Wednesday, May 25, 2016


IMPLEMENTING VALUE-BASED CLINICAL QUALITY IMPROVEMENT IN HEALTHCARE Bruce Ramshaw, MD, FACS Chairman and Professor, Department of Surgery University of Tennessee - Knoxville 

         At the Annual Meeting of the AVAS this Spring, Bruce Ramshaw, MD, FACS presented his experience in Implementing value-based clinical quality improvement in Healthcare. For those unaware, Dr. Ramshaw presented a series of podcasts on the General Surgery News website in September and October 2015 covering the gamut of current concerns revolving around patient safety and cost conservation, so this talked peaked my interest. Dr. Ramshaw explained in his introduction that NOW is the time for Surgeons to lead the way in making value the overarching goal in Healthcare (theme from Harvard Business review October 2013). In healthcare, VALUE is defined as the quality, safety, satisfaction and cost of the entire cycle of care for each patient. In his terms, value is comprised of a reduction in complications AND cost. He explained that our current thinking in terms of silos is antiquated and that we simply must deal with this situation utilizing complex systems thinking. We tend to think like a reduction scientist and view cause and effect as clear and predictable, but we all know this is far from the truth when dealing with human beings. We were cautioned to not equate standardization to absolute rigid uniformity but to move towards the optimal variety needed to perform that particular aspect of patient care. By the end of this discussion, it was clear that we ought to be able to identify subgroups of patients who will benefit or harmed from specific types/brands of devices.  Using this information, we should then be successful in identifying techniques that would improve outcomes in terms of satisfaction and quality. It was clear that multidisciplinary teams will accomplish many of our goals towards quality improvement. The presentation concluded with a reminder that continuous improvement never ends. There have been discussions through the year at our AVAS annual meeting of utilizing the VA as a focal point in cost conservation control in areas such as hernia repair and total joint arthroplasty just to name a few.

In October 2015 Dr. Ramshaw discussed his General Surgery News podcasts with me. We covered multiple topics including Patient Safety and Safety science, why attempts at improving Patient safety fail, Cognitive Bias, True Leadership in Healthcare, and so on, so I was eager to follow this presentation with a conversation with him on this recent talk. I inquired of Dr. Ramshaw what his single most successful method in driving this point home in the medical centers he worked in. Surgeons are extremely busy and while they are constantly focused on complication reduction, asking them to make a personal choice of shifting to a more cost effective method they are not comfortable with seems daunting. He stated I think after years of trying to push the multi-disciplinary, team approach, including the importance of having patient care managers, I have had much more success getting people interested in exploring the complex systems concepts by just asking- ‘shouldn't we be measuring the value of care we provide?’"  For certain, asking private practice surgeons to interrupt their busy schedule to assess models and reams of data will not work, so he is working at UT Knoxville to develop an ideal model that others can eventually use.  He concurs its not easy, but we have to focus on value of care. If we can measure the value of care then that will encompass safety, complications, outcomes and patient satisfaction and can then compare to cost (overall and at each point in care). We must accept that most hospital Administrators only see specific cost values that are not outcome driven; that is the data they understand.  Surgeons typically only see quality / outcomes data. We need to work together to assure everyone sees the same picture by developing a model that provides us with a VALUE figure we can all understand and the patients will accept. The model he is working on will hopefully lend itself to widespread use. Our conversation concluded with the notion that our VA is an ideal situation to assess this model as we have some of the most robust quality and cost data there is. He stated he can eventually forward his working model and thought to the VA to work collaboratively to test the potential to provide true value in the VA system.


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