Continuous quality improvement programme in cardiovascular surgery: the Latin American perspective

The greying of the overall population in developed and developing countries is associated with a progressive increase in both the number of cardiac surgery procedures as well as their complexity. To maintain a high level in the provision of care, continuous quality improvement has to become the standard rather than the exception. Ernest Codman was a pioneer in implementing quality improvement practices, who migrated from the technology industry to clinical practice [ 1 ]. These efforts have largely paid off, in that patient outcomes have improved [ 2 ], particularly when high-complexity procedures are involved. One of the highlights in improving outcomes was that it provided the spark towards the organization of large outcome registries across the world. Among these registries, the New York State Cardiac Surgery Reporting System was a pioneer in not only covering the entire state, but also making this report mandatory in the enrolment of consecutive patients [ 3 ]. As a consequence, a series of prediction models, risk-adjustment strategies and monitoring policies were subsequently developed. Currently in its second version, the EuroSCORE II has become the de facto mechanism for risk stratification and outcomes monitoring in cardiac surgery [ 4 ]. Twenty years after the seminal experience provided by New York State, Brazil has released unadjusted results for the first time [ 5 ]. As a consequence, scores previously validated in developed countries were now starting to be used in clinical practice. And, of importance, a locally developed model was developed within the Heart Institute–University of São Paulo Medical Center (InCor-USP) [ 6 ]. In 2012, the European Association for Cardio-Thoracic Surgery (EACTS) established its Quality Improvement Program (QUIP) with the goal of improving clinical outcomes as well as further integrating a number of scattered quality improvement initiatives [ 7 ]. Following this initiative, the InCor-USP has developed a set of operational policies for improving its outcomes registry, including the collection of data on risk factors and corresponding interventions. These efforts include the creation of working groups where different specialists meet on a regular basis to discuss therapeutic plans for individual patients. Additional efforts include the implementation of the World Health Program ‘Safe Surgery Saves Lives,’ including the cross-cultural adaptation of a programme that includes Briefing and Debriefing protocols. Through a partnership between the State of São Paulo Health Secretary and the Foundation for Research Support in the State of São Paulo (FAPESP), the InCor-USP is bringing forward a project to create a risk model through a state-wide registry [ 8 ]. In a state where up to 80% of all cardiac surgery procedures are reimbursed through the Brazilian National Health System (SUS), such quality initiatives are essential in providing the data to support decisions in the development of cost-effective public policies. Inside this, our programme's formal mission is to build a culture of safety, promote transparency, standardize training, enhance teamwork and monitor performance. To reach these goals, most of our effort is currently focused on minimizing the influence of organization-related risks, including both infrastructure and human factors. Given its size, the InCor-USP poses major challenges. It is currently one of seven hospital units integrating the School of Medicine at the USP, with over 800 thousand square feet and a total of 535 beds—157 of which are for intensive care units. Within this context, our programme was established in 2014 encompassing the evaluation of institutional, team and individual provider factors, ranging from the incorporation of less invasive diagnostic and therapeutic methods, surgical planning, surgical and anaesthesiological processes and workflow, and postoperative care. Quality interventions do not necessarily imply increased hospital costs, as it focuses primarily on the optimization of an existing organizational model following a set of basic principles: Medical care should be focused on patients. Protocols should be based on the best available evidence. Decisions are made by multidisciplinary teams. Health care data should necessarily be captured as the means to monitor quality and guide quality improvement protocols. The benefits of interventions can be measured by its impact on patients. Education is the primary means leading towards positive change. End-points measured through our programme include mortality, infection, stroke, myocardial infarction, acute renal failure, reoperation and readmission within 30 days. Regular meetings to evaluate mortality and morbidity outcomes are conducted in a constructive manner, focusing on processes and systems rather than finger-pointing at individuals. The executive committee is in charge of establishing treatment protocols while making use of the best available scientific evidence, but also involving the development of multidisciplinary workshops to address topics such as surgical wound infection. During these educational workshops, we emphasize that our implementation principle is the use of iterations, where problem identification is followed by evaluation, intervention and further evaluation through data collection as an integral part of the care process. Inclusion of all incoming patients in our registry is mandatory, including follow-up fields. When requests for data are submitted, all patient and provider identifiers are stripped, thus ensuring that privacy is maintained. Data validation is jointly conducted between our data managers and health care professionals, with reports being generated by the executive committee prior to being disseminated. When greater than expected complication rates are identified, a steering committee is formed to suggest quality improvement initiatives. If complication rates are not reduced, then a warning is issued and an active training process is initiated with the goal of bringing quality to acceptable levels. The impact of these strategies is then evaluated on a monthly basis. Finally, quantitative and qualitative metrics of the programme are presented in public monthly meetings, with the participation of all teams involved in the care of cardiac surgery patients. This open forum is organized so that anyone can openly question performance results and suggest alternative strategies. This path is promising in that continuous data-driven monitoring and feedback is a central tenet in quality improvement [ 9 ], while mirroring and adapting the EACTS experience [ 10 ]. But facing these challenges is certainly worth our effort given the significant positive impact this programme will have on our patients. Long road ahead, exciting opportunities to come. Conflict of interest: none declared.