Black Boxes in the OR

Photo courtesy Flickr user G A R N E T (CC)

From the annual meeting of the American Surgical Association in Chicago

Researchers at the University of Vermont compared potentially preventable deaths in a busy general surgery service as determined by peer review within 4 weeks of death vs. “excess mortality” predicted by three common risk-adjusted models—POSSUM, University Health Consortium, and the Charlson Index.

The bottom line is that they found significant disparity in the “excess mortality” reported by the three models.

The rub for surgeons and other health care professionals is that hospitals are increasingly being profiled using risk-adjusted mortality rates as a measure of quality.

In this era of general distrust and easy, on-line searches, both the public and government are demanding more hard data and transparency.

The audience consensus was that these databases have been over-mined, but it was suggested that the strategies used in the study are complimentary, not competitive. Lead study author Dr. Steven Shackford agreed, saying that the standardized risk adjustments help focus the peer review process.

What irked attendees more is the idea of opening the peer review process to the public. While journalists and attorneys may welcome such a move, it was noted that physicians may not respond truthfully in this setting.

“I don’t know what the best proxy for transparency is, but I am very concerned that trends in making the minutes of peer review available for general consumption will threaten this process,” Dr. Shackford said, adding that peer review is central to practice-based learning and to the improvement process and outcomes of care.

While Dr. Shackford said it’s unfortunate that hospitals don’t have black boxes in the OR or at the bedside, he suggests they take a page from the military and conduct a “hot wash-up” within 24 hours of an adverse event. The military uses these after-action discussions and performance evaluations to focus the attention of team leaders and to prompt dialogue on how to better complete a task.

Taking such an approach, “will get us closer to honesty and truth because the defenses haven’t gone up yet,” he said.

An intriguing idea, although the government’s track record for concealment would suggest that someone still needs to be plumbing (sorry, I just couldn’t resist) the data.

—Patrice Wendling (on Twitter @pwendl)
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Filed under IMNG, Surgery

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