Quality Assessment in Thyroid and Parathyroid Surgery

Institute of Medicine Reports and Policy Outcomes

In 1999 the newly established Institute of Medicine (IOM), now called the National Academy of Medicine (NAM), published To Err is Human: Building a Safer Healthcare System, a report highlighting the toll of medical errors on patients and the health care system. In this document the authors reported that up to 98,000 patients died annually due to medical error and charged the medical field as being woefully behind other high-risk industries, such as aviation, in reducing preventable harm. This report received wide media attention and led to a call for reform to ensure patient safety, energizing the movement for surgical quality assessment. A follow-up report published in 2001, titled Crossing the Quality Chasm, focused attention on six domains needed for a safer and more effective health care system: safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity.

In the wake of these publications, concerted efforts were made by hospitals, academic and professional societies, and accrediting bodies to prevent medical errors and improve patient safety. Figure 45.2 highlights the important events in the quality of care movement in medicine and surgery. In 1999 the U.S. congress passed the Healthcare Research and Quality Act, which started the Agency for Healthcare Research and Quality (AHRQ) with a mandate to support research focused on identifying the causes of preventable errors affecting patient safety and to track disparities in health care. In 2003 the AHRQ published its first annual National Healthcare Quality Report, which measures trends in quality metrics, such as patient safety, timeliness of care, and access to care. The AHRQ remains a leader in efforts to systematically collect and analyze health care outcomes to guide improvement in patient care with the support of federal funding. In 2008, the National Quality Forum convened the National Priorities Partnership (NPP), which included 28 organizations representing consumer groups, employers, governments, private insurers, health care professionals, accrediting and certifying bodies, and quality alliances, to align health care reform with a set of National Priorities and Goals decided upon by all parties. The coordination of all stakeholders in health care administration is essential to the quality improvement movement.

Pioneers of Surgical Quality and Morbidity & Mortality Conferences

One of the most notable early champions of surgical quality improvement was Ernest Amory Codman (1869–1940), a surgeon at Massachusetts General Hospital. Codman devoted much of his career to his “end result idea,” which he described as “the common-sense notion that every hospital should follow every patient it treats, long enough to determine whether or not the treatment has been successful, and then to inquire ‘if not, why not’ with a view to preventing a similar failure in the future.” Through this idea, Codman emphasized both documenting surgical outcomes and analyzing the root cause of variations in outcomes, which at the time was a novel and controversial topic. As a founding member of the American College of Surgeons (ACS), he participated in the establishment of the Hospital Standardization Program, which was the precursor to the Joint Commission on Accreditation of Health Care Organizations. He also contributed to the drafting of the ACS Minimum Standard for Hospitals in 1919, in which the ACS charged hospitals with ensuring staff “review and analyze at regular intervals their clinical experience in various departments of the hospital” and set the standard for the recording of patient data.

A direct result of Codman’s work was the establishment of what would become The Anesthesia Study Commission by Henry Ruth in Philadelphia in 1940. This group was composed of anesthesiologists, surgeons, and internists from multiple institutions who would review fatalities and adverse outcomes related to anesthesia and surgical care, with a key focus on medical errors, for the purpose of education and system improvement. These tenets formed the basis for the modern Morbidity and Mortality (M&M) conferences. In 1983, the Accreditation Council for Graduate Medical Education (ACGME) mandated that all training programs institute regular M&M conferences, which to this day are focused on review of complications and deaths for the purpose of quality improvement. However, there is little standardization in how these conferences are run or the methodology to implement change. Although the tradition of M&M conferences in surgery has focused on addressing adverse events and errors, focus on the responsibility of individual decision making often underemphasizes the need for addressing system deficiencies. In addition, the M&M system has been shown to underreport complications and deaths compared with more rigorous methods of documenting perioperative outcomes. Focused effort is required to structure M&M conferences to be effective for quality assessment and improvement.

Multidisciplinary Cancer Conferences/Tumor Boards

Unlike the retroactive approach to systems improvement employed through M&M conferences, the formation of multidisciplinary cancer conferences (MCCs) or tumor boards represented a proactive approach to improving patient outcomes by focusing on providing up-to-date and comprehensive cancer care. Given surgery was the mainstay of cancer care in the early 20th century, the ACS also led the charge to improve cancer care by establishing the Committee on the Treatment of Malignant Diseases in 1922, which became the ACS Commission on Cancer in the mid-1960s. This group established the standards for dedicated “cancer clinics” that were accredited to provide consistent diagnostic and cancer treatment services. To this day, the Commission on Cancer recognizes cancer care programs that are voluntarily compliant with standards that ensure quality, multidisciplinary, and comprehensive cancer care delivery. One aspect of care that is required of these institutions is documentation of MCCs/tumor boards. Given that there is evidence transdisciplinary cancer care improves adherence to guidelines, timeliness of treatment, and patient outcomes, MCCs/tumor boards are seen as important tools to facilitate this interaction to coordinate patient care. There is also evidence that surgeons find participation in MCCs/tumor boards important for their professional development. Although there is no definitive documentation that MCCs/tumor boards on their own function as tools of quality assessment, they are a component of multidisciplinary cancer care that likely facilitates the improved outcomes seen with the participation of practitioners from medical, surgical, and radiation oncology, among others, in treatment planning.