Person:

Huckman, Robert

National policies to improve health care quality have largely focused on clinical provider outcomes and, more recently, payment reform. Yet the association between hospital leadership and quality, although crucial to driving quality improvement, has not been explored in depth. We collected data from surveys of nationally representative groups of hospitals in the United States and England to examine the relationships among hospital boards, management practices of front-line managers, and the quality of care delivered. First, we found that hospitals with more effective management practices provided higher-quality care. Second, higher-rated hospital boards had superior performance by hospital management staff. Finally, we identified two signatures of high-performing hospital boards and management practice. Hospitals with boards that paid greater attention to clinical quality had management that better monitored quality performance. Similarly, we found that hospitals with boards that used clinical quality metrics more effectively had higher performance by hospital management staff on target setting and operations. These findings help increase understanding of the dynamics among boards, front-line management, and quality of care and could provide new targets for improving care delivery.

OBJECTIVE: We hypothesized that increased post-graduate surgical experience correlates with improved operative efficiency and long-term survival in standard cardiac surgery procedures.

METHODS: Utilizing a prospectively collected retrospective database, we identified patients who underwent isolated CABG (n=3726), AVR (n=1626), MV repair (n=731), MVR (n=324), and MVR+AVR (n=184) from 1/2002-6/2012. After adjusting for patient risk and surgeon variability, we evaluated the impact of surgeon experience on cardiopulmonary bypass and cross-clamp times, and long-term survival.

RESULTS: Mean surgeon experience after fellowship graduation was 16.0±11.7 years (1.0-35.2 years). After adjusting for patient risk and surgeon-level fixed effects, learning curve analyses demonstrated improvements in cardiopulmonary bypass and cross-clamp times with increased surgeon experience. There was marginal improvement in the predictability (R2 value) of cardiopulmonary bypass and cross-clamp time for CABG with the addition of surgeon experience, however, all other procedures had marked increases in the R2 following addition of surgeon experience. Cox proportional hazard models revealed that increased surgeon experience was associated with improved long-term survival in AVR (HR=0.85, P<0.0001), MV repair (0.73, p<0.0001), and MVR+AVR (0.95, p=0.006) but not in CABG (HR=0.80, p=0.15), and a trend towards significance in MVR (HR=0.87, p=0.09).

CONCLUSIONS: In cardiac surgery, not including CABG, surgeon experience is an important determinant of operative efficiency and of long-term survival.