Wednesday, May 25, 2016


INNOVATIVE STRATEGIES FOR IMPROVING SURGICAL PERFORMANCE Justin Dimick, MD, FACS; Chief of the Division of Minimally Invasive Surgery, and Director of the Center for Healthcare Outcomes & Policy at the University of Michigan.

         At the Annual Meeting of the AVAS this Spring, Justin Dimick presented his thoughts on Innovative Strategies for improving Surgical Performance”.  During this presentation he walked us through his process on developing a Michigan Bariatric Surgery Collaborative and their use of video-based peer coaching in an attempt to address the variability in bariatric surgery outcomes across the state of Michigan.

It was clear at the outset that what a surgeon thinks they did during a particular situation may not be what they actually did. As Malcolm Gladwell clearly notes in his book ‘BLINK’, what we perceive we did and what really occurred are not always the same. Reviewing a video of oneself can clearly erase the barriers we face during the process of change. Recently while I was at Langley AFB Virginia, I was admiring the features on their custom fitted $450,000 F35 combat helmet when Gen. Herbert J. "Hawk" Carlisle Commander, Air Combat Commander and a crew-member with the F35 – F22 Airforce Heritage flight team, explained the data capturing ability of the helmet. Within this is complex debriefing data that is immediately available for the pilots to download and utilize for their debriefing. They have the ability to assess immediately where “they can make improvements”. I thought, what a novel idea! Reviewing data and video about oneself after a mission to improve performance! This could easily be done in surgery if we reduce the barriers to make that successful. So clearly I had an interest in this discussion from the onset.

So what does the $450K F35 helmet have to do with surgical performance improvement? Dr. Dimick noted from the outset that the traditional learning paradigm of didactic and skills sessions for teaching is not optimum for promoting change. He reported a measly 10% success in long term skill acquisition using lectures, 19% success rate in feedback and a whopping 95% long term success rate utilizing coaching. In their program, Dr. Dimick attempted to address several of these issues by using video-taping to address the dissimilarity between what one thinks they did and what actually occurred and coaching by an expert in the field to assure that the learner had real-time processes to learn, reflect and adapt.

I asked Dr. Dimick to discuss this collaborative with me as I had a few questions:

  1. This collaborative involves an equal mix of academic surgeons and private community surgeons, so how did they attain buy-in from the busy private practice surgeons? This was intended to be a state-wide performance improvement project and gaining the trust of those in the community was a clear key objective.
  2. Several others have objected to the use of videotapes during their patient care or during team based training due to the fear of the tapes being utilized negatively for performance or legal action. So how do they avoid this?
  3. What are some of the success stories and lessons learned we can pass onto others?
        Dr. Dimick acknowledged immediately that this is all in the preliminary stage. They have not yet analyzed the transcripts and therefore have no feedback to provide at this moment. He did state that they can relay their success in obtaining the cooperation of several very busy private practice MD’s.  This was not an overnight success but a product of a long term relationship they already established. These MD’s already agreed to join what turned out to be a successful established quality improvement collaborative where they met three times a year. Through this they gained much trust in one another already and everyone was more than willing to extend the time to go forwards. His advice was that if anyone is entertaining such a collaborative, you must first establish rapport with the group you are seeking a working relationship with and the best way to do that is start small and return their trust as rapidly as possible.  Tying the individuals together using a common goal of quality improvement was extremely important. You must be keenly aware of individual discomfort and alleviate that early on by titrating the program’s processes to the point the participants feel relaxed and have mutual benefit.
    While the focus of this presentation was of video assessment of laparoscopic skills (solely of this individual) many are focusing video assessment of the entire surgical team membership under the same principles. Video assessment of surgical teamwork and individual performance may be in its infancy stage but has clearly shown its merits thus far. The airline industry has utilized the “black box” for use after an aviation incident but as far as I know, it remains a black box unless opened by the FAA. Video surveillance of the operative team potentially opens up a multitude of questions already being asked by others in the field. On a positive note, the secondary effects seen have been the realization that team members may actually not be focused on the task at hand (see Bowermaster, Eghtesady et al JAmCollSurg 2015) leading to crisper communication pathways. On the other hand, those in the field have expressed concerns about the administrative and medicolegal use of these tapes.  On this note, I was curious how the Michigan Collaborative jumped over that hump. Dr. Dimick quickly noted that all videos are de-identified and therefore not discoverable in court. Additionally, the collaborative was deemed a Performance Improvement project.  In this, the most sensitive data are outcome measures. He reminded me that NSQIP is not discoverable and as far as he is aware purely PI / QI data has never been discoverable and never sought in any instance. He said that if anyone is asked, they will confidently be able to state that they have no patient identifiable information, that laparoscopy video is for teaching (and all providers documented appropriate patient consent for video-taping for educational purposes), and finally that all tapes are brought in by the individuals and none collected by the collaborative (the provider has the tape on their laptops and then takes them with them). He likens this to providers utilizing non-identifiable laparoscopy videos used to discuss technique or complications in any conference. He readily admits that all this was taken into consideration during the over six-month process of working with their IRB and legal counsel to assure human protection for both the patients and the providers.
    His final piece of advice: Human trust is the most valuable part of capital one can gain when developing these projects, for with it you can achieve significant changes, but without it you will likely fail.



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