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Outline

CLINICAL PROFILING IN SURGICAL EDUCATION Michigan State University Department of Surgery Cheryl I. Anderson, RN, MSA, D. Chris Coffey, MD, Richard E. Dean, MD March 2001

Background Surgeons receive clinically profiled information from hospitals and insurers Based on a minimal cases, cost-based Resident clinical issues are reported, only when problems arise Educational issues may not surface Trends may be unrecognized

Methods Unique study environment to conduct Clinical Profiling: Access to all hospital and office charts Uniformity of office medical records Residents and Surgeons are all MSU Nurses are employed by Department

Objectives for Profiling To use simple, low cost methods, that include all faculty/residents Confidential, Non-punitive To involve residents in the profiling process

Clinical Profiling Any process that trends patient experiences or outcomes over time and compares those results to others, accepted standards, or benchmarks

Clinical Profiling Phase I.  Morbidity and Mortality Conference Phase II. Nurse Reports Phase III. Resident Reports

"PHASE I." PHASE I. Morbidity and Mortality Conference A.  Standardized Peer Review B.  High Volume Surgical Procedures C.  Common Post Operative Complications

A.  Standardized Peer Review   Each case presented at M & M is peer-reviewed, using a standardized format   Why?  Conclusion: • What?  Action: Acceptable None Misdiagnosis Refer Internally Delay Refer Externally Decision Needs Education Technical Health System Knowledge

A.  Standardized Peer Review All peer-review comments/impressions of the case are returned to faculty or resident Feedback is reported quarterly and any differences are re-evaluated Complication Rate: (by Qtr) Total # of technical errors            Total # of cases done

Technical Errors

B.  High Volume Surgical Procedures Breast  •  Appendectomy Cholecystectomy •  Thyroid/Parathyroid Hernia Repair •  Central Venous Catheter Appendectomy •  Tube Thoracostomy Complication rates calculated

Department Complication Rates

Algorithm Development 75 % reduction in variety of preoperative antibiotics (ABX) prescribed 21 % decline in use of post operative ABX LOS declined by 2.1 days for acute appendicitis with abscess/perforation

Resident Education Residents participated in algorithm development Observed the gradual change of faculty toward adherence to algorithm; changed resident practice Witnessed how individualism in surgery can affect patient outcomes and result in higher costs

C.  Common Post Operative Complications Wound Complications DVT/ Pulmonary Embolus Cardiac Events Respiratory Complications Post Op Bleed Iatrogenic Injuries Intra-abdominal abscess

"PHASE II." PHASE II. Nursing Reports

Nursing Reports Complication definitions varied Weekly telephone calls, office visits Expanded information collected Most complications were wound problems, i.e., infections, seromas, hematomas, cellulitis

Nursing Reports:  Wound Problems

"PHASE III." PHASE III. Resident Reports of Adverse Events

Educating Residents: Adverse Events Defined adverse events Residents were asked to assess system or process problems that occurred in patient care Weekly meetings were held with residents

Adverse Events: Cancelled Surgeries

System/Process Problems  Reported at M & M

Resident Education Residents instrumental in early identification and resolution of problems Participated in an organized multi-disciplinary approach to problem solving Adverse events expanded the meaning of “complication” to include broader clinical issues, i.e., process & system problems

"SUMMARY" SUMMARY

Summary: Department Benefits Data are more complete and accurate because we are comparing to our department Results are reported in a timely manner Faculty and residents become involved because profiling is non-punitive and self-improving Developed a low cost, effective system for profiling

Summary:  Resident Benefits

Conclusions Clinical profiling can improve resident education By actively involving residents in the process, it can serve as an educational tool that residents can carry into practice