I was a spine surgeon at Northwestern University but before that I was in practice in both the private sectors and academic sectors, so I’ve done both of those. I’ve done research in both basic science and clinical. I’ve also helped develop medical devices and held intellectual property in that area. So that gave me a broad view of healthcare from the surgeon, researcher, educator perspective as the residency program director at Northwestern.
When I left practice, it was to go into government. In government I served as a high level and policy making and policy implementation in the federal government. I left that role in 2012 and went back to Northwestern as the Senior Vice President and Chief Medical Officer for the health system. Then I was recruited and joined in the parent company of five Blue Cross Blue Shield plans, a company called HCSC overseeing all clinical operations for the plans. That has given me a look at healthcare from virtually every sector. And I should include that I’ve been a patient, which is probably the most important perspective, because I’ve received care and had my children receive care. So, I bring a broad perspective. It doesn’t necessarily give you answers to all the challenges we face in healthcare in this country, and frankly around the world, but it gives me a pretty broad and balanced perspective in how all the stakeholders in the space see a problem. And that’s important, because something as interconnected as healthcare, its very many actors and web of relationships. Anytime you look at a problem and think about solutions, you need to understand what’s relevant, how it meets the need, and how it will work, for not just one area of healthcare but all the various areas of the healthcare ecosystem that intersect on that problem.
KW: Do you have a personal safety story from your time in practice? What were some of the lessons in how it changed your practice?
SO: I wish I only had one. We all have far too many safety experiences. Let me pick out one that is not only memorable but led to figuring out how to address the problem and a solution.
I was doing something that wasn’t all that uncommon to my practice, which was a revision scoliosis surgery. It was upper thoracic spine to pelvis revision. Those are always hard, long days. And along the way the patient became increasingly coagulopathic. We had normal conversations with anesthesia and they didn’t feel that things were getting at risk but they definitely looked uncomfortable to me. A lot of conversation. At one point, the patient became so coagulopathic that I said, “you know what, I think we’re going to call it a day.” We’re going to close and go have an unplanned staging of this procedure.
At the end of that, we all too often walk away, grumble to our colleagues, and complain about the hard case, and that’s kind of where it ends. But I didn’t want it to end there.
We ended up creating a Morbidity and Mortality review, had a sentinel event safety meeting at the institution for everyone involved. In the discussion, it increasingly became clear that this wasn’t the first time that it happened. In fact, fluid management intra- and perioperatively has been a point of contention between surgeon and anesthesia. It became clear that surgeons were managing it in one way and anesthesia was managing it in different ways. There was far too much variability and inconsistency in what was being done, and people in general were just not on the same page. It was like Groundhog Day.
So instead of bringing surgeons and anesthesia together, we decided to bring specialists from many fields. Obviously, spine surgeons from the orthopedic and neurosurgery fields, we brought in anesthesia, critical care medicine, hematology, pathology, and other related fields to look at this problem of perioperative management and in particular fluid and fluid resuscitation management to see what we could do to create a protocol to give us more consistent and better management.
It was interesting that getting hematology involved really changed anesthesia’s thinking on what was state of the art to manage fluid management and resuscitation. It made the surgeons look at what we were doing and how we were doing it. Everyone came away from that being much more informed. We made collaborative decisions and that ultimately led to what became the Northwestern Spine Anesthesia surgical protocol that created that consistent, state of the art management that improved overall patient safety and around the country and the world because many institutions adopted that protocol. So that’s a good example of a safety and management problem that was looked at thoughtfully and created a solution that improved safety.
KW: Thanks for being so transparent. One of the goals of S3P is to create a safe space for others to share and learn from each other’s experiences so that it doesn’t happen to the next patient. Shifting hats a little, you have so much perspective of the various stakeholders. How do you see the landscape of spine care changing?
SO: The landscape for spine surgery is changing because the landscape for healthcare is changing We’re seeing the whole country make a transition from traditional Fee-for-Service, volume driven incentive to some sort of incentive related to the value of care. People ask, “Gee is that really going to happen, is it really happening?”
Around the country, in my current role as a consultant, I see it evolving around the country. If you look at the state of Arkansas, the dominant payor is Blue Cross Blue Shield. They are moving all commercial contracts to a frame looking at physician efficiency. So it’s happening. You see this around the country. There’s a futurist, William Gibson, who has a great quote. He says, “the future is already here, it’s just un-evenly distributed.”
So, we’re moving to some value-based incentive. It’s going to look differently in different spaces around the country. I argue that this will be better for patients but also some physicians. But the first thing is what do we mean by value? Some people will respond that very differently, but I think a good definition of value is the quality of an outcome divided by the cost with caveat that the numerator can never get smaller and the absolute number must get bigger. We could have a longer discussion, but for the sake of time, I’ll leave it at that.
For spine surgery, it’s going to have some real challenges because we have a really difficult time showing what our outcomes are because we have a hard time with low back pain. Is it from degenerative disc disease, an unstable spondylolisthesis, and stable spondylolisthesis? Is it deformity? Is that deformity sagittal or coronal plane deformity? How much axial plane rotation is there? So, we’ve had a hard time. Spine is such a diverse set of patho-physiologies underneath that we’ve had a hard time categorizing real outcomes and demonstrating real value compared to other treatments.
If we don’t do that, then we are putting ourselves at a real dis-advantage because as imperfect as it may be, as we bucket things together into subsets that we can look at, and in doing that won’t give us perfect answers, if we don’t do it as spine surgeons, someone will do it for us. That is an outcome that won’t give the kind of answers that our patients need and will be good for the field.
The landscape of spine surgery is changing. It’s changing because the landscape of healthcare is changing. and we need to recognize the unique challenges of our specialty and be a part of the solution.
KW: What are the new rules of engagement for spine surgeons? Three things they can do that can help them get a seat at the table.
SO: To get a seat at the table, we first must be willing to have the conversation. Physicians in general, but specialists, have too often used outliers in terms of patients, exceptionalism, and how approaches to value and value-assessment aren’t perfect, as a reason not to do it. “My patients are different; what about this exception” but at some point, we need to accept that a good solution is going to be alright and we can’t wait for a perfect solution. The days of waiting for a perfect solution, whether its intentional or unintentional stalling are over or coming to a rapid end. If we fail to come to the table with other specialists to objectively assess how do we group patients, what are the outcome measures we’re going to use (albeit imperfect) with incremental improvement with how we’re assessing value, it’ll be done without us or at the very least surgeons will be included as a token. We complain about it and it’s happened, but unless we’re included in the conversation, like how to group patients, the indications for each group, and the best practices for those groups. If we don’t have the courage to do that, then we’ll be left behind. And I think those things:
- how do we group patients;
- how do you develop indications for those groups;
- and what are the best practice patterns for those indications.
We as surgeons need to be a part of that discussion and recognize it won’t be perfect. There will be some unfairness but being part of it will create a more accurate, fair approach then would be done without us.
Editors’ Note: This transcript has been lightly edited for clarity.
How Do You Take a Quality Approach to Surgery at Your Own Institution?
We’ve really taken a team approach, a multidisciplinary team approach, to look at how surgical outcomes have less to do with the exact technical parts of surgery but more to do with how we approach the patient holistically from the first interaction to well after surgery. In fact we’ve developed this with lessons from approach with an organized to optimize team dynamics and to remove cultural and organizational barriers to care. Our success has been outstanding.
What was this approach that you used? Was this a secret sauce?
CUSP (the Comprehensive Unit-based Safety Program) started as an approach from Johns Hopkins safety research on how they could develop safety techniques from high reliable organizations like nuclear submarines and aviation and apply them to how teams work in the operating room and ICU. It’s really inspiring how teams have taken on these concepts and applied them to their own concerns, own them, and develop processes with their frontline wisdom and experience to make care better.
How Has This Quality Approach to Surgery Impacted Patient Care?
We have patient coming from all over the world, problems which are extremely difficult and too high risk to help with. NYP takes and approach from the very highest levels with a palpable difference in the cultural feel on the importance of quality and respect for people. Important too is the bottom up approach of leveraging the power of the group, the wisdom of crowds for driving improvement.
We do over 300 surgeries a year, over 20 fusions a month, and we are a major referral center for children with complex pediatric spine problems. So, we’re extremely proud of our extraordinary track record. We would expect far more infections then we currently see. It’s not about the surgeon. It’s not about the technique. It’s about people, nurses, infrastructure, and organization change and leadership, the power of the team and the power of the wisdom of crowds. I’m really proud to facilitate that in this organization. So, we’re extremely proud of our extraordinary track record.
I really like how you mention both a top down and bottom up approach. What are some of the pillars that make up this philosophy around making care better and driving quality?
The hospital’s three tenets of extraordinary care—quality and safety, patient experience and great working environment for the staff—are evident from not only a full year without an SSI, but also the heartwarming letters my team receive from the children they’ve treated and their parents, and the dedication the staff shows to improving patient outcomes.
Using everyone’s commitment to make care better, we brought together a team to implement a framework that would bring our infection rate down to zero.”
By asking, “How will the next patient be harmed?,” we can figure out everything that’s wrong, from surgery starting late to a trash can placed too far away from a surgeon. We’re able to start with the day before surgery to prep the patient and the room and continue all the way to recovery. That reduces the harried need to compensate for mistakes, which lessens the chaos.
By jotting down every problem—big and small—the team creates mutual goals, such as to prep the OR earlier, start surgeries on time and decrease room traffic, which reduces potential sterility breaches. The early prep work breeds efficiency, ensuring x-rays hang properly, equipment is readily available and neatly organized, and trash cans are easily accessible but are not obstructions.
What about throughput?
We’ve increased flow of patients through processes, reduced inefficiencies and waste within the hospital, and hopefully made it a better and safer place to deliver the best care possible.
The results speak for themselves, but will they last?
“To sustain change, you need to create a sustainable culture. That’s what we’re doing when we listen to the voices of everyone on the front lines. The people on the front lines create the checklists, change what’s on the checklists and are given a voice.”
If you want to see long-lasting change in the system, there’s no better place to start than within your own institution and within your own team. This way, you may work to improve your quality approach to surgery.