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Invited Presentation at the Eastern Cardiothoracic Surgical Society 2018
- 1. Hospitals’ Response to Robotic CABG Robert Poston, MD Chief, Division of Cardiothoracic Surgery SUNY-Downstate, Brooklyn, NY
- 2. NOVICE PROFICIENT EXPERT Credentialed in Robotic Cardiac Surgery Expert Robotic CABG Programs (>100 cases/yr ) National Marketing Database, Intuitive Surgical Corp, queried 2013 Robotic Cardiac Surgery
- 3. Robotic MIDCAB Programs Initiated by RP
- 4. Time Performance Low High Rapid ImprovementsNew program introduced Trial and error Status quo Organizational Learning Novice Proficient Expert
- 5. Morale Low High Status quo Organizational Expectations Time Novice Proficient Expert
- 6. Morale Performance Low High Low High Rapid Improvements Trial and error Status quo Novice Proficient Expert Reality – Expectations gap Time Novice Proficient Expert
- 7. Expectations Time Performance Low High Low High Rapid Improvements 1st case …Nth case Robotic program introduced Trial and error Status quo Organizational Learning of Robotic CABG Novice Proficient Expert STAGE 1: HYPE EFFECT AND DENIAL Reality – Expectations gap
- 8. Expectations Time Performance Low High Low High Rapid Improvements 1st case …Nth case Expectations- reality gap Robotic program introduced Trial and error Status quo Organizational Learning of Robotic CABG Novice Proficient Expert STAGE 2: INFORMATION ASYMMETRY AND CRISIS
- 9. Expectations Time Performance Low High Low High Rapid Improvements 1st case …Nth case Expectations- reality gap Robotic program introduced Trial and error Status quo Organizational Learning of Robotic CABG Novice Proficient Expert STAGE 3: ACCEPTANCE BUT NOT A NEW STANDARD
- 12. MY ADVICE • UNDERSTAND THE PATTERNS • GET TEAM TO SPEAK UP • LEARN FROM NEAR MISSES • REGULAR MEETINGS WITH ADMINISTRATION • RUN THE NUMBERS
Editor's Notes
- Robotic coronary bypass has been hindered by major technical challenges and inadequate training. Success with any high risk, high profile innovation inevitably depends not just on great patient outcomes, but also navigating the complex social dynamics of a highly conservative environment like a hospital. Communication is required btw groups from places as far apart as the OR and the hospital boardroom. The purpose of this talk is to consider the following rhetorical question: if you could predict all the political problems that are going to happen several weeks prior to them happening as you adopt robotic CABG, would you that increase your chances of success. I propose that miscommunication about robotic CABG occurs over three discrete and highly predictable phases. Placing the attention back on patient safety as the team’s north star is an excellent way to improve communication and the success of robotic CABG programs.
- Progress of robotic CT surgery stagnated not because of poor adoption, over 500 robotic CT programs have been initiated in the past 20 years, but because almost all of these programs ended up being discontinued. Each of these programs attended training, were credentialed and performed some robotic CABG cases, but only 22 have ever performed more than 100 cases/yr. Surgeon’s decision to adopt the procedure – often the hospital’s decision to discontinue it or at least the hospital plays a greater role in this decision.
- One word of caution, the views that I will present are based largely on my own meandering experience of initiating robotic CABG programs at 7 different hospitals. Each achieved high volume and good results yet always seemed to bring chaotic events and baffling behavior. My role as the chief of CT surgery provided me a perspective from which I was able to discern some meaningful patterns of from these experiences. These commonalities are based on personal knowledge, but it is supported by the experience of some colleagues and are consistent with findings of the psychological and social sciences literature. I am confident that my experience is not unique, and will resonate with at least some of you who have had the blessing and curse of having traveled these treacherous waters.
- One universal theme of adopting robotic CABG is that every organization goes through a period where their performance gets worse before it gets better. Performance can be measured by almost any metric that is analyzed – risk for adverse patient outcomes, long OR times, hospital costs, use of bottleneck resources, etc. Silicone valley refers to this period as death valley because many start up firms go broke. Surgery prefers more euphemistic term: the learning curve. The beginning of the end of this period is triggered through a process of trial and error, which is a good method of learning but it comes at a cost: error. It is also a period of great uncertainty about whether robotics will end up being better than open. Decision making under conditions of uncertainty is subject to important cognitive biases.
- Another consistent response to robotics is that the organization’s expectations change dramatically over time, which influences their acceptance of change. new ideas that are technologically advanced like surgical robotics are prone to an initial period of hyped expectations. But this always gives way to a period of disillusionment as the team starts to learn of the flaws of the new program. Programs survive this period often by reinventing the procedure, which optimizes the program according needs of their hospital. Kubler Ross cycle of grief – Denial, Anger, Acceptance
- Cant’ consciously lower expectations – formed subconsciously; speed up decisions High risk of adverse event; high expectations means not considering worst case scenarios; lowering expectations prevents harm, mitigates unhappiness and disillusionment. below expectation events - Culture of learning and continuous quality improvement
- Should give up before the peak expectations-reality gap. Rare due to Forming Stage Surgeons credo – not always right but never unsure. This high profile led to greater urgency of other programs to adopt. Don’t want to give up – accelerate the learning process. Culture of safety from the bottom up. Fuel that drives late laggards to object Impact bias – overestimate future happiness. Inability to envision the details. Mind exploits ambiguity. Self-limited because in the future we don’t think of the past. Discuss the bailouts with the team.
- Most common phase of giving up. Storming phase. Durability bias: Misconstrue reality – the problem is culture of safety, not the procedure/surgeon. Motivated distortion – psychologically more satisfying to id surgeon as the issue, negative overreaction is used to motivate change. Focalism – bad events don’t happen in a vacuum; predict the future mental state after death of a child (don’t consider future good events). Failure to consider other events leads us to overestimate the duration of effect. Lack of awareness of a psychological immune system that reverses negative feelings (when unexamined) *negative duration is shorter than positive in the person experiencing the issue but not outside observers. Survival advantage of these reactions after the fact controlling our behavior and not recognizing that this is going on within ourselves. Hard to disconfirm the durability bias. Crisis response: deferral to expertise, collaboration, communication. No trust – centralized decisions, poor collaboration/communication.
- Poor outcomes have less long term outcome on expectations/happiness than one might originally predict. Best outcome: Organization is perceived as skilled at innovation; intellectual capital is built Common outcome: program is a hot house flower
- Very little research on innovation failures. Robotic CABG is like the bastard child that has gotten too big to ignore but it is never likely to be granted full recognition. The more we know how to do open CABG, the harder it has been to do robotic CABG. (trained incapacity) Individual (poor performance) vs. system (miscommunication) blame for discontinuance of robotic CABG