The SAGES Manual of Quality, Outcomes and Patient Safety

Preface
Preface
Contents
Contributors
Part I: Surgical Quality
	Chapter 1: Defining Quality in Surgery
		Introduction
		Structure
		Process
		Outcome
		Composite
		Patient-Reported Outcomes
		Choosing the Right Measurement Approach
		Improving Quality Measurement
		Measuring Surgeon, Hospital, and Network Quality
		Conclusions
		References
	Chapter 2: Never Events in Surgery
		Introduction
			Understanding What Events Are Classified by the NQF as “Never Events” in Surgery
			Understanding What Events Are Classified by CMS as “Never Events” in Surgery
			Discussing the Ramifications of “No Pay” After the Occurrence of a Never Event
			Discussing What Systemic Answers Are for the Purpose of Preventing Never Events
		References
	Chapter 3: Creating a Surgical Dashboard for Quality
		Introduction
		Characteristics of a Surgical Quality Dashboard
		Dashboard Metrics
			Productivity
			Mortality
			Postoperative Outcomes
			Hospital Admissions Data
			National Standards and NSQIP
		Connecting to Quality Improvement
			SCIP
			AHRQ Safety Program for Improving Surgical Care and Recovery
			Empowering the Surgical Team
			Future Directions
		Conclusion
		References
	Chapter 4: Understanding Complex Systems and How It Impacts Quality in Surgery
		Introduction
		Flaws of Reductionism
		Our Current Scientific Paradigm Shift
		The Science of Complex Systems Applied to Healthcare
		Real-World Examples of Reductionism Compared with Systems Science
			Vitamin Supplements
			Football Injuries
			Hernia Mesh
		Clinical Quality Improvement: A Systems Science Tool
			Analyzing Data
			The Problem of Suboptimization
		Systems Science Applied to Healthcare: Implementing a Learning Health System
			Systems Science Steps to Implement a Learning Health System
		Real-World Application of Systems Science
			Eliminating Drains for Abdominal Wall Reconstruction (AWR)
			Understanding Chronic Pain After Inguinal Hernia Repair
		Systems Science Applied to Healthcare in Policy and Education
		Conclusion
		References
	Chapter 5: Clinical Care Pathways
		What Is a Clinical Care Pathway?
		How Are Clinical Pathways Used in Surgery and How Do They Improve Outcomes?
		Preoperative Recommendations
		Intraoperative Recommendations
		Postoperative Recommendations
		Impact of Clinical Pathways in Surgery
		What Are Best Practices That Have Successfully Integrated Clinical Care Pathways?
		Conclusion
		References
	Chapter 6: Tracking Quality: Data Registries
		Society of Thoracic Surgeons (STS)
		National Surgical Quality Improvement Program (NSQIP)
		Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP)
		Abdominal Core Health Quality Collaborative (ACHQC)
		Summary
			Editor’s Note
		References
	Chapter 7: Accreditation Standards: Bariatric Surgery
		Accreditation Standards: Bariatric Surgery
		Development of Accreditation Standards
		Current Standards for Bariatric Accreditation
			Standard 1: Institutional Administrative Commitment
			Standard 2: Program Scope and Governance
			Standard 3: Facilities and Equipment Resources
			Standard 4: Personnel and Services Resources
			Standard 5: Patient Care – Expectations and Protocol
			Standard 6: Data Surveillance and Systems
			Standard 7: Quality Improvement
			Standard 8: Education: Professional and Community Outreach
		Application of the MBSAQIP Data for Research and Quality Improvement
			Editor’s Note
				Minimum Requirements
				Institutional Support
				Maintenance of Privileges
		References
	Chapter 8: Resident Evaluation and Mentorship: Milestones in Surgical Education
		Introduction
		How Did the ACGME and Its Working Groups Come Up with Milestones?
		What Is Competency-Based Medical Education and How Does It Apply Here?
		What Are EPAs? How Do They Work for Surgical Training?
		Bibliography
	Chapter 9: Implementing Quality Improvement at Your Institution
		Chapter Objectives
		Introduction
		History of Quality Improvement Implementation
		Identification of Key Stakeholders
		How to Prevent Quality Improvement Fatigue
		Clinical Areas That Have Established Quality Improvement
		COVID and Quality Improvement: Synchrony in a Dyssynchronous Medical System
		Conclusion
		References
	Chapter 10: Creating and Defining Quality Metrics That Matter in Surgery
		Creating and Defining Quality Metrics That Matter in Surgery
		From Measuring Surgical Care to Designing Metrics
			Quality
			Safety
			Cost
		Checklist for Creating Surgical Metrics
			Conceptualization
			Specification
			Testing
			Implementation
			Evaluation
		Model for Patient-Centric Surgical Outcome Measure Development
		Conclusion
		References
	Chapter 11: The Role of Surgical Societies in Quality
		References
Part II: Surgical Outcomes
	Chapter 12: Perioperative Risk Assessment
		Introduction
		Delivery of High-Value Preoperative Care
		Who Is at Risk? Methods of Assessment of Perioperative Risk
			Preoperative Evaluation and Physical Exam
			Biochemical, Hematologic, and Nutritional Evaluation
			Surgery-Specific Factors
			Pulmonary Complications
			Cardiac Considerations
			Special Considerations in Obese Patients
			Chronic Liver Disease
			Frailty
		Risk Assessment Tools
		Current Standards of Care: Which Asymptomatic Patients Should Undergo Preoperative Testing and Consultation?
			Pulmonary Assessment
			Cardiovascular Assessment
		Conclusion
		References
	Chapter 13: The Current State of Surgical Outcome Measurement
		The Objectives for This Chapter Are as Follows
		Introduction
		Measuring Surgical Outcomes for Improvement
		Large Nationwide Standardized Databases
		Use of a Large National Database for Continuous Evaluation of Quality in Surgical Care
		Clinical Registries
		Administrative Registries
		Patient Safety Indicators
		Survey Instruments for Outcomes Assessment
			Patient-Reported Outcomes
			Patient-Reported Outcome Measurement System
			Press Ganey Surveys
		Use of Patient-Reported Outcome Measures (PROMs) to Evaluate Surgical Outcomes
			Phase 1: Goal
			Phase 2: Selection
			Phase 3: Define the Indicator
			Phase 4: Use
		Interpreting Outcome Measures
			Evaluating Surgical Innovation: Using the IDEAL Framework (Table 13.1)
		Future Methods
		Conclusion
		References
			Other Selected Reading
	Chapter 14: Developing Patient-Centered Outcomes Metrics for Abdominal Surgery
		What Are Patient-Reported Outcome Measures (PROMs)?
		Development of PROMs and Assessment of Measurement Properties
		Critical Appraisal of PROMs Used in Abdominal Surgery
		Consensus Recommendations for PROM Use in Abdominal Surgery
			The Future of PROM Assessment in Abdominal Surgery
		Summary
		References
	Chapter 15: Enhanced Recovery Protocols: A Toolkit for Success
		Introduction
		Understanding Enhanced Recovery Protocols
		Implementing an Enhanced Recovery Pathway into Practice
			Competency
				Goals
			Proficiency
				Goals
			Mastery
				Goals
		Conclusion
		References
	Chapter 16: Perioperative Pain Management for Abdominal Operations
		Introduction
			Summary
		Preoperative Measures
			Patient Education
			Receptor Blockade
			Summary: Preoperative Receptor Blockade
		Intraoperative Measures
			Prior to Incision: Anesthesiologist-Controlled
				NMDA Antagonists
				Lidocaine Infusion
				Continuous Epidural Analgesia
				Spinal Analgesia
				Paravertebral Block
				Quadratus Lumborum Block
			Summary
			After Incision
				Transversalis Fascia Block
				Rectus Block
				Intercostal Block
				Local Wound Infiltration
				Intraperitoneal Lidocaine
		Postoperative Measures
			Non-pharmacologic Measures
			Summary (Table 16.1)
		Special Considerations
			Chronic Opioid Use
			Morbid Obesity
		References
			Selected Reading and Resources
	Chapter 17: Classification and Analysis of Error
		Background
		Medical Error
		Adverse Events and Near Misses
		Sentinel Events
			The Joint Commission Sentinel Events [9]
		Surgical Never Events
		Error Classification
			Active and Latent Failures
			Types of Errors
		Error-Catalyzing Factors
		The Swiss Cheese Model
		Error Analysis
			Contributory Factors
			Root Cause Analysis (RCA)
			Failure Mode and Effects Analysis (FMEA)
			Fishbone Diagram
		Prevention of Error in Surgery
		Summary
		References
	Chapter 18: Disclosure of Complications and Error
		Toward a Taxonomy of Error
		Regulatory Aspects of Error Disclosure
		Error Disclosure and Risk of Litigation
		Communication and Resolution Programs (CRPs)
		Strategies for Disclosing Error to Patients
		Selected Reading
	Chapter 19: Avoidance of Complications
		Morbidity and Mortality
		Reporting Bias
		Checklists to Bundles
		Professionalism and Competency
		Simulation and Skill Assessment
		High Reliability
		Conclusion
		References
	Chapter 20: Safe Introduction of Technology
		Introduction
		Introduction of Surgical Technology in the Past: Laparoscopic Cholecystectomy
		Introduction of Surgical Technology in the Present: Introduction of the Robotic Platform
		Introduction of Surgical Technology: Proposals for the Future
			Defining Innovation
			Evaluation of Innovation in Pharmaceuticals and Surgery
			A Proposal for the Future: The IDEAL Framework
			Unique Challenges: Surgeon Learning Curve
		Conclusion
		References
Part III: Surgical Safety
	Chapter 21: Quality, Safety, and the Electronic Health Record (EHR)
		Best Practices for EHR Implementation
		Leveraging the EHR to Measure and Optimize Quality and Safety
		Improving Surgeon-Patient Communication Using the EHR
		Summary
		Selected Reading
	Chapter 22: Checklists, Surgical Timeout, Briefing, and Debriefing: Safety in the Operating Room
		References
	Chapter 23: Creating Effective Communication and Teamwork for Patient Safety
		Effective Communication Within a Culture for Patient Safety
		Structured Communication, Handoffs, and SBAR – The Tools of the Trade
		Rapid Response Team
		Good Teamwork Through Collaboration
		References
			Selected Reading
	Chapter 24: Energy Safety in the Operating Room
		Introduction
		Surgical Energy
			Cautery
			Monopolar
			Bipolar
			Ultrasonic Dissection
			Plasma Energy
		Safety Consideration in Electrosurgery: Unseen Energy Dispersal
			Open Surgery
			Laparoscopic and Robotic Surgery
			Endoscopy
		Operating Room Fires and Fire Prevention
		FUSE Curriculum
		References
	Chapter 25: Patient Safety Indicators as Benchmarks
		Quality Measures and Patient Safety
		Patient Safety Indicators as a Measure of Quality
		Efficacy of Using Patient Safety Indicators to Measure Quality and Surgical Outcomes
		Limitations to Patient Safety Indicators
		Conclusion
		References
	Chapter 26: Culture of Safety and Era of Better Practices
		Introduction
		Barriers to Achieving a Culture of Safety
		Hierarchy in Surgical Culture
		Communication Disconnects
		Team Dynamics
		Increasing Complexity of Surgical Services
		Strategies to Overcome Barriers and Establish a Culture of Safety
		Event Reporting and Promotion of a Just Culture
		Standardized Communication
		A Focus on Teamwork
		Surgical Leadership
		Conclusion
		References
	Chapter 27: Learning New Operations and Introduction into Practice
		Introduction
		What Different Steps Need to Be Taken to Evaluate New Technology and Surgical Techniques?
		What Are the Surgeon’s Responsibilities to Start NT&T?
		What Are Institution-Level Responsibilities to Start NT&T?
			Who Approves and Monitors the Introduction of New Procedures?
			What Should Be Assessed Before and After Introduction of a New Procedure?
			What Is the Pathway to Surgeon Credentialing and Privileging for NT&T?
		What Supervisory Options Are Available to Surgeons Adopting NT&T: Preceptoring vs Proctoring vs Telementoring?
			Telementoring
		What Is the Role of Surgical Societies in NT&T?
		Ethics of Patient Disclosure
		References
Part IV: Working Towards Surgical Quality, Outcomes, and Safety
	Chapter 28: Team Training
		Introduction
		Present Status of Teamwork in Healthcare
		Team Science and Developing Healthcare Teams
		Successfully Implementing Team Development Interventions
		Conclusion
		References
			Further Reading
	Chapter 29: Simulation and OR Team Performance
		Simulation
		Team Training
		Limitations of Simulation for Training
		Future Directions
		Summary
		Selected References
	Chapter 30: Debriefing After Simulation
		References
	Chapter 31: Using Simulation for Disclosure of Bad News
		Selected Reading
	Chapter 32: Teleproctoring in Surgery
		Introduction
		Definitions
		Current Landscape of Telemedicine
		Obstacles
			Learning Curves
			Technological Limitations
		Telementoring and Teleproctoring in Surgery
		Discussion and Recommendations
			Best Practice Recommendations
		References
	Chapter 33: Training for Quality: Fundamentals Program
		Introduction
		Fundamentals of Laparoscopic Surgery
			Development
			Components and Validation
				Self-Assessment Curriculum and Proficiency Targets
			Outcomes
		Fundamentals of Endoscopic Surgery
			Development
			Components and Validation
			Outcomes
		Fundamental Use of Surgical Energy (FUSE)
			Development
			Components and Validation
			Outcomes
		Current Uses of Fundamentals Programs
		Conclusion
		References
	Chapter 34: Training to Proficiency
		Introduction
		The Historical Perspective
		Simulation as a Training Tool
		Performance Goals for Training and Their Impact
		Lessons from Psychology
		Integrating Simulation into Residency Training
		Beyond Residency Training
		The Future of Proficiency Verification
		References
	Chapter 35: The Critical View of Safety: Creating Procedural Safety Benchmarks
		Introduction and Background
		SAGES Six-Step Program
		Importance of Avoiding BDI
		Implementation Considerations
		Future Directions
		References
	Chapter 36: Mentorship and Quality in Surgery
		References
Part V: Threats to Surgical Quality, Outcomes, and Safety
	Chapter 37: Disparities in Healthcare: The Effect on Surgical Quality
		Introduction
		Healthcare Access and the Surgical Patient
		Healthcare Delivery and the Surgical Patient
		Systemic Racism and the Differential Access and Delivery of Surgical Care
		Surgical Equity
		Strategies to Reduce Outcome Disparities in Surgical Care
		Conclusions
		References
	Chapter 38: Surgeon Wellness: Scope of the Problem and Strategies to Avoid Burnout
		Introduction
		Moral Injury and Victim Blaming
		Work Burden
		Cognitive Overload
		Medical Malpractice and Physician Wellness
		Physician Autonomy and Wellness
		Resilience
		EMRs and Wellness
		Leadership Perspective: How to Handle Burnout in a Department
		Putting out the Fire: Burning the Burnout
		Conclusion
		References
	Chapter 39: The Disruptive Surgeon
		What Is Disruptive Behavior?
		What Are the Underlying Causes of Disruptive Behavior?
		What Is the Extent of the Problem?
		How Does Disruptive Behavior Impact Patient Safety?
		How Do we Identify the Disruptive Surgeon?
		How Do we Remediate the Disruptive Surgeon?
		Summary
		References
	Chapter 40: The Surgeon as Collateral Damage: The Second Victim Phenomenon
		Introduction
		The Second Victim Phenomenon
		Risk Factors for Experiencing Second Victim Phenomenon
			Empathy Overload
			Perfectionism
			Training
			Female Gender
		Call to Action
		Recommendations for Practice at an Institutional or Department Level
			Step 1: Create a Just Culture in your Department, Hospital, or Organization
			Step 2: Create a Network of Support and Aggregate Additional Resources
		Recommendations for Practice at a Practice Group Level
		Recommendations at a Personal Level
		Addressing Challenges
		Conclusions
		References
	Chapter 41: The Surgeon in Decline: Can We Assess and Train a Surgeon as Their Skills Deteriorate?
		Introduction
		What Skills Are Needed?
		How Do We Know They Are Ready to Start?
		Clinical Skills In and Out of the Operating Room
		The Toll of Time
		Do Surgeons Decline?
		Are Assessments Available?
		Assessment of the Surgeon’s Head
		Turning Back the Clock
		Suggestions for Practice Groups and Hospitals
		Conclusion
		References
	Chapter 42: Fatigue in Surgery: Managing an Unrealistic Work Burden
		Introduction
		Etiology and Risk Factors for Burnout
			Personal/Demographic Risk Factors
			Workplace-/System-Related Factors
		Measuring Burnout/Fatigue
		Strategies to Address and Prevent Burnout/Fatigue
		Conclusion
		References
	Chapter 43: Training New Surgeons: Maintaining Quality in the Era of Work Hour Regulations
		Suggested Reading
	Chapter 44: Maintaining Surgical Quality in the Setting of a Crisis
		Hospital Resources During Crisis Situations
		Cessation of Elective Surgery and Ramifications for Patient Care
		Scarce Resource Allocation During a Medical Crisis
		Redeployment of the Surgical Workforce During a Crisis
		Delays in Care Delivery of Routine Problems Due to the Crisis
		Re-emergence Back into Elective Surgical Care Following a Crisis
		Conclusion
		References
	Chapter 45: Ergonomic Considerations for Surgeon Physical Wellness
		Introduction
			Why Does Ergonomics Matter?
		Ergonomic Challenges in the Operating Room
			Posture and Operative Fatigue
			Instruments and Equipment
			Implications of Poor Ergonomics
		Strategies for Optimal Ergonomic Approach
			Surgeon Awareness of Their Environment [20]
			Setting Up the Operating Room for Success
			Education
			Steps to Alleviate Strain
			Microbreaks
		Specialized Tools
			Surgical Instruments
			Loupes and Headlamps
			Lead Shields
			Footwear
			Office Ergonomics Should Not Be Ignored
		Conclusion
		References
Part VI: Surgical Controversies That Impact Quality
	Chapter 46: Hernia Repair: Robot or No Robot?
		Introduction
		Robotic Inguinal Hernia Repair
		Robotic Ventral Hernia Repair
			Robotic Intraperitoneal Onlay Mesh (rIPOM)
			Robotic Pre-peritoneal Ventral Hernia Repair
			Robotic Retrorectus and Transversus Abdominus Release (TAR)
			Robotic Extended (or Enhanced-View) Total Extraperitoneal Ventral Hernia Repair (eTEP)
			Cost of Robotic Ventral Hernia Repair
		Ergonomics of Robotic Hernia Repairs
		Conclusion
		References
	Chapter 47: The Consistent Operating Room Team
		Objectives
		Introduction
		Types of Teams
			Cross-Trained Team
			Consistent Teams
		Factors Affected by Team Format
			Communication
			Error Reduction
			OR Efficiency
		Training
		Conclusion
		References
	Chapter 48: Prevention of Common Bile Duct Injury: What Are we as Surgeons Doing to Prevent Injury
		History of Common Bile Duct Injury
		SAGES Safe Cholecystectomy Task Force
		Intraoperative Cholangiography
		Summary
		References
	Chapter 49: OR Attire: Does it Impact Quality?
		Introduction
		Types of Surgical Attire
		Current Guidelines
			AORN 2015 (Updated Publication in January 2020)
			ACS 2017
			CDC 2017
			WHO 2018
		Evidenced-Based Practices
			Surgical Head Coverings
			Surgical Masks
			OR Jackets and Bare Below the Elbows
			Facial Hair: Clean Shaven and Bearded
			Cost
			Environmental Waste
			COVID-19 Impact
		Correlation of Current Guidelines with Evidence
		Summary
		References
			Selected Readings
	Chapter 50: Learning When Not to Operate: From Patient Selection to Withdraw of Care
		Objectives
		Introduction
		Patient Selection: When to Wait First, Operate Later
			Smoking
			Obesity
			Diabetes
			Multiple Comorbidities and Cost
			Women of Child-Bearing Age
		End-of-Life Care: First, Do no Harm
		Conclusion
		References
	Chapter 51: The Changing Paradigm in Acute Care Surgery: Who Is the Best to Offer the Care?
		Introduction
		What’s in a Name?
		The Existing Standards
		Heartening Signs
		Nonoperative Contributors to ACS Success
		Obstacles to ACS Implementation
		Who Is the Expert?
		Alternative Means to ACS with Finite Resources
		Defining Quality and Standards with EGS
		Conclusion
		References
	Chapter 52: Super-subspecialization of General Surgery: Is This Better for Patients?
		Objectives
		Population Impacts of Care Access in a Specialized Model
		Who Owns the Patient in a Paradigm of Specialists?
		What Is Lost in Super-specialization?
		Where Do We Go from Here?
		Bibliography
	Chapter 53: What Is the Connection Between Physician Relationships with Industry and Patient Care?
		Introduction
		Examples of Ways that Financial Relationships Can Impact Quality, Outcomes, and Patient Safety
		SAGES Processes for Disclosure and Management of Relevant Financial Relationships
			SAGES Statement on the Relationship Between Professional Medical Associations and Industry
			Disclosure and Mitigation Process
		Conclusion
		References
Index