Recent years have seen a steady increase in the attention paid to quality and safety with regard to hospitalized patients. The topic has transitioned from being a lofty ideal to one that is put into practice in a myriad of ways in hospitals across the country every day. This evolution has taken several decades and shapes a great deal how care is provided for current neurosurgical patients. This chapter discusses the variety of different perspectives among those involved in quality and safety initiatives as pertaining to neurosurgery patients, including clinical care providers, allied health professionals, patients, administrators, and payers. We discuss the layers of complexity added with each perspective, and the challenges faced in improving safety and quality from all perspectives.
KeywordsNeurosurgery, Quality, Safety, Quality improvement (QI), Patient-centered, Database, Standards, Mortality and morbidity (M&M), Communication, Survey
The importance of the details of caring for a neurosurgical patient has increasingly become the focus of many groups that are involved in the patient’s clinical care. In large part, this focus has been driven by the field of quality and safety or quality improvement (QI). Patients have long assumed that their best interests were at the forefront of the care they experience in the hospital and while this is true from a philosophical perspective, the practice of such an assumption is more difficult to enact. In America, these ideas were articulated and put into an early framework by Dr. Ernest Avery Codman, who was quoted as saying, “The truth is, the patients and the public suppose somebody is looking into this important matter. They do not realize that the responsibility is not fixed upon any person.” He also advocated for the “End Result Idea,” which was the premise that hospitals would measure the effectiveness of the treatments they administered to patients. It was a thought that not many shared at the time, but unfortunately he did not live to see his ideas fully appreciated. However, this idea did help lead to the creation of the American College of Surgeons (ACS) and a published minimum standard for hospitals which became the preamble to what would eventually become The Joint Commission and the genesis of the field of quality and safety.
The most current and accepted definitions of quality and safety come from the Institute of Medicine (IOM) and the National Quality Forum, respectively, where quality is defined as “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge” and safety as “the prevention and mitigation of harm caused by errors of omission or commission that are associated with healthcare and involving the establishment of operational systems and processes that minimize the likelihood of errors and maximize the likelihood of intercepting them when they occur.” Both definitions embody the spirit that Dr. Codman initially posited but they also make clear the dynamic nature of the field of quality and safety. It continues to change and evolve as the patient and caregiver relationship become more complex and nuanced, particularly as innovative technologies and new groups with different perspectives are brought to the hospital and clinic setting. The IOM further defines specific dimensions of Healthcare quality which include the following :
Accessible—timely use of personal health services to achieve the best possible outcomes.
Client-centered—care is respectful of, and responsive to, individual client preferences, needs, and values.
Effective—scientific knowledge provides the basis to the services that are provided to all who could benefit.
Efficient—waste is avoided.
Equitable—patient characteristics such as age, gender, and ethnicity do not affect the quality of care.
It seems inherently clear why the field of quality and safety is so important. However, the magnitude of its impact may not be fundamentally obvious, as a highly functioning quality and safety program will quietly performs its function in the background of the patient’s clinical experience. Consider that annually approximately 100,000 American patients are injured while obtaining incorrect clinical care. As recently as 1999, fatal medical errors were one of the top 10 causes of death in the United States. Hospitals and healthcare systems are also supremely interested in quality and safety as many Medicare reimbursements are tied to quality measures, and in fact penalties are enforced for poor quality outcomes. While these facts summarize the toll on the patient, there are also financial and economic effects from these errors. In 1960, healthcare spending was 5% of the gross domestic product (GDP), and in 2008 it had grown to 17% with estimates from the Centers for Medicare and Medicaid Services (CMS) predicting an increase by 2018 to 20% of the GDP, or approximately $4.4 trillion dollars. Considering these economic facts as well as the healthcare system’s financial well-being and the health and welfare of the patient, it becomes clear pretty quickly that this area of quality and safety is important and that it has many facets that affect many different people.
Neurosurgery is in a unique position as a high-risk surgical specialty that has recently realized the importance of quality and safety.The breadth of neurosurgical practice and the heavy emphasis on experiential training make even basic data gathering regarding practice standards and outcomes difficult. Other areas such as General Surgery and Thoracic Surgery have implemented large, accessible national databases (National Surgical Quality Improvement Program, or NSQUIP and the Society of Thoracic Surgeons (STS) National Database) to collect outcomes data. Given the small size of the field of neurosurgery and its complexity, it lagged behind other surgical subspecialties. In 2012, the American Association of Neurological Surgeons (AANS) announced the launch of the National Neurosurgery Quality and Outcomes Database (N2QOD), later changed to Quality and Outcomes Database (QOD) in 2016 to better represent the registrants. This database represents a tangible starting point for the field of Neurosurgery to begin to assess the quality and safety of its specific and unique surgical practices. However, adoption and implementation of new practices will require dedicated personnel to be successful. Besides workforces, an increasing amount of resources will be required to implement future programs and tools deemed to improve safety and quality. Yet these large shifts in thinking will be required if large-scale change is to be realized.
There are many perspectives when it comes to examining quality and safety in the field of neurosurgery. These perspectives can be grouped into several broad categories: clinical care providers, allied health professionals, patients, administrators, and payers.
Clinical Care Providers
The medical care of the neurosurgical patient is shared between providers with diverse backgrounds, credentialing, and responsibilities. Broad categories include: nurses, APP (physician assistants and nurse practitioners), physicians (attending/staff, fellows, residents), and medical students. Attending physicians, or the doctors with admitting and operating privileges at a specific hospital, bring decades of specific history and traditions from their training. In a 2011 study that documented associations between various healthcare providers and their opinions on quality and safety, attending physicians showed that safety was highly associated with training. Training of physicians, particularly in neurosurgery, is highly individualized with different residency programs having different foci and a unique breadth and depth of different patients. There also exists the opportunity for further fellowship training in various subspecialties within neurosurgery: Pediatrics, Trauma, Spine, Functional, Skull base, Oncology, and Neurocritical Care to name a few. A review of the quality and safety literature shows that there is no current study correlating fellowship training in neurosurgical subspecialty with improved outcomes. So while attending neurosurgeons associated increased training with safety, there has been no objective data to prove that.
Another issue regarding quality and safety that has recently come under scrutiny, particularly for attendings in academic neurosurgery, is the performance of concurrent surgery or “running two rooms.” Owing to the recent attention that has been paid to the subject, there are not many published studies comparing the outcomes or cost of concurrent surgery. Zygourakis has published three separate articles detailing the lack of difference in cost, outcome, and 30-day readmission in academic vascular neurosurgery, spine surgery, and a general category of neurosurgical procedures. Obviously, this is a new and important issue to the field of neurosurgery, in particular the area of quality and safety, to ensure that all measures are taken to provide the patient with the best and safest care, particularly regarding their time in the operating room.
Neurosurgery residency program directors have been tasked by the ACGME to enlist residents in QI projects and ensure their guidance through these projects. This selective group of academic attending neurosurgeons is in a very unique position to help create a culture of safety not only in their respective departments, but in the field of neurosurgery as a whole and attempt to ensure an attention to quality and safety that will persist in the residents that they train. Their guidance and mentorship will hopefully help to create a generation of neurosurgeons who incorporate and engage in quality and safety projects throughout their careers.
Resident physicians also have important roles in ensuring the quality and safety of neurosurgery patients as alluded to in the previous paragraph. Residents participate in all facets of a neurosurgical patient’s care from clinic visits, Emergency Room visits, Intensive Care Unit (ICU) cares, bedside procedures, family meetings, and of course in the actual operating room. This ubiquity in their presence affords them the opportunity to see areas for improvement in delivering high-quality care to patients. A systematic review that was published in 2015 followed the outcomes of 26 separate studies involving safety education interventions for residents, and they were unable to find discrete evidence of the benefit to the patient.This should not serve to undermine emphasis on resident quality and safety projects, as this article only reports on projects involving resident education and omits projects that focus on changes in practice. Neurosurgery residents are given a unique opportunity during their postgraduate year-1 (PGY-1) to attend a national fundamentals curriculum put on by the Society of Neurological Surgeons (SNS). This practice began in 2010 and participation at the national level is approximately 95%. Given the unique position of neurosurgery PGY-1 residents to participate in bedside procedures and make critical decisions in acute settings, senior faculty leadership at the national level arranged and implemented this course. A follow-up study to assess the retention of the information was published in 2013. This study provided self-reported data from the participants asking if the knowledge and skills they received training on during the boot camp improved patient care and 99% of the survey respondents felt that was indeed the case. Providing neurosurgery residents with a strong foundation in bedside procedures and clinical decision-making as well as the culture of quality and safety is a great start to ensuring acceptance of future QI projects and an honest focus on the safety of the neurosurgical patient.
Advanced practice providers (APP), nurse practitioners, and physician assistants, are also highly involved in the delivery of care to neurosurgical patients. In many circumstances, they are also performing bedside procedures, seeing patients, addressing concerns and are available in the clinic, hospital ward, ICU, and, in some cases, even the operating rooms. Owing to their multifaceted role, they help to make diagnostic decisions, therapeutic plans, and communicate effectively between the multiple individuals taking care of neurosurgical patients. This importance of communication is often reflected in the large amount of documentation that APPs provide for patients. One of the key roles that all quality and safety initiatives must include is accurate and timely data collection. It has been shown that APPs provide a great resource, particularly regarding documentation within the electronic medical record.
Nurses are also an integral part of the team providing quality care safely to neurosurgery patients. Nurses are in the forefront of clinical interactions with the patient. They are also present in each phase of care for neurosurgery patients: clinic, floor, ICU, and operating room. It is the neurologic exams that they provide every few hours that form the backbone of daily cares for the patient. As mentioned for APPs, nurses also provide a key role in the documentation of a patient’s progress. This documentation informs assessments regarding quality and safety initiatives and it can often be one of the key metrics used in analyzing any QI projects.
Allied Health Professionals
Other important providers within the neurosurgical field who have direct patient contact include operating room personnel, radiologists, anesthesiologists, X-ray technicians, phlebotomists, nutritionists, social workers, case coordinators as well as speech, physical, and occupational therapists. All of these providers play an important role in the inpatient hospitalized care of a neurosurgical patient. They help with each aspect of the patient’s care. The difference between these providers and the ones listed above is the difference in continuity. Owing to an increase in the discontinuity between the patient and their experience with these providers, it is difficult to ascribe specific quality and safety metrics. However, the roles of these providers are often under the guidance and recommendations of the attendings, residents, APP, and nurses who often have specific guidelines and goals for the improvement of the quality and safety of neurosurgical patients.
One cannot forget about the most important stakeholder in the quality and safety of their own care, patients. Patients have been typically thought of as passive participants in the QI process. However, they have responsibilities as patients as well to improve the outcomes for patients who come after them. Patient-related experience measures and patient-related outcome measures can be important tools to measure patient experiences within a healthcare system. One way that hospitals attempt to assess this is patient satisfaction surveys. However, these forms are usually constrained in specific questions and answers, so even if the patient reports a high satisfaction score on the survey, it does not necessarily mean that the patient had a good and safe experience.The ability to understand the intricacies of the patient’s experience is paramount to being able to provide safe and effective care for the neurosurgical patient.
Another group that is involved in at least assessing the quality and safety of care provided to neurosurgery patients could be broadly categorized as administrative. This group would include Quality Officers, Health System executives, attorneys, accountants, actuaries, and companies as well as the governmental agencies tasked with overseeing the safety of patients. Since quality and safety initiatives are a relatively new addition to the basics of clinical care for patients, there has been little published on the involvement of these new executives. It is a diverse group, but a common theme is a lack of clinical training as well as clinical experience. The role these participants play in quality and safety is tied to the newly emphasized link between quality of care and financial reimbursements. A majority of private insurers as well as Medicare reimbursements are determined by reports of patient safety, patient satisfaction, patient outcomes, or a combination of these factors. This group adds a layer of complexity onto an already confusing and multifaceted relationship that exists between the patient and all of the previously mentioned healthcare providers. Matthews has recently described a model that incorporates quality and safety in a specific academic medical center in a meaningful way. The article describes a “fractal approach” to link clinical departments, which are typically the functional unit of a hospital in both a horizontal and vertical structure. It is the vertical association that “provides accountability to the hospital, health system and board of trustees,” which requires vice chairs for quality. These chairs are part of an independent institute that ensures each department has a physician leader with the skills, knowledge, and attitude to lead meaningful change. These chairs are also expected to participate in quality and safety research and have monthly meetings with each level of the department up to and including the health system executives. Since quality and safety initiatives are a relatively new addition to the basics of clinical care for patients, there has been little published on the involvement of these new executives.
Another perspective in this topic of quality and safety originates from an exterior perspective. It has to do with the financial aspect of healthcare, specifically reimbursements.This concept arises from a desire for quality of healthcare services at reduced or necessary cost. Payers and providers are seeking partnerships to develop the tools needed to make meaningful assessments of performance. Most of these assessments of performance will take the form of databases. While there are a variety of neurosurgical databases, none include specific patient reported outcomes. An example of a successful database comes from the STS Database. This database contains specific data on outcomes from cardiac surgery procedures that are available to the public. When making complex medical decisions or discussing outcomes for elective surgical procedures, an easily searchable and vast database can help to define expectations and help with decision-making. However, it is the linking of reimbursements to reported measures of quality and safety that provides a different perspective on those data. Providers are keenly interested as it will affect their income. Patients will also be able to utilize this information to make decisions about where and with whom they would like to do elective surgery. The aforementioned executives of quality and safety, who should be at the forefront of this movement, will have a high interest but their focus will likely be on new projects, implementation changes, and outcomes measures ( Table 1.1 ).