Introduction

Value in health care is equal to the quotient of quality over payment. In this context, quality includes outcomes, safety, and patient experiences while payment is the cost to all who pay for health care. Value in healthcare is not an abstract ideal; it is objective and comparable across countries. Improved value can come from decreased cost of care, increased quality of care, or preferably both. However, this definition of value, being narrowly patient-centered, does not necessarily take into account the value of training medical professionals to maintain and advance health care in the future. The pressure to increase the value of health care could further undermine the mission of education. Academic medical centers are particularly prone to this problem since they must serve two masters. That is, they must respond to competitive market forces by being lean and providing high quality care, and they must respond to trainee and student demands for high quality education. Above all, they need to continue to serve their multifaceted missions of service, education, and research. In the neurosurgical operating theater, rapid improvement events (such as Kaizen events, for example) commonly target cost reduction, increased faculty involvement, and reduced variability by standardization. This value agenda limits the involvement of a learning surgeon and seems mutually exclusive to the educational requirement with which academic institutions are charged. Measuring the education of resident surgeons is a primary focus of the Accreditation Council for Graduate Medical Education (ACGME) for good reason—young, untested surgeons need to be able to replace the aging and burned out population of surgeons leaving the workforce. Although many educational assessments are used, a highly granular mechanism to understand how a resident surgeon performs on different component parts of a given procedure has not been widely accepted. Despite diligence and a desire to perform with excellence, there is variability among surgeons which may be related to training level. This chapter explores the development and application of a risk matrix to neurosurgical procedures.

Current Educational Paradigm, Without Granularity of Resident Education

As a method to optimize operating room (OR) efficiency, quality improvement aims to standardize surgical workflow. Surgical resident education must be maintained in the setting of process improvement. There are limited published data on the impact of resident identified perceived risk or discomfort with procedural steps on operative time during posterior instrumented fusion (PIF). Self-identification of risk or discomfort in surgical steps may allow for shorter OR time and reduced cost when resident surgeons are operating without sacrificing resident education.

The current resident education paradigm is one of graduated autonomy, which is both evaluated holistically and generally standardized across the nation through the ACGME common program requirements and the Neurosurgery-specific program requirements. It includes 360-degree evaluations from faculty, peers, health care professionals, and often patient feedback. Faculty assessment of individual residents include procedural and operative clinical evaluations, end of rotation evaluations, and general competencies. Standard written evaluation incudes the SANS/ABNS to stratify individuals on a national scale. Residents also have the opportunity for self-assessment. Finally, the milestone project redefines individual training years to be conceptualized as individual component parts of a training level. This informs high impact decisions like promotion, graduation, or dismissal.

Unfortunately, none of these methods evaluates the granular, modular, and complex nature of a surgical procedure. They also do not assess directly the self-perception of trainees about the risk and comfort in each and every module/step of the procedure. This is necessary to maximize learning in a safe environment to the patient.

In summary, great time and expense are expended evaluating resident learning, which is used as a surrogate marker for credentialing. Although it is seemingly all inclusive, no evaluative method is highly granular; in other words, an individual resident’s ability to perform a paraspinal muscle dissection for a lumbar laminectomy is not individually recorded in any modality. A paraspinal muscle dissection can be conceptualized as a component part of many procedures, including instrumentation procedures, neural decompressive procedures, and intradural procedures. It follows that the ability to measure a resident’s competency in a component module of a procedure would be generalizable in predicting the surgeon’s skill set overall.