Defining the Value of Analgesia for Total Knee Arthroplasty Using Time-Driven Activity-Based Costing: A Novel Approach to Clinical Practice Transformation.

OBJECTIVE: To compare the relative value of 3 analgesic pathways for total knee arthroplasty (TKA). PATIENTS AND METHODS: Time-driven activity-based costing analyses were performed on 3 common analgesic pathways for patients undergoing TKA: periarticular infiltration (PAI) only, PAI and single-injection adductor canal blockade (SACB), and PAI and continuous adductor canal blockade (CACB). Additionally, adult patients who underwent elective primary TKA from November 1, 2017, to May 1, 2018, were retrospectively identified to analyze analgesic (pain score, opiate use) and hospital outcomes (distance walked, length of stay) after TKA based on analgesic pathway. RESULTS: There was no difference in patient demographic characteristics, specifically complexity (American Society of Anesthesiologists score) or preoperative opiate use, between groups. Compared with PAI, total cost (labor and material) was 1.4-times greater for PAI plus SACB and 2.3-times greater for PAI plus CACB. The addition of SACB to PAI resulted in lower average and maximum pain scores and opiate use on the day of operation compared with PAI alone. Average and maximum pain scores and opiate use between SACB and CACB were not significantly different. Walking distance and hospital length of stay were not significantly different between groups. CONCLUSION: Perioperative care teams should consider the cost and relative value of pain management when selecting the optimal analgesic strategy for TKA. Despite slightly higher relative cost, the combination of SACB with PAI may offer short-term analgesic benefit compared with PAI alone, which could enhance its relative value in TKA.

A survey of outpatient Internal Medicine clinician perceptions of diagnostic error.

Background Little is known about how practicing Internal Medicine (IM) clinicians perceive diagnostic error, and whether perceptions are in agreement with the published literature. Methods A 16-question survey was administered across two IM practices: one a referral practice providing care for patients traveling for a second opinion and the other a traditional community-based primary care practice. Our aim was to identify individual- and system-level factors contributing to diagnostic error (primary outcome) and conditions at greatest risk of diagnostic error (secondary outcome). Results Sixty-five of 125 clinicians surveyed (51%) responded. The most commonly perceived individual factors contributing to diagnostic error included atypical patient presentations (83%), failure to consider other diagnoses (63%) and inadequate follow-up of test results (53%). The most commonly cited system-level factors included cognitive burden created by the volume of data in the electronic health record (EHR) (68%), lack of time to think (64%) and systems that do not support collaboration (40%). Conditions felt to be at greatest risk of diagnostic error included cancer (46%), pulmonary embolism (43%) and infection (37%). Conclusions Inadequate clinician time and sub-optimal patient and test follow-up are perceived by IM clinicians to be persistent contributors to diagnostic error. Clinician perceptions of conditions at greatest risk of diagnostic error may differ from the published literature.

Incorporating Quality Improvement into Resident Education: Structured Curriculum, Evaluation, and Quality Improvement Projects.

BACKGROUND: Quality Improvement (QI) is essential for improving health care delivery and is now a required component of neurosurgery residency. However, neither a formal curriculum nor implementation strategies have been established by the Accreditation Council for Graduate Medical Education. METHODS: We describe our experience with implementing a formal QI curriculum, including structured didactics and resident led group-based QI projects. Course materials and didactics were provided by the Mayo Quality Academy. Participants were required to take a 30-question multiple-choice exam to demonstrate basic proficiency in QI methods following completion of didactic. An anonymous survey also was performed to elicit feedback from course participants. RESULTS: All of the 40 student participants (17 residents) were able to demonstrate basic proficiency in QI methods on a standardized exam upon course completion. Of the 9 attempted QI projects, 7 were completed, with 5 of those resulting in sustained process changes. The majority of participants felt formal training improved confidence in QI processes and was a valuable professional tool for their careers. CONCLUSIONS: A formal didactic curriculum and practical application of QI methodologies adds value to resident training. Further, it has the potential to positively impact practice. Consideration should be given to adopting a formal QI curriculum by other neurosurgery departments and perhaps standardization on national level.

A Collaborative for Implementation of an Evidence-Based Clinical Pathway for Enhanced Recovery in Colon and Rectal Surgery in an Affiliated Network of Healthcare Organizations.

BACKGROUND: In 2015 the Mayo Clinic Care Network (MCCN), in an effort to extend medical knowledge and share these best practices, embarked on an education mission to diffuse the clinical practice redesign involving the practice of colon and rectal surgery at Mayo Clinic (Rochester, Minnesota) to members of the MCCN. They elected to use a collaborative framework in an attempt to transfer knowledge to multiple teams in an efficient and supportive manner. METHODS: Eight MCCN members assembled a multidisciplinary team, which participated in both a didactic learning session delivered by frontline experts, as well as follow-up remote sessions regarding Mayo Clinic's enhanced recovery pathway for colon and rectal surgery. Teams departed the group session with established immediate next steps, communication plans, and an awareness of potential barriers and strategies for mitigation. Monthly coaching calls followed in an effort to help all teams meet their time line and overall goals. Finally, all participants met again after six months to report their clinical outcomes, as well their unique individual organization's successes and barriers encountered. RESULTS: Participating teams felt overwhelmingly that the collaborative program exceeded their expectations and equipped them with the tools to be successful. They also felt that the extended support provided by the Mayo Clinic team was essential, and the collaboration with other members markedly enhanced their experience. Importantly, all teams were able to successfully reduce length of stay, which was the desired main clinical outcome. DISCUSSION: The collaborative format was instrumental in the rapid diffusion and successful implementation of a transformative practice redesign involving colorectal surgical care of patients.

Innovative model of delivering quality improvement education for trainees--a pilot project.

BACKGROUND: After incorporating quality improvement (QI) education as a required curriculum for our trainees in 2010, a need arose to readdress our didactic sessions as they were too long, difficult to schedule, and resulting in a drop in attendance. A 'flipped classroom' (FC) model to deliver QI education was touted to be an effective delivery method as it allows the trainees to view didactic materials on videos, on their own time, and uses the classroom to clarify concepts and employ learned tools on case-based scenarios including workshops. METHODS: The Mayo Quality Academy prepared 29 videos that incorporated the previously delivered 17 weekly didactic sessions, for a total duration of 135 min. The half-day session clarified questions related to the videos, followed by case examples and a hands-on workshop on how to perform and utilize a few commonly used QI tools and methods. RESULTS: Seven trainees participated. There was a significant improvement in knowledge as measured by pre- and post-FC model test results [improvement by 40.34% (SD 16.34), p<0.001]. The survey results were overall positive about the FC model with all trainees strongly agreeing that we should continue with this model to deliver QI education. CONCLUSIONS: The pilot project of using the FC model to deliver QI education was successful in a small sample of trainees.

Colorectal surgery surgical site infection reduction program: a national surgical quality improvement program--driven multidisciplinary single-institution experience.

BACKGROUND: Surgical site infections (SSI) are a major cause of morbidity in surgical patients and they increase health care costs considerably. Colorectal surgery is consistently associated with high SSI rates. No single intervention has demonstrated efficacy in reducing colorectal SSIs. The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) is a nationally validated system that uses clinically abstracted data on surgical patients and their outcomes to assist participating institutions drive quality improvement. STUDY DESIGN: A multidisciplinary team was assembled to develop a colorectal SSI-reduction bundle at an academic tertiary care medical center. The ACS NSQIP data were used to identify patterns of SSIs during a 2-year period. Multiple interventions across the entire surgical episode of care were developed and implemented in January 2011. Monthly ACS NSQIP data were used to track progress. RESULTS: Our ACS NSQIP overall colorectal SSI rate for 2009 and 2010 was 9.8%. One year after implementation of the SSI reduction bundle, we demonstrated a significant decline (p < 0.05) in both overall and superficial SSIs, to 4.0% and 1.5%, respectively. Organ space infections declined to 2.6%, which was not a significant change (p = 0.10). During the entire analysis period (2009 to 2011), there was no change in our colorectal-specific Surgical Care Improvement Program performance. CONCLUSIONS: Using our ACS NSQIP colorectal SSI outcomes, a multidisciplinary team designed a colorectal SSI reduction bundle that resulted in a substantial and sustained reduction in SSIs. Our study is not able to identify which specific elements contributed to the reduction.