Strategies to Reduce Surgical
Mortality and Morbidity
Leigh Hamby, MD, MHA
EVP and Chief Medical Officer
Agenda for this AM
• Important contributions of surgical
mortality and morbidity to overall hospital
• Is there a difference between
“complications” and “preventable events”
• What can we do to reduce surgical
morbidity and mortality?
Is Mortality a Useful Measure to
• Can it be measured?
• Is there a gap between what we “know”
and what we “do”?
• Does it excite people and tap into “intrinsic
• Does it invite continuous feedback and
• Does it build our “improvement capacity”?
Surgery and Mortality Data
• Surgical cases were Preportion of Deaths FY 10
24% of Total IP cases
• Surgical patients were
17% of Total IP
Mortality for FY 10
• However 50% of 0%
deaths after elective Emergent Urgent Elective
admit were surgical Surgical Non Surgical
Mortality Rate for Urgent
/Emergent FY 10
Surgical Non Surgical
Morbidity / Complications
• Complications of anesthesia • Post-operative respiratory
• Death in low mortality DRGs failure
• Decubitus ulcer • Post-operative pulmonary
• Failure to rescue embolism or deep vein
• Foreign body left in during • Post-operative sepsis
• Iatrogenic pneumothorax • Post-operative wound
• Selected infections due to • Accidental puncture or
medical care laceration
• Post-operative hip fracture • Transfusion reaction
• Post-operative hemorrhage or • Birth trauma- Injury to Neonate
• Post-operative physiologic and • Obstetric trauma – vaginal with
metabolic derangements instrument
• Obstetric trauma, vaginal
• Obstetric trauma, cesarean
My Philosophy on Complications /
• “When you are the numerator, the
denominator doesn‟t matter”
– Dale Nordenberg
• We should strive to eliminate the things
that we don‟t want to happen to someone
Framework for Consideration
• Surgical Mortality has two different
– Emergent / Urgent
• Highest Risk / Most Impact
• Strategies around intra-op and post-op
• Most compelling
• Strategies around pre-op / intra-op / post-op
• Strategies should address both Morbidity
Specific Pre-op Strategies
• Pre-op Briefing
• Medical staff governance has to “own this”
• Make sure your pre-requisites are in place
Preoperative Briefing - Kaiser
Human Factors addresses the interpersonal skills generally implicated in adverse outcomes. It is about
detecting threats to patient safety, avoiding errors, and managing in a team–based environment. The
primary concept applied in the preoperative setting is the use of briefings similar to the pre-flight
briefings in the aviation industry.
A Briefing is an opportunity for team members to share pertinent information regarding the patient‟s
care prior to and during the surgical procedure. This allows all team members to share the same mental
WHO participates in a Safety Briefing? There are 4 roles in a Safety Briefing, each equally important. A
Safety Briefing is the responsibility of the entire team.
WHEN & WHERE does a Safety Briefing occur? In the operating room-post induction, precut.
Surgeon Circulator Scrub Anesthesia
•ID patient and site •Do we have all the •What type of anesthesia will be
•Identify patient site and marking
What type of surgery? •Allergies?
•Are there any instruments •Risks?
Realistic Time Estimate missing from the tray? Should we anticipate any
•Verification of Medication on the
•Are all the instruments
What is the desired position? working? •Any special needs –
•X-ray available and other special
services, (i.e., X-Ray, Pacemaker, positioning, medications?
Any special equipment needed? •What special
Cell Saver, Sales Rep, Laser)
Blood available? instrumentation do we •Special Lines driven by
Is this a standard procedure or are there need? Anesthesia
special needs? •Does the team have
Are there any Anticipated problems? Anesthesia any questions about the
Will we need pathology?
Are there any special
Use of drugs on the field?
intraoperative requests, i.e.,
Surgeon Successful Scrub wake-up, hypothermia?
Intra-op Framework / Strategies
Intra-op Failure Modes
June 2003 • Volume 133 • Number 6
Surgical Outcomes Research
Invited commentary: Analyzing adverse medical events—it's the system!
• Robert Rhodes, MD Philadelphia, PA
… error in medicine is almost always seen as a
special case of medicine rather than as a special
case of error … The unfortunate result has been
the isolation of medical errors from much of the
body of theory, analysis, and application that has
developed to deal with error in fields such as
aviation and nuclear power … Much as human
behavior in a medical setting is still behavior and
not medicine, human error in a medical setting is
still an error and not medicine.3
3. Gaba DM: Human error in dynamic medical domains. In: Bogner MS, editor. Human error in
medicine. Hillsdale, NJ: Lawrence Erlbaum Associates, Inc; 1994. p. 197-224.
• We should think about “surgical errors” the
same way we think about any other error
• What would you guess is the most
common cause of intra-op „error‟?
• Develop an understanding of failure modes
– Need surgeons / anesthesia/ OR staff participation
• Start a journey of a thousand steps
• Capture useable information for learning and
• “What an organization becomes emerges from
the relationships of its members rather than
being determined by the choices of individuals..”
– Ralph Stacey
• Prevent things we know are a risk and
– DVT, SCIP, etc
• Assessment of patient risk after surgery
• Early detection if things begin to go awry
– Is Sepsis going to be the 6th vital sign?
• Prevention of Surgical M&M goes WAY
BEYOND prevention of DVT and SSI
• Break up strategies into Pre-op, Intra-op,
• Consider different levels of risk for elective
• Would like to close with a (hopefully)
Think about this…
• Recall the “organizational” energy you expend to
drive SCIP improvement at your hospital (for
example colon resection)
• To move our system from 93% to 95% on all
SCIP measures positively improved care for 20
additional patients in 1 year
• We improved colon cancer screening by 10%
from Jan – Sept 2010
• This improved care for 900+ patients!
– Some of these will NOT NEED surgery!