CAGS Meet Week – Revitalizing The Morbidity And Mortality Conference

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Ameer Farooq  00:10

This is a special episode of Cold Steel. The Canadian Association of General Surgeons, or CAGS, is the national organization that unites general surgeons across Canada. And normally, we have a national meeting every year that brings together surgeons from across the country. At our meeting, that’s called the Canadian Surgical Forum or CSF. But unfortunately, due to the COVID-19 pandemic, this was obviously not possible this year. But in lieu of that, we were lucky enough to have a virtual CAGS meet week on a variety of topics. From the perennial favorite of alone in the night, difficult scenarios in ACS, to the COVID-19 elective surgery crisis, to diversity and health outcomes research. All of these sessions were recorded and put on the CAGS website. And I would encourage all of our listeners to check those out. I was lucky enough to be able to present and moderate at one of those sessions for the meet week on a topic that I’m passionate about, which is the morbidity and mortality rounds or M&M conferences. As always, I would love to get your comments, feedback, and suggestions. And once again, I’d encourage everyone to go to their CAGS website where you can check out all of their sessions. In addition, they have seminars every month, and all of them are excellent, and I encourage all of you to listen to them. Good afternoon, and welcome, everyone to our webinar today. I’m super excited to be able to present our seminar today on revitalizing the morbidity and mortality conference. My name is Ameer Farooq. I’m a colorectal follow at St. Paul’s hospital. And I’m very excited to be moderating the session and to have a fantastic group of panelists joining me today and I hope that this can lead to some really lively discussion and conversation across the country. Of course, we always miss the in person meeting that we have every year with the CSF. But in lieu of that, I’m hoping that at least we can connect virtually. And I’ve really enjoyed the last few talks that we’ve had over the last week. So I hope we can continue that trend tonight. While we’re still waiting for any last minute stragglers that might be logging on to the session, I will just introduce our three panelists today. So I’m so lucky to be joined by Dr. Chelsea Harris. Dr. Harris is a general surgery resident at the University of Maryland. She completed her Bachelors of Science at Brown University and earned her medical degree at the University of Vermont College of Medicine. During a two year research fellowship at the University of Michigan, she also earned a Masters of Science in health services research. Her academic interests center on how to better understand the needs of diverse patient populations, and the clinical cohort that treats them and is one of the founding members of the now famous cultural complications curriculum. And I’m really looking forward to seeing how we can maybe incorporate cultural complications into our weekly or monthly M&M rounds. I’m also very lucky to have Dr. Christian Finley join us today. Dr. Finley is a thoracic surgeon at McMaster University. Dr. Finley trained in general surgery at UBC in Vancouver, and thereafter completed his training in thoracic surgery in Toronto. After completing advanced training in Belgium and England, he started working in St. Joseph’s Healthcare in Hamilton in 2010. He completed his Master’s of Public Health at Harvard University and since joining the faculty of thoracic surgery at McMaster, he has been awarded hundreds of thousands of dollars in research funding for his active research programs, particularly in thoracic surgery, quality improvement. And according to his own bio, he is the proud father of three crazy girls. And he’s going to talk to us today about incorporating a data driven approach to M&M rounds. And lastly, we have Dr. Morad Hameed. Of course, he needs no introduction to this audience. Dr. Hameed, as many of you will know, is a trauma surgeon intensivist at the Vancouver General Hospital, and an Assistant Professor of Surgery at the University of British Columbia. He completed medical school and surgical residency at the University of Alberta, graduate studies at Harvard, and fellowships in trauma, surgery and surgical critical care at the University of Miami. He spent three years on surgical faculty at the University of Calgary before moving to Vancouver, and is the head of UBC and BGH Division of General Surgery. And he’s going to be speaking with us on how we can move into the M&Ms of the future and creating learning health systems. And I’m just going to start my presentation here. So thank you once again for joining us on this evening. And we’re gonna be talking about revitalizing the morbidity and mortality conference. I have no disclosures. So just as an outline for today, we’re going to talk a little bit, and my goal for my presentation is to just give you a bit of a background and set the stage for why we’re even talking about this as a topic on CAGS, week 2020. So I’m going to talk a little bit about the background and history of the morbidity and mortality conference. I’m going to interchangeably call this M&M rounds, really talk about some of the challenges to the traditional M&M rounds, and talk a little bit very briefly about the successes in rounds that we put on in Calgary as complementary or alternative rounds, and then really move to the the exciting part of the evening, which is to hear our panelists presentations. So as many of you will know, the M&M rounds really originated with Dr. Ernest Codman. Dr. Codman was a surgeon at Massachusetts General Hospital in Boston, sort of in the early 20th century. And, you know, he was way ahead of his time and really a visionary. And one of the things Dr. Codman started doing with all his patients is collating what he called the end results. And what was really unique about what the end result was, is that he would document sort of very briefly the patient’s clinical presentation, the operation that they went to, and followed them to at least a year out to see what their outcomes were. And despite doing things that we now perceive as being very kind of normal and standard of care, he was vilified by his colleagues at MGH and was actually kicked off the faculty and he went on to found his own hospital which he had dubbed the very imaginative name, the End Result Hospital. And he continued to collect data on the patients that he saw and the end results that he had and many famous surgeons ended up actually joining his hospital, including Dr. Cushing. So here’s an example of the cases that he would collate and collect. So case number 90 on January 27, 1913, stout female abdominal pain of 12 hours duration pre-op diagnosis sub-acute appendicitis operation was an appendectomy. The appendix showed evidence of a previous attack, but no sign of acute inflammation. Complications – none. Although he editorializes and says error and diagnosis. Results, August 1913. Well, August 18, 1915. So two years later, now has symptoms of gall stones. Operation devised, scar solid. And what’s really amazing about this as a couple of things. One is that, you know, his presentation of missed or misdiagnosis of appendicitis still sounds very plausible today. And two, that he links the optic error and diagnosis to a post operative complication, which is that the patient required another operation two years later. And one of the cases that I find most amazing that he documented was case number 77, which was where he ligated the hepatic duct and where he himself makes comments. And remember that these comments are all published in an annual report of the hospital. So these are publicly available reports. And he wrote, I had made an error of skill of the most gross character and even during the operation, failed to recognize that I’d made it. And this just strikes me as incredible humility. So we fast forward today to the modern M&M rounds, and  really this has expanded beyond surgery to pediatrics, internal medicine, obstetrics and gynecology, pharmacy, you name it. People are using M&M rounds. And really, it’s a core component of surgical training. And it’s actually mandated today by ACMGE. And there’s a whole host of literature that’s actually grown up around the morbidity and mortality conference. And in fact, M&Ms have permeated culture so far as to even penetrate mainstream media, as demonstrated by this Grey’s Anatomy’s clip.

Grey’s Anatomy Audio Clip  09:10

Grey’s Anatomy clip plays: “Yes, let’s get back to this patient’s need for an emergent transplant. You’re saying that his left ventricle had been weakened by the elvet malfunction. His left ventricle was weakened by the fact that he’s suffered from congestive heart failure. Come on, Dr. Burke. We all know the LVAD was cut by an intern. I’m going to my happy place. That chain of events remain unclear. It remains unclear to you because you’re in the ER with a gunshot wound. Why aren’t we hearing from Dr. Bailey? She was a senior physician on the case. I am the attendant on record. Yes, I was the resident in charge. Dr. Burke has summarized the medical facts of this case. Are there any questions for me?

Ameer Farooq  10:04

I think my heart rate is picked up at least an additional 10 beats per minute just watching that clip. But certainly, the clip captures many of the emotional aspects of M&M rounds that we’ve all, I think, come to understand and appreciate. So what do M&M rounds look like across the board in 2020? So what I would say is it’s extremely heterogeneous and very different depending on the institution that you go to. And that varies across every single component of M&M rounds. So from the goals to the structure to the frequency of M&M rounds, to the number of cases, to the participants that are in the rounds. So of note, you know, it’s not often that other specialties are included, although 60% of the cases reviewed in this narrative review did include nurses. But again, participants are very heterogeneous. Who’s presenting the cases is very heterogeneous. How these cases are selected is extremely heterogeneous, whether it’s even morbidity or mortality sometimes varies depending on the institution. And interestingly, only 20% of the studies reviewed in this narrative review found that there was a structured literature review as part of the M&M rounds. So the way that we do M&M rounds today is extremely heterogeneous and diverse. And really, that starts to beg the question, and really what prompted our session tonight, which is what are M&Ms good for anyways? Are they an educational platform? In which case, I would argue that they’re extremely heterogeneous in the case selection, and the very unstructured format makes it difficult to actually have some distinct learning points for trainees. Is it a quality improvement effort? In which case, you know, it’s hard to make a strong case for quality improvement when you don’t have consistent data collection and reporting, which I think is often the case with M&M rounds. And backed up by the literature in this area. Is it a method of error analysis on the individual or systemic level, but less than 10% of M&Ms that are reviewed in the literature actually employed a structured method of error analysis. Is there an individual or system wide impact? And I would argue from the M&M rounds that I’ve gone to, and the many people that I’ve talked to that the impact is often quite limited, particularly because it’s very limited who’s in the room when it’s limited to the surgical faculty and residents and trainees. Then the system level impacts often can be quite limited. And there are many competing challenges in 2020. You know, in terms of attendance for busy clinicians, and then the blame aspect of it that we’ve sort of highlighted with that Grey’s Anatomy clip. But I’m hoping that today that we can actually show that the M&M rounds are really a vital part of our surgical quality and surgical systems, and that there are a number of ways that we can really revitalize our M&M rounds going forward. And I’m delighted to have Dr. Chelsea Harris, Dr. Christian Finley, and Dr. Morad Hameed, joining me today to talk about various ways that they have tried to implement changes for quality improvement and M&M rounds in their institutions. I’m going to talk briefly about one variation that we did in Calgary, which was the S&S rounds, or “Successes and Saves” conference. And I can’t take credit for originating this idea, I actually saw it on Twitter. Kevin Kniery is a vascular surgeon in the US and he wrote on Twitter. This is a common sentiment in surgery that surgery is quite humbling. And we beat ourselves up over our failures, both personally and formally at M&Ms and we need to do a better job of celebrating the many wins that we have. And when I’m in charge, we will have S&S conference successes and saves and I felt really inspired by that. And the faculty at the Peter Lougheed Hospital in Calgary were very gracious and allowed me the latitude and the leeway to try this. So our S&S rounds were held at the same time as our regular M&M rounds with the same audience which consisted of surgical faculty, residents and medical students. And we chose to highlight two cases. The first was a case of a 91 year old co-morbid male with diverticulitis and septic shock. And really the discussion focused around the fact that sometimes we cannot predict who’s going to do well. And despite the fact that you know, the anaesthetist actually called us into the operating room and did an echo while the patient was still awake and said, “you know, this person’s ejection fraction is 20%. What are we doing here?” And that highlighted a whole other host of discussion points about how we deal with colleagues and how that discussion should go forward at one or two in the morning. And really focused on our ability to assess perioperative risk and generated some really good discussion from all the faculty. And the second was to highlight some new technical skills and technical ways of approaching an operation. So another geriatric ECS case was presented of a 95 year old male with a closed loop, and he’s a small bowel obstruction, who was taken to the operating room by a new faculty surgeon who performed the laparoscopic lace of adhesions in a totally intracorporeal anastomosis. And again, generated some really good discussion about technical points, whether this was a good idea or not, although it went very well, and again, highlighted some really different aspects I think of decision making than a traditional M&M rounds. So, you know, we didn’t have the opportunity to study this systematically, but overwhelmingly there seemed to be positive response. And I think, as I said, the S&S rounds really allowed the audience to learn from the decision making and technique of others, and celebrated our unexpected successes, shifting our attention from avoiding morbidity and mortality to really trying to achieve excellence. And it reminded me of the shortest poem in the English language, which is by Muhammad Ali, which was “Me, we”, and really, I think, highlighted the shift of culture to try to move towards a group effort towards the highest levels of success. I did get some feedback that this is the most millennial thing ever to talk about successes and saves. And what I would say is that this has been well studied. And Steve Kramer and Teresa Amabile, who are two well known psychologists studied this and published their findings in the Harvard Business Review. And they actually did a longitudinal study of workers looking at their inner life, and they would send them surveys at the end of each day. And what they found is that little small wins, so small areas of progress that people had, were the most likely things to actually prompt people to have their best day ever. It was the most common triggering event for a best day. So celebrating these little small wins could actually change and shift the meaning of what people were doing, and really change culture. And I think that is ultimately what I was trying to do with with the S&S rounds. Obviously, there are many future directions that this can be taken. And one of these, I think, was highlighted by a recent Annals of Surgery publication, actually just this year, where they use the concept of resiliency engineering, and use a similar methodology where they actually reviewed all the cases that had been performed over the last week. And really interestingly, and importantly, took that into a forward facing perspective where they actually talked about all their upcoming cases. And I really see that as an important aspect of our rounds going forward. Where we can actually start to predict difficult complicated cases. And use that to have a proactive approach rather than dealing with the morbidity and mortality afterwards. So that’s all I have to say to just try and set the scene. And we’ll start with Dr. Morad Hameed’s presentation. I just want to once again thank Karen Norris, who has been a huge influence in making this meet week a success. She’s been the real driver behind this at the Canadian Association of General Surgeons. I will also say that this webinar will be available to the listeners of the Cold Steel podcast on your iTunes, Spotify, Google Play wherever you get your podcast, RSS feed, and love to continue this discussion. On Twitter, via email, either to myself or to the @CAGS Twitter handle. And with that, I’ll stop my presentation and we can key up Dr. Morad Hameed. Thank you.

Morad Hameed  19:01

Thank you so much. I’m actually honored and thrilled to be invited to this event and so happy to see so many friends in the participants and call them friends and family. It’s great to see everybody and I miss you. I wish we could meet in person. And Ameer, thank you for that feed up. That was a summary of the M&M conference that I can hardly improve on. So I always look forward to going to M&Ms. I see it as a sort of participation in an age old time honored tradition and the conversations are always excellent. I think that you know in other in other areas of healthcare, we have sometimes structured debriefings. I know in the ICU, the nurses get together and debrief when they have moral distress and it’s often like a big event and often a tearful event, but I noticed that surgeons don’t really have those sorts of meetings. And it’s the burden, obviously, of decision making are great and successes are so extraordinary. And the failures are so devastating. And it’s a lot for people to shoulder. But I often think that our form of debriefing and coping is by discussing cases and decisions with each other and reflecting on outcomes together. So there is an intangible benefit of the morbidity and mortality conference, which is to sort of to strengthen the bond and culture in support of surgical care. But that said, I’ve always had a few frustrations with M&Ms. And Ameer, you pointed them out so beautifully. M&Ms, we always like pick two or three cases, we get to about two cases. It’s sometimes frustrating to think about how those cases are chosen. You know, you get the sense that you’re just shining the flashlight in the darkness, and that there’s a big denominator that you don’t get to see or consider. And sometimes you wonder if you’re really getting a picture of the performance of your surgical system. And beyond that, sometimes the discussions are meandering. The recommendations are imprecise. And the action on those recommendations is often inconsistent. And we always see the same sorts of things, sometimes the most dramatic events, and whether  we have the leverage to action any of them is always kind of left in doubt at the end of the hour. We did this narrative systematic review that we published in the CJS last year. And just to try to explore what the state of the art of M&M conferences is. And Ameer, you summarized this already really well. But in that narrative process, we came across five themes of M&M conferences. And these relate to their educational role and their role in quality improvement. So M&Ms are thought to have educational value, they’re thought to be a good forum for error analysis, that they rely on good case selection and representation. And they’re also dependent on attendance, and dissemination or knowledge translation. And each of the 20 or so papers that we reviewed, came up with some interventions to optimize one or more of these themes, such as standardizing presentations or taking an error analysis approach to morbidity and mortality, to select cases comprehensively, for example, from databases, and to improve faculty attendance and resident attendance, and to figure out ways to disseminate the knowledge that’s gleaned from these sessions. So that was inspiring to see that people have thought about this and thought of ways to make it better. And I think that one of the things that comes from this is how inextricably linked quality and education are. Sometimes our hospital administrators, they tell us that they don’t really care about residency training or the time we spend teaching. And yet, education is so fundamental to quality and system performance. That it’s hard to see how these are not totally synergistic, and inextricably linked. Still, though, you get the feeling at M&Ms that you’re trying to find leverage to change very complex systems. And to get truly meaningful change on some things, requires coordination of many different inputs. And it doesn’t in the end require a change in culture. We often hear that it’s impossible to change the culture of an organization that is too daunting a task. But I was very inspired by this book, the Culture Code. One of the stories in the Culture Code is is about coach Gregg Popovich of the San Antonio Spurs. And one thing they say about coach Pop is that if you look at his team, the Spurs, over the previous decades, and you predict their win/loss record, and their success in the playoffs, by the salaries of their players, or by the performance of their players individually, their performance always exceeds or excels their predicted performance. And that’s again based on income or based on individual player performance. And so the idea is coach Popovich creates a culture in which the sum of the means is greater. That the sum of the parts is greater than the whole. The whole is greater than the sum of the parts. Sorry. And so how does coach Popovich do this? And it’s all about creating a culture that allows players to play together, excuse me, sorry, to fulfill their individual potential, and also to fulfill their collective potential. And you can see that this is the graph of coach Popovich, his performance in wins compared to other excellent coaches. So how do we engage with that complexity when we try to improve the performance of our systems? Well, we decided in Vancouver to take sort of a holistic approach to surgical system performance. And, in particular, we wanted to begin to start with the why, like, why do we do things? And from there, we thought it would become clear about how we do those things. And then ultimately, what we do. So the idea is, instead of trying to optimize some outcome, like wound infections, or urinary tract infection, that’s kind of a what. More fundamentally, we wanted to ask, what is the underlying motivator for this at a very basic and fundamental level? Why do we do things we do? And we thought we could find inspiration from that type of reflection. To make those other questions about how and what more easy. We came up with a vision statement for our division. I think for any group of surgeons, that the vision or the priority that would make it to the top of any list is Clinical Excellence. When you get a roomful of surgeons to say that they prioritize Clinical Excellence above anything else, then suddenly you have buy in, in writing, about performance. And so you can say, well, you want to be excellent. But how do you know you’re excellent? How rigorously have you examined your excellence? Are we average? Or are we truly excellent? And what are the benchmarks of that excellence that we should strive to? Another way of looking at values is from provincial and national organizations. And according to the BC safety and quality Council, the value of a health system is based on these aspects safety, effectiveness, appropriateness, efficiency, but also access, equity and respect. So you can see that there’s clinical elements to a high value surgical system or healthcare system, but there’s also cost related priorities, and also cultural priorities. So now we’re kind of moving beyond sort of individual clinical measures to thinking about the culture of care. So morbidity and mortality conferences are an essential element of a system of surgical excellence. And I think they’re an indispensable part of it, for the reasons that we’ve discussed. But they’re ultimately just one of many inputs into a comprehensive approach to surgical excellence. Examining the processes of healthcare and it’s so intriguing that Dr. Farooq opened with a discussion of Codman examining process. His ideas are codified and the activities of American College of Surgeons and all of the quality improvement programs. Those principles of optimizing process and outcomes come from industrial engineering, which is fascinating. You can optimize industrial processes by reducing variability. That was at work of W. Edwards Deming in the mid 1900s. And then industrial processes eventually made it into healthcare, largely through the efforts of Avedis Donabedian, who emphasized the importance of structure, process and outcome. But still what’s missing from structure process outcome type analyses is the heart or the culture that drives this. And I think you can strive to optimize a process. But it would be difficult unless you get the buy in of the actual human beings, the healthcare teams and the patients that engage in those processes and fulfill those outcomes. And so, it is important to map processes and to reduce variability in processes and also to measure outcomes. But it still is only part of the inputs that you want into that system. Cost is also very important. And producing incremental changes in quality at high cost may not be in the best interest of society or public health. And so any effort to drive quality should balance that against the cost of care. And then what is the experience of patients and providers in those systems? And so how do you get inputs of data into your system to inform the way that people experience their lives. And I think in this age of equity and inclusiveness, patient and provider reported experience is more important than ever. We’re increasingly also concerned about planetary health and how healthcare impacts the planet. And so there’s another input about what we do. Are we doing it in the most efficient way that’s respectful of the environment and of the planet? And then all of these things, or many of these things can be combined into the notion of value based healthcare. This is a popular thing in Vancouver right now. We just had a symposium on value based healthcare. This thought is based on some of the work of Michael Porter. And this is a article that he wrote in the Harvard Business Review, about how to solve the cost crisis in healthcare. Essentially, what Porter says is that, to solve the problem of sustainability in health care, we have to balance quality over cost. So M&Ms are primarily concerned with quality but morbidity and mortality certainly have a cost effect as well, which makes that type of thinking even more important. So Porter has a sort of a construct about how you pursue value. How do you optimize the quality over cost? And the very first step in optimizing quality over cost is to organize into fundamental units. These are multi disciplinary units that are capable of not only measuring quality and cost, but actually acting on it. And so I’m just going to jump ahead to the integrative practicing. This is the most important part of Porter’s model. And we actually built this into our mission statement that we want to provide high value surgical care. That is care that optimizes the ratio quality over cost. And so how do we do that? So we did create communities of learning, or integrated practice units. The integrated practice units that Porter mentioned, we took that to heart, and we sort of deconstructed our Division of General Surgery into small, agile, integrated practice units or IPUs. Each IPU has a surgeon lead. And each IPU is what we consider to be like a small startup company. It has its own business plan. And it’s entrusted to pursue this optimization of quality over cost. We try to realize economies of scale by streaming data to all of these integrated practice units. And we ask each of these integrated practice units to compile objectives and key results. So every one of these startup companies or the small integrated practice units, develops a set of objectives and key results. The objectives must be measured by quantifiable key results. And so this is sort of a deconstructed or grassroots approach to quality where we actually empower the frontline providers or in this case, the leaders of each integrated practice unit to pursue the objectives that they care about most. So this isn’t like a nice quick benchmark, like surgical site infection. This could be recidivism in trauma, or it could be retransplantation in liver transplant. And so it suddenly becomes a more dynamic and interesting environment when people can pursue the objectives and key results they want. And as I mentioned, we provide them with dashboards. So we’ve basically worked closely with our quality and patient safety group to create dashboards. And here’s, for example, a dashboard of our liver transplant integrated practice unit that summarizes their four objectives and key results and provides them a real time report of whether they’re hitting targets for that quarter on that OKR. And then more convention on this group outcomes are listed below. But this is the place where people get to really define what constitutes excellence in their own integrated practice unit. We can map their data temporarily, we can even provide them with costs. Here’s a, you can see, these are some of our analysts who are collecting costs on liver transplant you can see right there, variability in cost per transplant in our group. There’s some variation left to stay as was seeing that the cost variation probably comes from wanting to stay. All of these together go into a business transformation approach and ultimate pursuit of high reliability. We want to create systems that not only are just minimized variation of all expense. We want to create resilient systems. Systems that when a disaster happens, they identify it early, they minimize it, they reverse it, and they move on. And so creating this resilience or high reliability is the net effect of this work. And the high reliability literature is fascinating to read. But it really comes from high reliability organizations outside of healthcare. This is a graph that I really love. This is innovation over time and healthcare. And you can see their waves of innovation that drive down patient mortality and improve quality. The first wave they say is technical advancements, things like laparoscopic surgery or improvements in anaesthetic. The second wave is standardization – considering healthcare processes to be industrial processes to try to minimize variation in best practices. And then the third wave, the cusp, where we’re at now, I think we’re sort of getting towards optimization and some diminishing returns of standardization is high reliability organizing. And this is again, embracing complexity. And being sensitive to operations, and creating agile and dynamic healthcare systems. We talked a lot about diversity. I’ll just finish up by saying that I think we’re increasingly understanding that surgical systems are complex. They may be surgeon led, but there’s so many inputs into them as we’ve seen. And to try to embrace that complexity is an important matter. And we know that in ecological systems, the more complex they are, the more resilient they are. So starting to kind of think through how to embrace complexity is an important idea. And so we came across this notion of learning health systems. Systems in which science, informatics, incentives and culture are aligned for continuous improvement innovation, with best practices seamlessly embedded in the delivery of processes and new knowledge. And so that’s kind of the model that we’ve followed in our own work. So that’s the learning health system. It’s got an afferent limb of data collection, where we have a lot of data. Healthcare systems are increasingly awash in data, sometimes where we fall short is in the implementation of actions to change, and to achieve high reliability and to change culture. And I think that’s the promise of learning health systems approach to surgical quality improvement. So finally, just a note on cultural safety. We’re so grateful to Dr. Harris. I emailed her one day, and she allowed us to adopt some of her work into our own work on learning health systems. And we had our first rounds with cultural safety principles the other day, and that’s very much part of our learning health system. So the “why” is the mission and vision. Value based care, pursuing high value values. The “how” can be learning health systems. And the “what” is transformation of surgical care costs and culture. So thank you very much for this opportunity.

Ameer Farooq  38:42

Thank you so much Dr. Hameed. As usual, very visionary talk. The more I get to know you and talk to you, I realize that if you’re going to talk about a subject, I better be ready get my binoculars on so that I can see way far in the distance along with you. So thank you again for sharing with us your vision. There’s certainly some questions coming in through the chat box. And I encourage any of our listeners to fire off some questions as soon as you think of them, and we’ll try to answer them. But I had a question on my own for you, Dr. Hameed. You know, this is a very complex, very nuanced, impressive way of thinking about how we’re going to change surgery going forward and creating learning health systems. But one of the things that I always find difficult to kind of reconcile is sort of the tension between individual responsibility and sort of the team or the system. And, you know, you brought up the example of basketball teams. Let me let me push back a little bit and talk about MJ right? So MJ, you know, everybody’s seen the now famous Netflix documentary about MJ and how he kind of brought an incredible drive to each game and can literally motivate himself to get to the next level. Where it is, you know, how do you balance this tension between trying to build an amazing system with also restoring some individual responsibility? Because I would argue that one of the historically important things about M&M rounds has been that it really, you know, made people think, “I don’t want to stand up in front of my peers and have to defend myself on M&M rounds”. So how do you kind of reconcile those two tensions?

Morad Hameed  40:32

Remember, Ameer, that MJ couldn’t win a title. He couldn’t beat the Pistons until he gave up the ball. So his coach, Phil Jackson, when he came, he said, MJ you got to give up the ball. And so he said, you know, I’m counting like 60 point games, why should I do that? But he said, okay, you know, you might be right, we haven’t won the title, despite everything, all my best efforts. And when he started to share the ball around court, they started winning titles. So, you know, Ameer I think it’s such a thoughtful question. We have a provincewide rounds every day, every morning. You know about it, it’s called the Five and Fives. And we reviewed an article about surgical technique, and surgical outcomes. And it was interesting. They video reviewed these people doing right hemicolectomy. So they rated them, and then they measured their outcomes. And surprisingly, or not surprisingly, at all, the technical ability of a surgeon was very much related to patient outcomes. And so sometimes when we do this broad systems thinking, we focus on things like the temperature in the room and glycemic control stuff and we forget that there’s such a thing as technical ability. So there is a role for individual excellence in learning health systems. But I would say that it’s a bit more nuanced than somebody just being excellent. Like, how is that person excellent? Is it because they work in a system where they’re continuously learning from their peers, where they’re doubling up with other attendings? So in a very pure way, you could say surgical technique and individual excellence matters. But that individual is embedded in the system. And their excellence really depends on what they learn, how they interact between surgeons with their broader healthcare team, and with the entire system. So no question. I mean, I don’t want to say that the key to surgical excellence is systems but  individual excellence is certainly an element of it.

Ameer Farooq  42:48

We have a question from the audience Dr. Hameed. Actually from Dr. McLean. Dr. McLean says, Dr. Hameed, great talk. I was wondering how you fund retrieving the key results data for each of the subgroups in the division? Who gathers the data? And how do you ensure its accuracy? And I think this is a super important point, because, you know, this is I think one of the troubling and difficult things about M&Ms or quality improvement in general. It’s very difficult to collect this data.

Morad Hameed  43:18

Yeah, absolutely. That’s such a key point. Thanks, Tony. So the learning health systems are very data intensive. Now, I think, in some ways, learning can just be making sure that the entire division is familiar with the literature, the best practice that you have frequent rapid rounds to disseminate knowledge and reduce latency between published literature and surgical practice. But in terms of measuring performance, you need a lot of data. And so we actually partnered very closely with our NSQIP people. In our place, it’s called quality and patient safety. And then this group abstractors would send us reports. You guys have seen those super long tables with surgical site infections, superficial deep, UTI, etc. But our surgeons never took much interest in those measures. When you started asking those NSQIP abstractors to collect stuff on retransplantation rates or recidivism or whatever was really important to the group, they started to love that work. So we’re kind of repurposing our NSQIP abstractors to this work. And the hospital’s gotten behind this and actually funded three full time. Repurposed three full time NSQIP abstractors to the IPU model.

Ameer Farooq  44:41

There’s so much more I could ask you about this Dr. Hameed, but just in the interest of time, we’ll move on to our next panelist. Once again, I’m delighted to have Dr. Chelsea Harris. She’s already been set up by myself and Dr. Hameed. And so everyone in the audience knows that she has been making waves for sure. So I’m delighted to hear about Dr. Harris’ work on cultural complications. So welcome, Dr. Harris. Thank you.

Chelsea Harris  45:08

Well, thank you all so much for having me. I’m delighted to be able to join and grateful for the virtual format because otherwise I would not be permitted by travel bands to come visit all of you. Wonderful. I’m going to be talking about cultural complications, leveraging M&M to redefine medical error. I have no financial interest to disclose. However, before we dive in a bit deeper to the cultural complications, I think it is important to disclose the context that I bring to this work. And so as you can all see, I’m a white woman, I grew up in a small town in Vermont in an environment as showcased here by my high school yearbook. And that was about as homogenous as they come. I have no formal training in critical race theory, sociology, or any of the other relevant disciplines that this curriculum touches on. And I really came to this work during the course of my general surgery residency, when it became apparent that my gender was playing a larger role in my interactions with my patients, attendings and staff than it really had in my conception of myself, and in many respects, in more ways than I wanted it to. Thankfully, with the help of some excellent teachers, and some very deliberate self education, I have been able to expand my perspectives beyond gender. And I’ve learned a lot, but I readily acknowledge that when it comes to discussing lines of difference, I often feel uncomfortable. I’d worry constantly that I’ll say the wrong thing or the not quite good enough thing. Or that I’d make a mistake. But I’m here to learn and to do better and to make any mistakes. Today, I welcome input on how I can improve. And I also include this disclosure for the people in the audience who may feel like they want to be more involved in this space, but they don’t know all the correct language or the data. And I encourage you, instead of waiting until you feel perfectly prepared, that you just begin and you learn as you go. So the fundamental question is, how does all of this relate to M&M? And I think that the root of that is the question, does context contribute to medical error? And I think that there is ample evidence that in fact it does. If you look across virtually every identity parameter, you will see that it contributes over and over again to disparities in healthcare. And I think that disparity in healthcare is in fact one of our most fundamental errors. Moreover, if you look at the provider experience, you can see once again, if you look across any line of difference that there’s disparities in everything from the owners that we award to resident autonomy in the operating room to gender differences in position resources, startup packages, permanent leaders position. Basically, every meaningful accomplishment you look at in a surgical career is impacted by identity. So as we began to recognize this concept, and members of my team began to wrestle with how could we intervene to improve the patient and the healthcare worker experience, we began to dial in on another fundamental question, which was: why does diversity training fail? And as we began to reflect on our own experience, and some of the literature that had been published primarily in the business sector, we began to identify some emerging themes. First, a lot of it is just “check the box online” module, which everyone hates. I care deeply about this topic. And my primary goal, when I’m forced to do online DEI training is to click through as quickly as possible. And I think are the crux of our hatred towards online modules is not that we are resistant to change, but that we can recognize that they lack authenticity. We are all savvy consumers, and we can readily tell the difference between a genuine investment in culture and some tickbox that an administrator has created for us. We also contend that the knowledge that online modules might confer is fairly transient, and the only thing that anyone remembers is how long it takes to complete them. Another issue is that example based curricula can be alienating. I can’t tell you how many cultural trainings I’ve attended that are aimed at a mixed group across the hospital where every example of bad behavior uses a surgeon. Now, I’m sure that we’ve all seen examples of surgeons behaving badly in the wild, but when the whole training focuses on one person or one group as an aggressor, it’s very easy to flip from an effective context to a defensive posture, and the message gets lost. I think the same thing happens when we discuss any line of difference. Similarly, training often focuses on the extremes, while manifestations of overt sexism, racism, homophobia, etc. certainly occur, subtle displays of bias, such as failing to recognize a woman or a person of color as a physician, are actually far more common. And in many ways, these are harder to address because the person who is committing the offense often isn’t aware that what they’re doing is wrong. And the recipients often have to parse out whether actual discrimination is occurring or if they’re just being sensitive. This can also make calling attention to this behavior difficult. Because recipients can feel like reporting will be seen as overreacting, and training that doesn’t speak to this reality therefore misses a major aspect of the problem. DEI training, (that is diversity equity inclusion training) also often comes in single big chunks in the forms of annual retreats or seminars. And let’s face it, it’s hard to hold anyone’s attention for a whole day or even a half day without constant reinforcement and re-education. It’s hard to sustain change. For students it’s also been that these trainings are very rarely actionable. There may be a lot of awareness raising, but what to do next is often much murkier. Furthermore, if all of the strategies focus on those egregious events, those extremes that we spoke about, and these don’t occur often, the training also loses a lot of its potency. Furthermore, as denoted in our very titles, much of the education focuses on trainees because our time is more accessible. And of course, it is important to train residents and students. But often culture is a top down affair. And in a very hierarchical medical environment, the degree to which a department invites or promotes change often stems directly from the leadership. A leader who believes in this message can be a really powerful agent for improvement. But there are contexts where DEI isn’t seen as particularly valuable. More broadly, I have found that in my own experience, voluntary DEI activities have a lot of preaching to the choir, that is the people who already believe in the message and are doing the work are in the room. And the people who need to change the behavior or get this new information are nowhere to be found. So in simultaneously holding our conviction that clinicians cannot provide the standard of care without understanding patient context, and that a tremendous amount of diversity training does not meet the needs of the providers that it seeks to inform, our break through and our stroke of insight came in asserting that we needed to address instances of cultural breakdown with the same rigor that we applied to medical error. And with that, the idea for the cultural complications curriculum was born. The idea, which you can learn about in more depth on our website, was that once a month, in place of a standard medical or surgical complication, we would instead present an instance of cultural breakdown and discuss it in a similar fashion. To our minds, leveraging M&M was potentially really powerful because the format would be familiar to the audience and its rigor was widely accepted. The combinations of case presentations, didactics and group discussions was ideal because it could raise awareness that DEI issues were neither abstract nor isolated to the ever nebulous outside hospital, but a reality for the patients and providers on a daily basis in the room. The didactics, we hoped, would establish a shared scientific basis, and the group discussion to help establish best practices. We also felt like M&M was an ideal forum, because it could be longitudinal, because it was one of the few places where all levels of the departmental hierarchy from students to the chair have congregated. So the foundation of the toolkit is a PowerPoint based curriculum that introduces 12 core topics in DEI. We do seek to make it highly customizable to the individual local environment. Each didactic session defined key terminologies based on national science and where it exists evidence based response strategy, and efforts to reflect the reality of the science section includes an explicit acknowledgement of the presented data’s shortcomings and the context in which the study’s conclusions may not apply. Each module is fully scripted, so that presenters require a minimal a priori familiarity with a given topic and we strive to make each presentation deliverable and under 10 minutes. Like standard  M&M, the heart of the curriculum are the cases. We have a case bank on our website and in the individual PowerPoint presentations and it includes hypothetical scenarios that draw from the contributors personal experience, existing literature and social media. We have purposely selected a wide range of perspectives and perceived levels of harm to avoid including only the most egregious examples, and we have several aims with this approach. First, by supplying a standardized case bank, we hope to avoid any of the accusatory overtones that may accompany specific instances related to be discussed at your institution. At the same time, we hope that by accurately reflecting how cultural complications manifest in everyday life, and by giving people space to discuss similar experiences, that we’ll raise awareness about the frequency of this kind of behavior, and also establish a group consensus that this is not acceptable, decrease its overall incidence, and help the group develop strategies to better respond. So over the last year, we piloted this approach at both the University of Maryland and the University of Michigan, and in both the lead up to deployment and its actual delivery, we have learned a tremendous amount. So first, if you’re someone somewhere towards the bottom of the hierarchy, as I very much was when I attempted to start this at my home institution, you need to find a local champion. Some eyerolling is inevitable. Not everyone will be a fan. However, a champion, particularly someone in a position of power and perhaps outside the standard “go-to” diversity leaders, you can introduce the curriculum and then backing sends a strong message that this work is important and may help dampen some of the more vocal critics who could create a chilling effect on participation. This also speaks a bit to who should deliver these talks. Our pilot experience has demonstrated that inviting leaders in the department to give their first few sends a message that this is important, and then opening it up to residents and students, it sends a message that everybody can participate in this discussion. It is also important to know your gatekeepers and invite them in. Thanks to some really great clinical champions, the rollout at Michigan was fairly smooth. However, my experience was much rockier. Most notably, when I opened up our inaugural session for questions. The first one I got was from one of the moderators asking why was I wasting m&m time with this? Now, I’m happy to report that after a lot of work, the reception has warmed, considerably. But I’ve encouraged anyone who thinks that they might be facing a more skeptical audience to try to meet and seek out these individuals ahead of time, go over the curriculum with them and try to make them part of your team. One of the mistakes that I have made early on with that – I thought that notifying emails were enough and they categorically were not. You need to actually talk to people, put yourself on their calendar and show them what you’re planning to do and why. If you don’t, you risk losing what could have been a productive and private conversation into a very public and potentially destructive one. Our somewhat computational debut also taught me that you need to be able to adapt. As I began to play catch up and work to better understand the opposition, one of the major critiques that came to light was that the curriculum focused a lot on the provider experience, and M&M was supposed to be a time for patients. So I was able to say, okay, I can find more studies, I can focus the data in a new direction. I can shift the scenarios to send our patients. And before the next session, I sat down with everyone, went over all of my slides, made all of the suggestions that everyone requested. Now, if I’m being perfectly honest, there are times in the darker and more exhausting times of residency where I want to stomp my feet and yell that I should just be allowed to do it exactly the way I want to. But if you’re unwilling to bend, to include your critics, you might be shut out entirely. And had I taken this approach, I would have missed a really important opportunity to expand the curriculum and make it applicable to more institutions. There are also a lot of less contentious ways that you need to be able to adapt to your organizational needs. At Maryland, some of the foundational concepts like implicit bias, or microaggressions, were fairly new to a lot of the audience. So we really need to build a common knowledge base before we could effectively discuss the cases. In contrast, a surgery department at Michigan had been talking about these topics for years, so when they started, they actually found the didactic portion to be less useful, and wanted to spend more time on the case discussion. With this in mind, they would give everybody the fully scripted curriculum. We encourage local leaders to adapt to their specific environments, and to shorten or expand portions if necessary. You also have to be mindful about how you cultivate participation. We recognize that jumpstarting discussions on thorny topics can be tricky, but it helped each case comes with some suggestive prompts. Much like medical M&M, we include points regarding how individuals could have responded better what they would hope to do differently in the future, as well as questions examining how the system needs to change to improve behavior. We would suggest that early deployment for particularly for anyone who thinks that they may be facing a more skeptical audience, organizers may want to let people know what the prompts are going to be ahead of time. And this is not necessarily to create a propaganda machine, but so that people can prepare their thoughts to jumpstart the discussion. And particularly depending on how formal your M&M is, and particularly if you had an event like mine, where the reception is a bit chilly, it can make people a bit reticent to speak out. So having departmental leaders who are prepared to talk at the early ones can help set a culture that will allow people to participate. It is also important to understand your ask. Unfortunately, academic medicine is not a very diverse place. So when you’re talking about issues of diversity, equity and inclusion, the natural tendency may be to draw on the same people over and over again. And this repeat sampling is taxing in and of itself, (the Lorax speaking for the trees). But as we discussed on our modules and gender schemas, success in academia is often tied to conforming to a gentic, white, male heterosis norms. So asking members of your community highlight aspects of their experience, or their identity that they may have actively tried to downplay and be unfair and in some environments unsafe. Furthermore, being expected to be the voice of your community over and over again, can be extraordinarily difficult. As we continue to deploy the curriculum, we also become acutely aware that we don’t have all the answers. One of the key questions that the Michigan experience in particular has highlighted is how can we holistically support our participants. Bringing up instances of discrimination in a public forum, asking people to tap into their trauma, and not always having great response strategies is a challenge. 20 minutes is not a lot of time and some participants have felt that they’ve opened up painful wounds, and then are expected to go right back to their clinical duties without a lot of follow up. So we are still working on how best to fix that, whether it’s identifying faculty members who’ve expressed interest in continuing the discussion offline, voluntary sessions in the evenings to pick the conversation back up, or perhaps everyone’s favorite,  online resources. But I encourage everyone who wants to implement this curriculum to think about this process and try to integrate that into your deployment as well. One of the other issues that I personally have struggled with is how do you educate yourself or your group without pretending to speak for someone else. For example, we have a module on intersectionality. The idea that being a woman of color brings with it a set of compounding challenges that are different than those experienced by all women, or just shared by people of color. As I have explained, I don’t really have an intersectional identity. When it came time to present this module, I was worried about the line between raising consciousness about the concept and being the voice of someone else’s oppression. So what I ended up doing was reaching out to members of my department and inviting them to engage to the extent that they wanted to. And as I build new modules that continue to be more outside of my area of expertise, I try to get critiques from people with lived experience – kind of a “nothing about us without us” approach. But this once again, does place the burden on the very people contending with bias. And it remains an area that I still feel a lot of trepidation. And so ultimately, the curriculum remains a work in progress. But we think that it can be a very powerful tool in helping departments learny, face their own shortcomings, and improve the environment they create for the patients and their providers. It’s currently freely available at our website, and today has been requested by over 170 departments both in and outside of surgery and across several countries. So we are very hopeful that this will help them take the first steps towards improvement. And with that, I will say thank you and invite any questions.

Ameer Farooq  1:01:29

Thank you so much, Dr. Harris, for talking to us about your experience. And I can only imagine the courage that it takes, particularly as a resident to do the work that you’ve done. So congratulations to you about all this. I’m curious about some of the logistics of this. You talked about the fact that you held an M&M rounds in the same time, same place, sort of the same format. Does it matter the venue? Like you know, this is obviously a very different kind of discussion. And really, a lot of what’s happening here is playing into the broader conversations that are happening within our society. So was are there any key things that you did even logistically, structurally, within the room that you found were really important in doing this?

Chelsea Harris  1:02:25

Yeah, so I think the setting is really important. People often ask, you know, can we just do this for the residents? Or can we just do this for the medical students. And I think there’s some amount of flexibility to take the time that you’re given. But I really do believe that having this in M&M is a really important component of it. Because there’s very few other places you have all levels of a department coming together, and you have people who may not be getting this content in any other format. I will say, I didn’t go into it in today’s presentation, but zoom is actually offering some really unique and new opportunities for this curriculum. I think it gets rid of some of the trepidation people may have in raising their hand and saying yes, this happened. Something like this happened to me. You have some anonymous functions, which allows people to ask questions to the moderator that they maybe didn’t feel all that comfortable asking in a format which requires some finesse on the part of the moderator. But I think it really gets through some of the first step barriers of people participating in this sort of thing. And as we get more sophisticated in integrating polling functions to say, you know, what percentage of you have felt something like this. I think, really helps overcome this idea that this is not an “us” problem. We are nice, and we treat everybody the same. When in reality, it’s an everyone problem. And even if you’re good in one category, you know, as I tried to highlight when I started, like, I knew a lot of the gender stuff, I knew very little on sizeism, or ableism, or many other things. And I really had to educate myself on those things.

Ameer Farooq  1:04:01

Dr. Kortbeek, who’s one of the faculty in Calgary asks, “Are there adopting departments using primarily cultural complications as is? Or are they tweaking it significantly? Or are there other examples of things that people have done with the curriculum that you’ve seen kind of rolled out?”

Chelsea Harris  1:04:25

Yeah, so I think we’ve gotten a couple of different feedback. We are actively trying to survey this. It sort of exploded a little bit faster than I was prepared for. So I’m trying to retroactively fit a survey component as part of it. I think it depends on where the department was to begin with. So I think places that have been doing this work for a while are modifying it a bit more, and they’re really just using the cases. But for example, MD Anderson adopted it and they were sort of where Maryland was in terms of understanding some of the exact terminology. And they used it as is. So I think it’s really kind of what your department brings to it. And we really want it to be as adaptable as you need us to be.

Ameer Farooq  1:05:13

Dr. Harris, thanks again. And hopefully we can have some discussion at the end of the session as well and get some more questions from the panelists and the participants. But I’d like to, in the interest of time, just move to Dr. Finlay’s presentation. So Dr. Finlay, take us away.

Christian Finley  1:05:36

Dr. Harris, that was amazing. I will happily adopt that into your local champion. So I think whoever that was that shut you down has been on the wrong side of history. And I was a bit reminded of… I once saw a 100 year old physician present, and he talked about all the things that had changed in his lifetime. And he was talking about all the things that had changed; immunization, antibiotics, and he put up the whole list. And he looked up and he said I was against them all. And you know, I sort of think that is sort of telling sometimes: when you get resistance that you’ve hit on the right thing. So, what I would say is I have nothing to declare. And a lot of what I was going to speak to you about has been spoken to beforehand, but I will try to editorialize as I go about my perspective on data. You know, I’m a third generation thoracic surgeon, my grandfather was a thoracic surgeon, my dad’s a thoracic surgeon, I’m a thoracic surgeon. And I have my grandfather’s operative reports from the 1940s, where he was doing one of the first pneumonectomies in Canada. And he was doing it through the eighth intercostal space, which is about two spaces too low, maybe three. He does it backwards. So he took vein bronchus artery, he sutured the pulmonary artery with chromic gut. And at the conclusion of his operation, he says, “no, I don’t think that this was the easiest way to do this operation”. And clearly he was giving a message to himself on next time, don’t do this. And I think that’s really what we do as surgeons to each other when we’re teaching. I think that’s what you do when you read a textbook. And I think that’s what we do in M&M rounds. In its best format, you show what’s happened, either something really severe, or something really common, you review what’s the best out there, and you try to make sure the next patient does better. And I think that we all, when we’re participating in the successful M&M rounds, we know that. But I think, as has been, you know, elucidated so many times, either the data isn’t good, or the participants aren’t engaged, or the outputs aren’t what they could be. And I think that’s what I’m hoping to speak to both in general, but also specifically with regards to data. So I think it’s really about quality improvement, about breaking down those silos. But I also think it’s about fostering that sense of community. And I’ve heard it said by Dr. Harris and others that, you know, if the chair is for it, everybody gets onside, or a local champion. And if people are out there sniping it, it’s in trouble. So, I went in Vancouver General Hospital, when I came back from my MPH at Harvard, I presented on surgical timeouts before it was presented in New England Journal, and before it was anything, and I got eviscerated. And I think that we need to take those opportunities to take those new ideas in and to foster that sense of community because it’s amazing the ideas that can come out. Because there’s real costs, both human and financial. And there’s innumerable papers that try to quantify how expensive it is to have a run of atrial fibrillation, how expensive it is to have a wound infection. But suffice it to say, it’s a lot. And the lower complications you can have, the better you do. I’d liked when Dr. Hameed was talking a bit about technical prowess, and I think that, you know, I’ve seen that reproduced in bariatric surgery, thoracic surgery, general surgery where clearly like anything, there are people who are very good at their jobs. But I would contend that there’s a lot more to it about everything else wrapped around the person. But the Ameer Gaffey paper in the New England Journal talked about high mortality and low mortality hospitals having the same complication rates, but it’s really your ability to rescue a patient that minimizes the downstream trauma. And I think that that’s what we’re talking about with complications is both minimizing the chance of them happening but also the team wrapping around the patient to minimize those errors. You know, I think that they do need to be regular and scheduled. Certainly any time in my life that I’ve tried to do things, like going for a beer with a friend or going for a run, they seem to fall apart when I leave myself the opportunity to do it PRN. And so I think that it needs to be put in a schedule and held to that schedule. I do think the data, which I’ll get to in a secondy, is fundamental. And I think that we all want to have NSQIP or some really comprehensive, systematically captured data that somebody else does. But in reality, there are a lot of good sources of data that are cheap and available. And I think that administrative data sets has its uses. I think that pathology has its uses. I think that even anecdotes have their uses. But you need to make sure that you get data and not just one source of data, but have an open mind to all the potential useful sources of data, whether they be really high level or really low level. I do think that you need to go through them in a structured format. And I do think you need to have specific outputs that are written down and circulated. I know M&Ms are the ultimate audit feedback system. And if you don’t write something down and disseminate to people with a specific action plan, then the chances of it becoming something are much lower. I do think that you need to mandate attendance. You know, I’ve certainly again participated where, as has been said before, all the people that you want to be there that could learn the most aren’t there and all the people that, even if they don’t know how to be culturally competent, are at least going to try show up. And so to some extent, it just speaks to team leadership. To really make sure that everybody shows up. And I think that M&Ms can be broadened beyond the one institution. You know, I think that when you work in a practice that has two physicians, two general surgeons, four general surgeons, six general surgeons, you’ve probably heard each other’s stories pretty quickly. You know, if you don’t have residents and medical students to reinvigorate it, by bringing in the respirologist, the thoracic surgeons, the anaesthetists, the nurses partnering up with a spoken hub model with other institutions gives different opportunities. In thoracic surgery, as I’ll speak to in a second, we have created a national database. So we capture the same stuff in Hamilton that they capture in Vancouver, that they capture in Ottawa. And you can make the same thing from NSQIP. But we do regional and national rounds. And so we have positive deviance rounds that are not defined to a single institution. And I think that has been very powerful for us. We’ve done it in a positive format. And so it’s positive deviance, we celebrate the best. Though we show all the data and you know who you are. But I think that also it allows you to look between institutions and that natural sense and desire to improve pulls you up. Ottawa has really gone through and has quite a nice documentation on a newer approach to M&Ms included. They went through some soul searching. And I think it’s worth a good read, for those that are interested in this subject as a good way of thinking about it. And so I pulled our M&M rounds off my email. So our M&M rounds are generated from our national database. And we employ a half time FTD person to capture all the data for the biggest thoracic center in Ontario. And it automatically populates our M&Ms and it has made our M&Ms incredibly more powerful. We instantaneously know what our conversion rate is, what type of minimally invasive versus open operations we’re doing. The elective versus emergent operations. We know our complication rate overall. We know multiple complications to the same person. We know high grades and low grades, we quantify on a clavien dindo scale, our complications and we do nationally as well. And so you know how many low grade and high grade complications. You can compare that to historic norms. And you can drill down on specific pulmonary complications, and you just plug in. You can go down to gastric complication diarrhea. You know how often it happens and how we do relative to our peers nationally and regionally. As well as case adjusted. We’ve pulled out and identified what we think are key variables that we need to keep an eye on prolonged air leak, readmission, return, unplanned OR, unplanned ICU. And if we have a blip, if we have a signal to our noise, or if we’re different than our peers, then we discuss that. So we discuss all grade five, which are deaths, all grade four, which are return to the ICU, and anything that is above historical norm. So that is how we quantify our M&Ms. But you can do that with NSQIP. You can do that even with administrative data sets. Administrative datasets are very good at capturing critical care, bed usage, death, obviously, length of stay, and all those things are useful things to talk about. Administrative data sets aren’t particularly good at capturing complications. And that’s where I think something like NSQIP is better. And I think a disease site specific database like we have is even superior to that and capturing really robust data. Coming out of that we make sure that we look at patient factors, provider factor, system factors, and then we have specific recommendations which are distributed. And we follow up with them at our business meeting. So we try to make sure we have action items from our each of our M&Ms and then circle it all back. And we have noticed a reduction in our complication rate associated with this. And certainly when we did trials when Ottawa, which led this for us nationally to trials, they showed a statistically significant reduction. Atrial fibrillation and an anastomotic leak by just doing a positive deviance, and seeing how they progressed with time. So I do think M&Ms can be quantitatively impactful on patient care. And we’ve tried to replicate and have replicated their work and are trying to do that nationally. Now I wrote up a white paper really looking at resource risk, high risk intensive cancer surgery and showed that in Canada, your chances of dying from an operation can be double or triple, depending upon the institution and province you live in. But I think that equally importantly, the flip side of that is your access to care is also dependent on where you live and where you go. And when we look internationally. So I also am on the international clinical benchmarking trial, Canada lags in a number of different disease sites and how we’re doing. We’re improving, but we’re certainly not the best. I mean you might say, okay, well, we’re near the top. We’re doing reasonable compared to all these single pair centers, fine. But each of these green dots is a province in Canada, we have a bigger difference within our country than they have internationally on outcomes for cancer surgery. And you could extrapolate this to anything. I have the numbers for institutional MIS rates for colorectal cancer, showing that your chances of getting an MIS colon vary from 0% up to a national average of about 70%, depending upon the institution you live in. That your re-excision for breast cancer, if you have a breast cancer lumpectomy can vary from an incredibly low number to seven times that depending upon where you live. And so all of those things are worthy of discussion. And I think an M&M is a great spot for them and that data is available. And to go back to my previous point, it matters that when we look at who lives from cancer, it depends on who gets access to curative surgery. And if you don’t have the same access to care, and it’s directly attributable to how we deliver care, it’s very impactful. I do think we tend to focus a lot on outcomes. And part of the other conversation should be access to care. That we are the single best way of curing people from cancer as surgeons, and that we need to make sure that we are at the table and advocating for it. And if our local results aren’t there, we need to use that. And I think that’s something that data is very powerful for. And so just to show you that each of those is a province in Canada, and the five year survival is directly proportional to resection rates for lung cancer, pancreatic cancer, colon cancer all across our country. So we have variability that requires attention. And we can benefit our patients for that. This is data that is accessible to all of you. If you just go down to your little people down in the basement and ask them to extract some data for you, this is the readmission rate. But suffice it to say, two thirds of our patients come to our hospital, but 1/3 of them go to a different hospital. And our readmission rates can vary by 50%, depending upon where you live. And so we have, again, a single payer system, we have reasonable health home care. A lot of people come back into hospital, almost 15% after major surgery. And often they go to another center. And in some of the research we’ve done, the chances of dying is actually quadruple if they go to their non index center. So I think all of these things are data that is at our fingertips that are worthy of conversation. And those complications. So this is a blowout of the complications of the reasons people go to the emergency department who get readmitted – almost all of them are directly attributable to their operations. You know, some of them are unrelated but most of it is pneumonia if you’re a thoracic surgeon, urinary retention if your prostate surgeon and bowel concerns. And then also that people die after they leave the hospital. Our mortality for major cancer surgery in Canada has dropped by 50% in the last decade, which is laudable, but our post discharge mortality is now over what our in-hospital mortality is. And you’re more likely to die after you leave the hospital within 90 days than you were in the hospitalization. And the we have not improved that at all. So I think that’s the next bridge to cross for for us: that our care does not stop at the doors of the hospital. Our care extends out there. And I do think that the M&Ms should have a comprehensive, both pre and post. So we developed standards that I think speak to this and part of those standards really talked about that. The data collection and continuous quality improvement is really something that we as surgeons do, and that our techniques are going to change with time and we need to evaluate ourselves so that when the next MIS, the next robot, the next poem, the next whatever comes along, we need to be pushing that envelope. But we also need to be seeing how we’re doing and discussing it. And so I think that you do need to continuously capture your data and talk about it and have it systematically evaluated. And so, you know, looking with all the national societies, we put out very recently, this pan Canadian action plan on optimizing surgery. And yet again, Pan Canadian benchmarking and data driven quality improvement, I think are fundamental to where we’re going in the future. And I think it’s something that we need to do, that we need to prioritize. It doesn’t pay, it tends to go after hours, we’re tired. You know, if you don’t have residents to do it, or other data extractors to do it, it can be problematic. And we don’t want to have the point where it is thrust upon us. And I do think it’s something that we need to do for all the reasons that have been discussed today. So I’m going to leave you with John Cleese. And he was talking on a TED talk about what it takes to be creative. And I think that you could say the same thing for quality. In this case, M&Ms. That you need space, you need time, you need to give your brain the ability to think about the problem and not just push for it. You need to have confidence that you’re going to do it. And then you need to go out with humor, because I do think that we have a very serious business. And it can be completely overwhelming. But I do think that our culture of surgery is actually very supportive of each other. And one of the reasons I miss CAGS and I miss CATS is I miss my friends. I missed seeing people and sitting with them after being in between sessions or ad sessions, talking about things and talking about those complications, talking about those challenges. And I think that that in its best form, that’s what M&Ms are for. So I would put it back to you. Although I was going to somehow crack a joke about on the bottom of Dr. Hameed’s slide, he had the best coach, on the bottom was Brett Brown, he seemed to lose almost everything, and have a very short career. So I think the next time in M&Ms, we can talk about Brett Brown.

Ameer Farooq  1:22:10

Thank you so much, Dr. Finley. As usual, fantastic talk, and I just love listening to you and love listening to the way you think about things. So, you know, I have a few questions for everyone. And I know we’re kind of getting towards the end of the session tonight. And thanks everyone for joining us. But I will pose a couple questions to Dr. Finley. So the one thing that’s been interesting from hearing everyone speak today is just that so much attention to the system wide culture, and really thinking about the system and how we improve the system. How do individual M&M cases factor in? So, if there’s a bad outcome you have to take someone back. Are those cases that you actually discuss? Or are you, when you’re doing your M&M rounds, just looking at the statistics or the data? And how do those two things intersect? Because, you know, I do wonder about where that rule is for actually putting some education or some attention on the individual again and seeing how we can improve as individuals as opposed to just looking at the numbers across the system?

Christian Finley  1:23:26

Yeah, no, it’s interesting. Like, I do think that all significant and frequent problems should be discussed. You know, I think that and I like having metrics like NSQIP where you can see how you’re doing relative to your peers. Because if you’re waiting for deaths, it happens very infrequently, you know? The mortality even in really bad operations is quite low. And so if you’re looking for a signal on mortality, it’s not going to happen. So, I think that you need to talk about those. But I do think that you have to keep your eyes out for things that you can do better. Modifiable factors. Have the humility to discuss them. And it’s really hard. We try to not pick on people. I think in the spirit of ethos, we try to look at those positive examples as well. But we’re sometimes sensitive to the morale of the group if it isn’t critically important to discuss. But I do think that you need to dig into those difficult conversations and give yourself the time to do it. You know, I hate when you spend the first 90% talking about something inconsequential, like the MIS rate, though that might be consequential in different contexts. And then you have something really important and awful to discuss. And the OR starts at 8 you start the discussion at 745. Like it’s just, you have not left that sufficient space, which is why I try to talk about it. So I do think that when there’s important things to talk about, you should flip it on its head and start with the important things and not get bogged down in the process. Because in so much time, there’s showmanship or pomp and circumstances are the crescendo to the conversation. And in reality, you need to give the time. So I think that you need to be sensitive to that.

Ameer Farooq  1:25:10

I do want to pick up on one one aspect of your talk also, that I was hoping you could expand upon, which is sort of the positive deviance rounds. How do those positive deviance rounds work for those of us who haven’t seen them? Because it just sounds like a fantastic idea.

Christian Finley  1:25:28

Yeah, so we’ll present anonymized institution or practitioner data and say, who’s got the best a fibula? You know, so it’s a waterfall plot. And with everybody’s consent, we will unmask the best person or the best couple people and say, “what are you doing”? Like, oh, I always correct the magnesium of the patient. I’m really aggressive about doing minimally invasive surgery, because that’s been shown to have less a-fib. And I do blank. And then we have a conversation. And we usually prep to have a talk on the evidence behind atrial fibrillation. And so you talk about the evidence, we show our results, we show the best person to talk about their things. We come up with specific recommendations that are then cycled to everybody to have a conversation. And in our particular model, those are then done across the country at different institutions. We correlate them and then we do a national meeting about the same topic with atrial fibrillation. And so everybody’s talked about it locally, and then you see which institution is doing the best, and then they talk about it. And then we measure. So it’s actually a very fun way to do it. You can’t solve all problems that way. You know, if you have to discuss a really bad outcome, you have to discuss a really bad outcome. But it’s a nice way to frame it positively, allow that building up of people. And interestingly, it’s never the same person. And it’s never the same institution. And you know, it’s the same when I did my report cards. I’d start out saying, you’re bad at some things, you’re good at some things, let’s talk about it all. And it’s the same with this. It’s so nice that you know, our best length of stay was different than our best a-fib, which is better than our anastomotic leak. And so everyone got their moment to shine in the sun. And it allowed for that evidence based conversation. It really sunk in because it was personal.

Ameer Farooq  1:27:18

That’s fantastic. Once again, I’m conscious of the fact that we’re over time here. But I did want to ask Dr. Harris, sort of a final question on this, and this is a sort of a two parter. The first is, you did talk a little bit about your response. But I’m curious about how things have evolved, especially since you shifted from your work in Michigan, back to your home institution, and what that response has been like. And my second part question to that is, you started off with a curriculum of general cases. But you know, in the spirit of M&M rounds, do you ever think that there will be a role for actually discussing real institutional problems? Or using real examples of things that have actually happened? And how do you see that playing out? Or do you think that maybe that’s not a wise way of approaching this?

Chelsea Harris  1:28:11

Sure. So I’ll briefly touch on both of those. So one, I’ll say one of the things that have been has been most encouraging to me is that the reception to this changed tremendously. And so even the person I spoke about, who called me out at the beginning, I had been away at one of our partner institutions for a couple months. And so I had paused a little bit. And he sent me an email saying, when are we going to restart this? I think that’s really important. And I’ve had people, you know, attendings, you came up to me and say, you know, when you first started this, I thought I was kind of fluffy and kind of nonsense. But I’ve seen it, and I think this is starting to be important. And one of the other parts that’s been an important learning aspect for me, was, we still don’t always have the most robust conversation in the room. But I see that people are having these conversations and shared spaces. We are having the conversations around the cases at the start of the OR, or in the downtime and that people really are taking some of the message and thinking about how it relates to their own experience, or their trainees experience or, you know, becoming better advocates for one another. So I think that all of the learning and all of the progress doesn’t necessarily happen at that specific M&M, but it opens the door to being more receptive to that. The second part, we get asked this question a lot about “should you present from actual experience”, and I will say, I have yet to participate in one of these where someone hasn’t raised their hand and said, oh, something like this happened to me in this respect, or here’s the aspect. So I think having the standardized case doesn’t really matter all that much because they’re meant to be so recognizable, that it resonates with people’s experience, and that way it takes away the perpetrator. So you don’t have the, this doctor said this to the trainee, and everyone’s trying to figure out who it was that set it. Rather than focusing on it, you can say, this is kind of the standard and the people say, oh yes, I had that this week, or I had that last week, I witnessed this. I didn’t know what to say, and what would have been better. Or you’re in clinic and someone says something inappropriate to the resident. I was the Attending and I didn’t know what to do. I think not having the exact specifics, doesn’t detract from it at all. But certainly people like when we presented this at UT Houston, and one of their medical students had an experience that he wanted to share, and he wanted to discuss. That also gives people an opportunity to process some of the more traumatizing things that may have happened to them, and help get some resolution as well. So I think once again, you can really customize it to your individual departments and needs.

Ameer Farooq  1:31:01

Well, I was overjoyed to have all of you on the session. Dr. Hameed had to leave a bit early, so we couldn’t ask him any more questions. But thank you once again for joining us today. And thank you again to the Canadian Association of General Surgeons for allowing us to put on this session. And have a good evening and everyone stay safe. Thank you. You’ve been listening to Cold Steel, the official podcast of the Canadian Journal of Surgery. If you’ve liked what you’ve been listening to, please leave us a review on iTunes. We’d love to hear your comments and feedback. So feel free to email us at, or connect with us on Twitter @CanJSurg. Thanks again.