The History and Future of Quality and Safety in Neurosurgery

Introduction: The Perspective From Patient Safety Science

The practice of neurological surgery has always attracted a select group of highly motivated individuals. These practitioners typically possessed qualities of excellence and the pursuit of the best outcomes. Neurosurgical training programs recruited the brightest minds with stellar test scores and demonstrable academic skills. These trainees were taught to maximize personal performance and hone their skills in order to procure the best outcomes for their patients. This emphasis on the power of the individual was steeped in a culture of sharp hierarchy gradients among physicians and their coworkers. This culture bred a reluctance to share lessons learned from poor outcomes, or to alert superiors when adverse events seemed eminent, and to use workarounds instead of restructuring when processes were poorly constructed. When errors occurred, the organization reacted by identifying the personal failings of the individuals involved and resorting to direct appropriate reprimand and corrective actions. The main driver of quality improvement, it was thought, was to get individuals to gain better knowledge and procedural training, and to expand their skill sets.

Alas, safety science has informed us that this approach to safety is not sufficient and frequently misguided. Without an understanding of the sociotechnical environment and the system elements leading to error, organizations will gain little from blaming the individuals involved. Organizations must understand that people will always be fallible, and the most efficient error prevention will come from ensuring that the systems they work within are geared for safety. Organizations must recognize that the design of their processes, their mechanisms for nonpunitive error reporting, the technical tools they use, the makeup of their teams, the power structure that prevails among the workers, as well as their training programs, are all essential factors in the genesis of errors and adverse events. To place blame on individuals and ignore all these other factors will result in an endless cycle of corrective actions and human resource manipulation, but no real change in safety accomplishments.

There is certainly a trade-off, and a necessary balance, that must be accommodated when considering personal accountability and organizational error reporting. If individuals predict punitive action following error reporting, they are motivated to underreport. This underreporting robs the system of valuable opportunities to diagnose and remedy inherent systemic failures. On the other hand, when individuals are encouraged to report errors, the organization will be able to recognize patterns of adverse events and near misses, and analyze the conditions leading to these failures. Such analysis is paramount for quality improvement and the continual refinement of organizational processes. The aviation and automotive industries have applied these lessons and created organizational cultures of safety that value the learning potential from error reporting. These safety cultures are able to discern errors committed by well-meaning and dedicated individuals—who are undermined by systemic deficiencies—from those errors that are caused by careless or impaired practitioners.

The care for neurosurgical patients is a complex endeavor, mandating a sophisticated approach to error prevention. In a study of closed malpractice claims, Taylor and Ranum showed that up to 40% of unsatisfactory outcomes resulted from factors unrelated to the technical performance of surgery. These factors included inappropriate diagnosis and assessment, poor selection of treatment options, and poor communication with patients and among providers.The take-home point from the study is that error prevention cannot be improved solely using a strict singular focus on perioperative care. The modern approach requires systems thinking, and a wider lens, vetting the processes that influence patient care outside of the acute care episode. This new approach will require a revamping of residency training, a fresh look at error and outcomes reporting, and a steadfast emphasis on the creation of a culture of safety within the ranks of neurosurgeons.

Training for Safety in Neurosurgery

Organized neurosurgery recognized the need to incorporate the recommendations from patient safety science in the training of residents. The neurosurgery Boot Camp was an example of a proactive step toward that goal. The Boot Camp curriculum includes simulation training, safe learning spaces, iterative learning, and other features that enhance the training and promote patient safety. In particular, this training emphasizes communication skills, professionalism, and collaborative teamwork. Furthermore, the Neurosurgery Milestones Project framework for residency training incorporates systems-based practice, safety education, professionalism, and compassion, among other domains of standardized training. This framework mandates the attainment of specific goals for skill and knowledge acquisition, in addition to requiring the program directors to validate that the training has been satisfactory. Simply spending the required minimum time on a service is not sufficient to satisfy training requirements. From a certification perspective, the American Board of Neurological Surgery mandates minimum numbers of cases in subspecialty areas, and requires testing of core competencies on the topics of patient safety, medical error, interpersonal skills, communication training, systems-based practice, and practice-based learning among others.

In order to further bolster the safety agenda in surgical training, more emphasis has to be placed on training residents in quality improvement programs. The University of California in San Francisco neurosurgery program instituted new graduate education requirements in quality improvement projects. They included hospitalists in their neurosurgical department, and they incorporated education in safety science and systems thinking in order to create a safety culture in their training program. Parker et al. discussed the implementation of a national quality improvement program into neurosurgical residency training. Such a program will require residents to be active in the pursuit of quality improvement projects throughout their training, tracking data on their own patients as well as those of others, and learning the skills needed for analyzing these data sets from a comparative effectiveness standpoint. The challenge for neurosurgery is to establish a reliable, widely accessible, web-based data entry and storage platform whereby quality improvement projects can be shared across training programs. Such a platform can be modeled after the American Medical Association's Resident and Fellow Quality Improvement Forum and Project database.

Simulation Training in Neurosurgery

There exist strong data linking the use of simulation training with improved clinical outcomes. The role of simulation in neurosurgery training has been well established. Training modules including placement of ventriculostomy and central line catheters, endovascular, and dural repair procedures have been available for a few years.

We can find exciting applications of three-dimensional (3D) printing in the training for neurosurgical procedures. For example, a patient-specific, 3D cerebral aneurysm model can be created to allow residents to conceptualize and practice clipping technique preoperatively. Similar models have been created to practice a host of neurosurgical procedures such as resection of intraaxial brain tumors, biopsy of pineal lesions, performance of third ventriculostomies and others.

With advancing technology, there is clearly an opportunity to advance the breadth of simulation training and the creation of a formal simulation curriculum in residency training. This effort will require a sophisticated approach to validating the training and standardizing the evaluation tools. Ghobrial et al. proposed a video-based objective structured assessment tool to quantitatively assess a resident's proficiency and progress through their training. This video recording would allow for excellent feedback and allow multiple evaluations of a resident's performance as well as for tracking progress over time.