Improving cardiac surgical quality: lessons from the Japanese experience

In this issue of BMJ Quality & Safety , Yamamoto and colleagues1 describe an innovative national quality improvement intervention to identify and remediate low-performing Japanese cardiac surgery programmes. This is the most recent of numerous quality initiatives by Japanese cardiothoracic surgical leaders,2–11 and they deserve recognition for their ambitious and ongoing efforts. In 2000, emulating the Society of Thoracic Surgeons Database,12 they developed the Japan Cardiovascular Surgery Database (JCVSD), the foundation for all their subsequent quality activities. Because their board certification requires JCVSD participation,4 this assures that every board-certified cardiac surgeon, and presumably every CT programme, has access to rigorous, nationally benchmarked results. With their newest quality programme, these results are used to target low-performing centres. What can we learn from their experience, and where might there be additional improvement opportunities? Selection criteria for the Japanese site visit initiative are based on JCVSD outcomes data and include high-mortality outlier status for isolated coronary artery bypass grafting (CABG), heart valve or thoracic aortic surgical procedures, as well as hospital volumes and the number of procedures for which a hospital is an outlier. During the study period, 10 hospitals (about 1.7% of all Japanese programmes) were visited. We were not provided with the number of initial candidate hospitals that were high-mortality outliers for at least one procedure but were not visited. It is also not clear if selected hospitals were required to participate in the site visit intervention or whether this was voluntary. Previsit observed mortality rates for site visit hospitals were quite high compared with non-visited hospitals (9.0% vs 2.7% for CABG, 10.7% vs 4.0% for heart valve procedures and 20.7% vs 7.5% for thoracic aortic procedures). They also had, for each of the three procedures, about double the rate of postoperative kidney injury requiring dialysis, which …