A statewide quality collaborative for process improvement: internal mammary artery utilization.

BACKGROUND: The Michigan Society of Thoracic and Cardiovascular Surgeons (MSTCVS) Quality Collaborative is a voluntary, surgeon-directed quality initiative involving all cardiac surgery programs in Michigan. Understanding that internal mammary artery (IMA) use during coronary artery bypass grafting is an important process measure associated with improved outcomes, this analysis reviews our methodology to understand IMA use and increase appropriate IMA use statewide. METHODS: Adult cardiac Society of Thoracic Surgeons data were collected at each Michigan site and submitted quarterly to the Duke Clinical Research Institute and the MSTCVS. Seven cardiac surgery programs with IMA use less than 90% in isolated coronary artery bypass grafting were identified as low IMA users. An improvement plan was adopted at the state level and included quarterly monitoring of IMA use, documenting the rationale for IMA exclusion, evidence-based lectures, feedback letters to sites, and physician-led site visits if no improvement was noted. RESULTS: From 2005 through 2008, 29,114 patients underwent coronary artery bypass grafting in Michigan. Internal mammary artery utilization varied widely at the beginning of this investigation, ranging from 66.2% to 98.4%. Seven Michigan programs were identified as low IMA users. Using the MSTCVS Quality Collaborative's process-improvement plan, collectively the seven low IMA users increased IMA grafting from 82.0% to 92.7% (p < 0.0001). Michigan IMA use increased from 91.9% to 95.8% (p < 0.0001) and is now higher than The Society of Thoracic Surgeons' average. CONCLUSIONS: The MSTCVS Quality Collaborative identified programs with low IMA use and created an environment to enhance IMA utilization during coronary artery bypass grafting, a significant operative process. These findings illustrate the value of a statewide surgeon-directed quality initiative in improving processes and outcomes for patients.

Cardiac surgeons and the quality movement: the Michigan experience.

The Michigan Society of Thoracic and Cardiovascular Surgeons created a voluntary quality collaborative with all the cardiac surgeons in the state and all hospitals doing adult cardiac surgery. Utilizing this collaborative over the last 3 years and creating a unique relationship with a payor, an approach to processes and outcomes has produced improvements in the quality of care for cardiac patients in the state of Michigan.

From 'acting on' to 'acting with': the functional anatomy of object-oriented action schemata.

In this chapter it is proposed that object-based actions can be broadly classified into types. In the first, objects are 'acted on' without a specific purpose. In the second, objects are 'acted with'. In the latter case the grasp reflects the subsequent goal of the subject. Recent evidence from human functional imaging suggests different neural substrates for acting on an object (dorsal parietal cortex) and for acting with an object. Specifically, it is argued that conceptual knowledge of tool use and the pragmatics of action rely on an inferior parieto-medial frontal network in the left hemisphere.

Intact motor imagery in chronic upper limb hemiplegics: evidence for activity-independent action representations.

Four experiments were undertaken to examine the effects of chronic hemiplegia on the ability to internally represent actions involving either the paralyzed (contralesional) or relatively unaffected (ipsilesional) limb. An experimental group of chronic, densely hemiplegic patients was compared with controls who experienced nearly full recovery from an initially dense hemiparesis. All participants suffered cerebral vascular accidents that spared sites in premotor and parietal areas directly involved in representing upper limb actions. Despite chronic limb immobility, hemiplegic patients performed all four tasks at a high level of accuracy and showed no differences in their ability to represent actions of the contralesional versus ipsilesional limbs. On tasks that involved representing actions of the hands and lower arms, hemiplegic patients were as accurate as recovered controls. Hemiplegic patients were, however, less accurate than controls on a task that involved representing actions of either upper arm. Overall, chronic hemiplegics performed more accurately for decisions based on their contralesional limbs: a "hemiplegic advantage" that may be related to an ongoing focus on planning and/or imagining currently impossible movements. These findings reveal a dissociation between the ability to internally "represent" versus "produce" manual actions. Further, they demonstrate that internal action representations can be robust to even years of limb disuse.

Viewpoint-dependent recognition of scenes.

Three experiments investigated scene recognition across viewpoint changes, involving same/different judgements on scenes consisting of three objects on a desktop. On same trials, the comparison scene appeared either from the same viewpoint as the standard scene or from a different viewpoint with the desktop rotated about one or more axes. Different trials were created either by interchanging the locations of two or three of the objects (location change condition), or by rotating either one or all three of the objects around their vertical axes (orientation change condition). Response times and errors increased as a function of the angular distance between the standard and comparison views, but this effect was bigger for rotations around the vertical axis than for those about the line of sight or horizontal axis. Furthermore, the time to detect location changes was less than that to detect orientation changes, and this difference increased with increasing angular disparity between the standard and comparison scenes. Rotation times estimated in a double-axis rotation were no longer than other rotations in depth, indicating that alignment was not necessarily simpler around a "natural" axis of rotation. These results are consistent with the hypothesis that scenes, like many objects, may be represented in a viewpoint dependent manner and recognized by aligning standard and comparison views, but that the alignment of scenes is not a holistic process.