This one's on quality and patient safety, and it will reflect some of the other things that some of the other speakers have said. So just, again, to give you a little bit of history, I always like to look at some of these timelines. 1984 was the death of Libby Zion. 1989 was the start of the four or five regulations, which were in New York, and they predated the work hour regulations, which came along in 2003. In 2010 were the revised work regulations. And also as a reminder of what prompted some of this reform, in 1994 there were some disastrous chemotherapy overdoses that resulted in the death of a number of individuals. In 1995 there was a highly publicized wrong-sided brain surgery in the New York area. Also in that same year there was a wrong foot amputation. You can imagine that kind of thing didn't actually carry over very well in the press. And in 2001 two patients that had the same name had each other's procedure. That was also kind of one of those things that prompted the public to say, maybe we as doctors are not always doing the best things. In 2002 there was a switch between nitrous and oxygen, causing the death of a number of different individuals. In 2007 an institutional cluster of wrong-sided surgery, a healthy kidney removed, and then the most recent alleged wrong-sided brain surgery was just a couple of years ago. I won't go through all of this, but there is also a strong history, particularly within neurosurgery, of work and error reduction. Starting with the Hippocratic Oath, I found it amusing that the first malpractice crisis was actually in 1835 to 1865. Okay, it's hard to imagine, but it goes back. Cushing in 1902 was really the father not just of neurosurgery, but of neurosurgery error reduction, because he started reporting and codifying his reduction in surgical errors. And many think that Dandy, who came along in 1919, was really the forerunner of neurosurgical error reduction because of his meticulous documentation of his cases. And there has been a debate as to which of them was the safer neurosurgeon that I won't go into. There's a whole other list of things, and you can look at all of these time points. But coming up to the more current time, we started doing things like the Million Lives Campaign, TeamSTEPPS and LifeWings, universal protocols, and the patient checklist. And hopefully all of you in your communities have already been a part of things like the TeamSTEPPS and LifeWings protocols. I think that there's really only one rule you need to know when it comes to patient safety and patient quality. And that's to treat every patient and every single patient encounter like the person was your favorite relative. And other than my husband, these are my two favorite relatives, my son and my daughter. You never know who that patient is. We've had some experiences when I was in an academic practice when someone came in from a car accident. He looked like a junkie, a terrible person. Turned out he was like a leading television personality. But, you know, he had blood all over him, and his clothes were all torn. And several of the residents really, you know, treated him like that dirtball, you know, trauma patient or whatever else. It's just a strong reminder. It doesn't matter whether they're a TV personality or whether they're just the grandmother that lives next door. Each and every one of them deserves to be treated, whether they're insured or uninsured, young or old, you know, whether they have diabetes and heart disease and things that are maybe of their own doing and then they're obese and they come in and they don't have clean clothes on or whatever else. There's still somebody's loved one. There's still somebody's relative. And if you remember that and treat every patient and inpatient encounter as if they were somebody that you loved, then you're probably going to keep yourself out of trouble. Leave your egos behind. Treat only what you can do and can treat well. Now, that doesn't mean you have to be the best surgeon at every operation that you do. But if you really, really, really know that in a complicated case there are people down the road or a hundred miles away that do that case two or three times a week and you do one of them every three or four years, you know, maybe that's not a case that you should take on. I mean, I do perineal nerve tumors. Now, you know, I've seen three or four of them in my whole career. So it's not like perineal nerve tumors are common, so no one's doing a lot of them. But I operate on the perineal nerve a lot. So it's okay if you do rare cases, but you shouldn't do a rare case that is outside your area of expertise if it's a complex case and if there's somebody else who can really, really do it better and more safely for the patient. Also in terms of leaving your ego behind, I mean, somebody once said to me when I was young, you know, you are not the knight in shining armor just because you're just out in practice or just because you've had extra tumor work or just because you were the pioneer and such and such. You know, if two or three other doctors have failed to fix a patient, there's only a limited number of cases in which you are going to be able to do what three or four other very, you know, competent, conscientious doctors have not been able to do. You know, a complex scoliosis case there, you know, that might be the case. But again, the exceptions to that rule are very limited. Discussing things with your colleagues is a good thing. I know we get into the whole malpractice thing and all the rest of it. But I frequently sit in between cases and show my colleagues, you know, my partner, my spine colleagues different cases and say, would you do this from the front, would you do it from the back, would you do all, you know, would you do two levels or would you just do one? I mean, we muse over these things because for most of these things, there is no one right answer. And sometimes somebody else in discussing them out loud can point something out to you that you didn't think about. And often there is more than one answer and that's okay. You need to work and be part of establishing a culture of safety no matter what the setting is, whether you have residents that you're working with or colleagues or coworkers. You are part of the leader that has the most important person who establishes that culture of safety is the team leader. And I believe that whether you're working in academic settings such as, you know, John and Bill, that your residents have to be able to be as safe as you are when you, if you were personally taking care of that case. And it's the same thing if I'm working with colleagues and I'm letting them do a portion of my case and my patients frequently ask me, well, who's going to do the surgery or who are you going to do it with? And I can tell them very, very directly that whoever I'm doing this case with is going to be able to do their part with the same quality that I am. They may do it a little bit differently or they may come from a different background, but I can assure that the quality is going to be consistent. So that's a very important part of being consistent in what you do and how you approach this culture of safety. And it really has to be a do as I do. You know, you can't tell your residents, okay, you know, you can't make any decisions without going to see the patient if you then are constantly, you know, deciding to operate on patients before you see them. I mean, you have to send the message to your residents, to your colleagues, to your partners that what you're advocating in terms of safety is the rules that you're willing to live by. And this message is really important as you also work with the scrub nurses and circulating nurses and anesthesiologists, that you really have to be consistent in your culture of safety. And part of this comes with the verbal and nonverbal. I have a colleague who's a general surgeon, and he sort of goes through the time out, and he does all the things he has to do, but boy, he is constantly like, yeah, you know, I'm doing this. And like everybody in the room knows as soon as he starts a time out that he thinks it is the stupidest thing. And that does not encourage the other people in the room to take that component of the operation seriously or to think that he is really invested in it. Now, he does all the parts. He says all the right things. But it's very clear that his nonverbal language is contradicting that in terms of that. So a little bit on the science of mistakes, and this is really important. I would encourage you all to Google this and read a little bit about this. I can't go into it in detail. But mistakes are inevitable. They have shown in study after study after study that the best surgeon, the best engineer, the best mathematician will never be right 100% of the time. It is impossible. It is impossible. In fact, it's almost impossible to be more than about 89 to 92% right. Even if it's like just reading a passage, you will read one of those words wrong now and again. So no individual can avoid making mistakes. So the best outcomes they've determined can only come about when you have systems in place so that there's checks and balances, so that the accumulation of you and your partners or you and your colleagues or you and the other people who are in the room making decisions are all part of that process. And it's not uncommon that somebody, you know, reminds somebody else in the operating room about something that needs to be done or something that hasn't happened yet. So systems development require complete buy-in. You have to honor each individual. So if a nurse is going to, you know, remember that, you know, you didn't tighten the last, you know, screw or whatever because you were waiting for the x-ray. And if when they remind you, you bark at them and you say, okay, you know, I know. I mean, they're obviously not going to remind you the next time. So you really have to honor each individual that's a part of the team. Take it seriously. And also to not overly complicate the systems because if you build in systems that are so complex, then they defeat the whole purpose of the science of undoing the science of mistakes. Teamwork is scientifically proven to be valuable. If you take a new procedure, say an interventional radiology, and you take the nurse and you train them, and then you take the tech and you train them, and then you take the endovascular surgeon and you train them, and then you bring them all back versus if you take all three of them together to a place and train them together, the mistakes that will be made will be significantly less if you train the whole team together. And this says a lot about the importance of building and maintaining teams. And there's science that shows that mistakes are much more likely when there is a disruption of the team. And this also emphasizes the need to know the cost of turnover. So if you have a big nursing turnover in your operating room, then that's not going to allow you to develop the teamwork that's necessary to promote patient safety, and it's going to be very costly. In your own practice, the most common source of making an error is relying on dependent information. So what do I mean by this? This means that you read a referring letter and whatever, and the referring doctor says, I'm sending you Mrs. Smith because they have a herniated lumbar disc and they have back pain. And so you approach that patient, and what you're doing is you're determining whether this lumbar disc needs to be operated on or not. Okay, inherently, you have made the prima facie mistake that was most likely to get you into trouble. We have all had patients that have been sent to us with huge herniated discs that have MS. Okay? I mean, and the huge herniated disc is on the wrong side of where their pain and their symptoms are. But if you're approaching it because somebody has already given them a diagnosis, and this happens a lot. I just reviewed a medical malpractice case in which there was a patient who had a subarachnoid hemorrhage and as a result fell and hit his head. And everybody subsequent to the original ER treated that as a traumatic subarachnoid until the patient died from re-bleed of their aneurysm. Why did it happen? Because everybody took the previous ER's records and said traumatic subarachnoid, traumatic subarachnoid, traumatic subarachnoid. And unfortunately, even the neurosurgeons, when they looked at it, they said, oh, well, you know, it might be aneurysmal. I mean, it was in the sylvia and fissure in the temporal lobe. I mean, it was a classic middle cerebral artery, you know, bleed. But it was billed. We're transferring this traumatic subarachnoid hemorrhage to you. And when the patient deteriorated, they said, oh, it's head injury craziness. And they just kept sedating the patient until he re-bleed. So that's another case where you're relying on dependent information. Other mistakes that you make near the beginning is not understanding the patient sufficiently. You know, know those red flags. People that come in with, you know, 50 CDs. People that come in with 50 diagnoses. People have seen 50 neurosurgeons or spine surgeons before you. These are all red flags that should alert you. And they may have something wrong on their x-rays. But I will tell you, if I don't think I can deal with that patient on whatever level, they can have a grade 2 spondy. I will not offer them surgery. Because I know that they're going to be a difficult patient. And should they have a complication, you know, they're not going to be the kind of patient that I can go through dealing with that complication on. You really need to take the time. I have a rule that I, unless it's an emergency, I'd never offer surgery on their first office visit. I make them come back. And I almost never will consent somebody for surgery if they don't have a surrogate with them. Those are my office rules. And they are reinforced by my nurse. So too quick to surgery is something else that's going to prevent patient safety. In the middle, you can get yourself in trouble by taking shortcuts from breaking from established practices and not listening closely enough. I will tell you that your patients, they know if they're having a complication. You know, if they tell you that their back pain was okay postoperatively and now it's getting really bad, listen to them. Don't just say, oh, you know, you probably need to take more medicine. Listen to your patients. Listen to the family. They will oftentimes give you clues as to what's going on. Timeouts and checklists, they have been proven effective. They are not a substitute for common sense. They should be routine. And the routine and the team of this is essential. And it's part of the culture of safety. They are limited by how well they're developed. So if they are not developed at your institution, it's important for you to get involved in the development because you're going to be participating in them. And if the nurses or the administrator and the OR develops it, chances are it's not going to be what you think is the right thing. It also depends on how well they're tested, whether they're valid, and how well they're implemented. I will tell you that in a recent study, 26 out of 35 wrong-sided neurosurgery procedures were done after checklists were in place. So obviously checklists are not an absolute in preventing these. If you do get a complication, never blame the patient. It's never their fault. Rarely blame another team member. And always consider if there was something that you could have done better because that's the way that you will be able to treat your next patients better. Have mechanisms in place to assess at all of your hospitals or wherever you work. And listen carefully to other people's criticisms about a case because it's about getting better. And are there system changes that are indicated that could maybe have helped you or helped this patient in some sort of way? Those will always be good if they're there. Quality outcomes are the new mantra. It's more than just good and bad. And this requires physician engagement. And beyond quality where we're going to be measured on this, and Katie touched on a little bit of this, is the concept of value. And value sort of relates a little bit to what Jim was saying about profit. It's not just the best outcome, but it's the best outcome related to the cost. Obviously a Kia is not equivalent to a Mercedes. But if you can do an ACDF and it costs the world or whatever $12,000 versus $50,000 and your patient does as well, isn't it better to do that ACDF for $12,000 than for $50,000? And I think we would all agree that that's probably the case. There's a whole new world of cost-effectiveness research that's part of this world of value. And we have to be players in that or else somebody else is going to tell us what to do. So should you care? Of course. You can share in the gain. And this is now legal because of health care reform. And you can help by bringing costs down and learning how to better bring down costs in your own practice. And that will help preserve the physician piece of the pie. The easiest piece of the health care dollar to reduce is unnecessary hospital admissions. And for us that means readmissions or admissions where we're just doing a workup, where that can be done as an outpatient. Dr. Christensen recently spoke at the AANS meeting and he pointed out to us that nothing should be done in one setting that can be done in a lesser setting. So in terms of the health care value, nothing should be done in a quaternary hospital that can be safely done in a tertiary hospital, that can be safely done in a community hospital, that can safely be done at an ASC, in the clinic, and ultimately at home. Because in all of these subsequent settings, the cost of providing that care is going to be less. So quality and safety must be foremost a part of your practice. You need to be a part of setting a culture of safety and value become an ever-important part of your practice, and including your reimbursements from Medicare over time. Thank you.

patient safety

medical errors

healthcare reform

teamwork and communication

value in healthcare