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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1498_Библиотеки_им_академика_М_И_Перельмана.pdf
xx
Contributors
E. Matthew Ritter , MD
Division of Academic Surgery, Norman M. Rich Department of
Surgery , Uniformed Services University/Walter Reed National
Military Medical Center , Bethesda , MD , USA
John R. Romanelli , MD
Department of Surgery , Baystate Medical Center, Tufts University
School of Medicine , Spring fi eld , MA , USA
Michael J. Rosen , MD
Division of GI and General Surgery, Department of Surgery ,
Case Comprehensive Hernia Center, Case Medical Center,
Case Western Reserve University , Cleveland , OH , USA
J. Scott Roth , MD
Department of Surgery , University of Kentucky College of Medicine ,
Lexington , KY , USA
Karla Russek , MD
Department of Minimally Invasive Surgery , Texas Endosurgery
Institute , San Antonio , TX , USA
Marc H.F. Schreinemacher , MD
Department of General Surgery , Maastricht University Medical Center ,
Maastricht , The Netherlands
C. Daniel Smith , MD, FACS
Department of Surgery , Mayo Clinic Florida , Jacksonville , FL , USA
Nathaniel Stoikes , MD
Department of Surgery , University of Tennessee Health Sciences
Center , Memphis , TN , USA
Chee-Chee H. Stucky , MD
Department of General Surgery , Mayo Clinic Arizona , Phoenix , AZ , USA
Malini D. Sur , MD
Department of Surgery , Mount Sinai Medical Center , New York , NY , USA
Daniel E. Swartz , MD, FACS, FRCSC
Department of Surgery , Central California Institute of Minimally
Invasive Surgery , Fresno , CA , USA
Victor B. Tsirline , MD, MS
Department of Surgery , Northwestern Lake Forest Hospital ,
Lake Forest , IL , USA
xxi
Contributors
Jignesh V. Unadkat , MD, MRCS
Department of Plastic Surgery , University of Pittsburgh Medical Center ,
Pittsburgh , PA , USA
Guy Voeller , MD
Department of General Surgery , University of Tennessee Health
Science Center , Memphis , TN , USA
Part I
Essentials of Inguinal Hernia
3
B.P. Jacob and B. Ramshaw (eds.), The SAGES Manual of Hernia Repair,
DOI 10.1007/978-1-4614-4824-2_1,
© Springer Science+Business Media New York 2013
1. Establishing a Hernia Program
and Follow-Up Regimen: A Complex
Systems Design for Care and
Improvement
Bruce Ramshaw
It is tempting to write a chapter describing the development of a
hernia program in the traditional “center of excellence” model. In that
model, there would be criteria developed for certi fi cation, documented
protocols, and standardized process and outcome measures reported to a
national regulatory group. This has been the model for bariatric surgery
programs for the past decade. However, there is growing awareness that
this “center of excellence” model, while helping to prevent extremely
poor care, actually fosters mediocrity and inhibits positive innovation.
By implementing standards and static criteria as well as requiring
resources focused upon reporting, attention is often placed on maintaining
the status quo rather than on continuous learning and improving. The
transformation to a sustainable health care system will require us to
design programs around patient problems in a way that allows for
continuous learning and improving, facilitated by a diverse community
that includes the patient and family.
The “center of excellence” model is also designed either around a
limited portion of a patient’s cycle of care and/or based on a particular
physician specialty, rather than the entire cycle of care from the
perspective of the patient. To understand why we need to evolve beyond
the “center of excellence” model, it might be helpful to understand how
our global health care system has become unsustainable in its current
form. Our health care system has become what it is today through a
complex history involving the evolution of hospitals, physicians, nurses,
and other specialties, combined with insurance policies and other health
4
B. Ramshaw
Fig. 1.1. Average health care spending per capita in many developed countries
over a period of almost 30 years. Although the total spending per capita varies
country to country, the overall spending trend over time (the slope ) is similar for
every country. This result re fl ects the predictable output of a complex system
(our global health care system) where each part of the fragmented system is
focused on revenue growth and pro fi t margin (or bond rating for nonpro fi ts). The
system is producing the result (unsustainable costs) that it is designed to
produce.
care laws, enacted in an attempt to help people be able to afford and have
access to health care. Over time, the health care system has grown to
become almost 18% of the US GDP. A look at other developed countries’
spending on health care shows that, although they do not spend as much
on total health care costs, the trends of increasing costs are essentially
the same (Fig. 1.1 ). This represents a global health care system designed
for the revenue growth of each part rather than for optimizing the value
of the health of a population, including the entire patient cycle of care
and the health care system itself. In addition to care givers and hospitals,
a variety of industries within health care, led by the pharmaceutical
industry, have grown to serve patients by providing diagnostic and
therapeutic intervention and have also been successful in creating a large
amount of wealth for a relatively small group of shareholders and top
corporate executives. It is this fragmentation, with each part focused
5
1. Establishing a Hernia Program and Follow-Up Regimen…
primarily on its own optimization, which has led to the current
unsustainable situation in health care. [ 1, 2 ]
There are many other parts in the system that extract pro fi t and
resources which I will not describe (medical publishers, general
purchasing organizations, etc.), but even with the few components
mentioned, it is evident that the system inherently functions by attempting
to optimize and protect its parts. Hospitals work to optimize hospital
performance and maintain pro fi t margin and growth targets; physicians
focus on the fi nancial needs of their individual and group practices as
well as the portion of care they provide for the patient based on each
physician’s specialty. In addition to these providers of care, pharmaceutical
and other health care companies have a fi duciary responsibility to
maximize shareholder pro fi t while they are producing products to be
used in patient care. An understanding of complex systems science
makes it clear that when each part is attempting to optimize itself, then
the whole process (in this case, the hernia patient’s entire cycle of care)
WILL NOT be optimized [ 3 ] .
Complex systems science also helps to explain why one type of
treatment or device (such as hernia mesh) can be bene fi cial to one group
of patients but cause harm to another. During the past decade, with the
help of a dedicated hernia team and in collaboration with many hernia
experts worldwide, we have discovered the complexity of mesh used to
repair hernias, and just this one example is a re fl ection of the increasing
complexity of the world, in general, and health care in particular. When I
started residency (1989), there were basically a few meshes available, and
today there are hundreds. Most importantly, the same mesh used with the
same technique in two different patients can have signi fi cantly different
outcomes. This variability is due to the fact that we are all (caregivers,
patients, and the health care systems we function in) complex adaptive
systems. The concept of complex systems means that outcomes are
variable and dependent upon many variables, as well as the interactions
between them. The design for organizations attempting to optimize the
value of a complex system is very different from one that is designed to
optimize the value of a simple system (in which the cause and effect are
directly related and predictable—mass producing one type of hernia mesh,
for example). For a simple system, the parts may be optimized to improve
the entire process for a predictable, repeatable output. For a complex
system, many parts may need to be suboptimized and all the interactions
between the parts need to be managed, measured, and continuously
improved. This allows for optimization of the whole process and output
(providing care for a group of hernia patients, for example) [ 4 ] .
6
B. Ramshaw
Developing an Academic Hernia Program
The core concept behind the development of a hernia program using
a complex systems approach is the design of the program with a new
organizational structure. This must be one which provides person-
centered care coordination with the implementation of continuous
clinical quality improvement (CCQI) cycles. If these are developed as
the essence of care delivery, it will drive increased value for both the
patient and the system itself.
A core component of care coordination is the development of person-
centered patient care managers. By facilitating patient and family member
engagement and responsibility, the patient care managers ensure that an
outcomes-based relationship is developed among the patient, their family,
and the care team. With patient and family engagement, better decisions,
better outcomes, and lower costs are more likely [ 5 ] . This patient and
family relationship continues throughout the entire cycle of care for the
patient, and of course, accountability is built into this important process.
The principles of care coordination and CCQI implementation
include:
1. Identify a diverse group of people to address the needs of a
de fi nable group of patients with hernia disease and hernia-
related complications and problems. This will make up the core
hernia team. Figure 1.2 represents the concept of a diverse team
designed around the needs of a de fi ned group of patients with
hernia disease and related complications.
2. Engagement and participation of patient and family in the care
process, as a part of the hernia team and a part of the extended
care community development (shared decision process for all
elective care decisions).
3. Continuous access to all information (patient record, dynamic
care processes, outcomes, etc.) for the patient and family.
4. Care coordination led by patient care managers who are
considered and treated as equal members of the care team. This
requires time to develop genuine relationships and trust between
all core team members.
5. Development of transparent, dynamic care processes based
upon best available evidence and which are continuously
improved, based on evolving evidence.
6. Development of outcome measures that identify value of care
for both the patient and the system: quality, satisfaction, safety,
fi nancial, etc.
7
1. Establishing a Hernia Program and Follow-Up Regimen…
7. Care processes and outcome measures are developed and
adapted to local environments and are continuously measured
and improved through the CCQI process locally.
8. The hernia team has the authority and resources to function
within this complex systems structure and is accountable to
make outcome measures transparent to governing boards made
up of leadership and the community.
This plan addresses the system structural problem of why our health
care system has not been able to evolve into a sustainable model, namely,
the vertical department and hierarchical structure of most health care
organizations in addition to the individual physician practice model.
These system structures have led to fragmentation of care, and as
complexity has increased, this fragmentation has led to poorer outcomes,
Hernia
Disease
Patient Care
Managers
Nurses
Internist/
PCPs
Financial/
Scheduler
Surgeons
Clinical
Quality
Improvement
Manager
Biologic/
Materials
Engineer
Design
Expert
Fig. 1.2. An example of a diverse team built around a group of patients with
hernia disease and hernia-related problems.
8
B. Ramshaw
less ef fi ciency, and more waste within the entire health care industry.
Recent attempts to improve quality, such as surgical site marking and
timing of antibiotic dose in suspected pneumonia patients in the emergency
room, have not led to signi fi cant improvement and, in some cases, have
caused unintended harm [ 6– 12 ] . Because these attempts are simple
solutions applied to complex problems and complex systems, they do not
provide signi fi cant or sustainable improvement. Addressing complex
problems within complex systems requires a different approach.
In person-centered care, the focus is based upon de fi ned patient groups
and problems rather than upon the physicians’ specialties. The care is
provided by diverse team members (including patients and family
members) with the different skill sets necessary to effectively meet the
needs of each patient group. For a person whose primary current problem
is related to hernia disease, the hernia team provides integrated management
for all care needs of the patient cutting across the traditional vertical
department model. Integrated management of multiple comorbidities has
been shown to improve outcomes [ 13, 14 ] . In CCQI, the cost of all steps
of the health care process for patient groups are documented and analyzed,
and the value is determined. This, in turn, is used to decrease the cost and
waste as well as to improve the outcomes of care.
To effectively implement the CCQI process, an understanding of the
patient processes associated with the entire cycle of care is necessary.
These work fl ows document the patient steps, resources, data, and
personnel associated with the care of the patient through the entire cycle
of care. The care process begins with fi rst contact with the patient and
continues through the return to maximum quality of life, which may
encompass the entire life span of the patient in some cases. One example
of a dynamic patient care process is represented in Fig. 1.3 .
One challenge in determining the value for these processes is to
determine the real costs for each step in each care process, termed
activity-based accounting. In “How to Solve the Cost Crisis in Health
Care” (Harvard Business Review, September 2011), Robert Kaplan and
Michael Porter outline a process by which the value of health care is
documented [ 15 ] . This involves determination of the true cost of care
through a seven-step process: (1) determine patient population to be
examined, (2) de fi ne the delivery care chain, (3) develop process maps of
care delivery, (4) obtain time estimates for each step, (5) estimate the
cost of supplying each patient care resource, (6) estimate capacity of
each resource provider, and (7) compute the total costs over the entire
cycle of care for a patient [ 15 ] . True costs of each step in the patient care