 
effective, lasting change.
2. “Many hands make for light work” versus “ Too many 
cooks spoil the broth”
3. We all carry our faults in our back pocket, which 
everyone else - except us -can see … and so we must 
ever so often check our back pockets”
4. We can’t effectively change things alone. We need to 
build teams and recruit allies, keeping opposers in the 
loop but out of the way.
5. The Quality in Training Initiative entails teaching our 
trainees about surgical quality improvement methods 
now, even while they are still learning basic surgical 
skills.
6. Define Measure Analyze Improve Control (D-M-A-I-C)
7. The “Swarm Theory” - individual ants don’t accomplish 
much, but their collective ant colonies function and 
outlive the almost inconsequential individual
8. Pick the “low-hanging fruits” first for easy success … 
celebrate each small success in order to keep the team’s 
efforts motivated towards the “higher hanging fruits”.
9. Planning for change should take 60% of the time; the 
rest is spent on implementation.

As all these information swirled around me, I could not help but wonder how such concepts and models could be applied in the Philippines, particularly in the face of the inevitable propagation of surgical quality improvement initiatives worldwide. True, we have many problems in terms of logistics, funding, personnel and archaic practices. Certainly such programs will require collaboration between DOH, Philhealth, HMOs, and hospitals, both government and private; but such collaboration is not actually beyond our reach. One dichotomy we will need to resolve is whether to simply adopt and join ACS NSQIP, which will save us time, money, effort and personnel (at the expense of nationalist self-determination); or to create our own Philippine surgical quality improvement initiative, despite obvious challenges in funding and structural support.

I am happy in fact that there are established quality improvement pathways for colorectal surgery that have been validated, not just by ACS NQIP, but by other European programs. ERAS (Enhanced Recovery After Surgery) is now an accepted program for colorectal surgery in England, and I had the opportunity to read on it during my flight here. Indeed, ERAS for me is a “low-hanging” fruit which I can implement in the hospitals I am connected with, improving outcomes for my patients, but also allowing me to develop models and strategies to bring further change within the national framework. We can analyze our results, write about them, and then cascade them to other institutions, as well as other fields of surgery. Let’s see where that leads us afterwards.

Finally, I was fortunate to meet a Filipino surgeon also attending this year’s ACS NSQIP. His name is Jhun de Villa, who finished general surgery in Ilocos (and rotated in pediatric surgery in PGH, where we crossed paths), after which he emigrated to the US, retrained in general surgery, but now works quite effectively as the Surgical Performance Improvement Officer of the Department of Surgery, University of Florida. He has had much experience in implementing and propagating ACS NSQIP in his hospital. He will be a valuable resource for us Filipinos, as we develop our surgical quality improvement programs for our national organizations, governmental institutions, specific hospitals, and individual surgeons.

Till my next blog tomorrow….

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