It is my strong contention that patients facing cardiac surgery should choose an institution, not a particular heart surgeon. Although individual judgement and technical dexterity are obviously important, best surgical outcomes reflect the performance of many medical providers before, during and after the operation. Professionalism and a competitive business environment both stimulate open heart centers to continuously focus on quality assurance programs to improve patient safety. Also, continuing medical education of surgical staff, advances in technology and classic peer review of adverse outcomes have impacted death and complication rates. However, preventing avoidable harm is still a significant challenge despite innumerable checklists, preoperative briefings, postoperative debriefings and team training programs.
That is why a recent report published in the Journal of the American Medical Association from the Veterans Health System is so remarkable. Seventy-four facilities underwent a team-training program comprised of 2 months of instruction, a 1 day conference and 1 year of quarterly coaching interviews and audits. The program was aimed at forming a cohesive approach towards improving patient safety by surgeons, anesthesiologists, nurses and associated operating room heathcare staff. Over a two year period, the 30 day mortality rate for major surgical procedures at participating hospitals was reduced 18% which absolute rate was only 1/2 the concurrent mortality at hospitals that has not undergone the training. Supporting the value of institutional commitment to this approach was the “dose-response” relationship between successive calendar quarterly training and mortality rate. The death rate progressively decreased with each sequential 3 month period of participation. The 182,409 procedures were not cardiac, but the principles certainly apply to open-heart surgery. The efficacy of this new approach is more impressive given the fact that the hospitals not yet enlisted had in place what were felt to be effective, up-to-date quality programs.
The secrets to success were frequent and open communication, a decision-making structure that welcomes imput collegially regardless of rank, a just culture towards reporting adverse events and constant training of all team members that was not limited to new hires. What most distinguished the training protocols was mandatory participation by all team members, i.e. no one was too senior to participate, and training sessions were embedded in the workload, not sporadic or after hours.
The lay public may read this information and wonder what the big “breakthrough” is. Do not surgical team already “work together”? Do you have to teach medical staff how to talk to each other? The truth is that all the well-meaning medical personnel involved in an open-heart operation come from different types of training programs, report to separate administrative departments, are rewarded and disciplined by different criteria and have varying personal and professional goals. Cohesion does not come naturally. But obviously, when the leadership of surgical centers are committed to getting all the team players continuously focused on systematic safety procedures and open communication not only can work place morale be enhanced, but patients’ lives can be saved.
Norman Silverman is a cardiothoracic surgeon and founder of Heart Surgery Guide.
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