SlideShare a Scribd company logo
Mt. View CT Surgery 2017
and in the future
Timeframe N Observed
Mortality
Expected
Mortality
O/E
ratio
Jan 2016 – Sep 2016 17 5.9% 2.2% 2.9
Timeframe N Observed
Complications
Expected
Complications
O/E
ratio
Jan 2016 – Sep 2016 17 17% 13% 1.1
Timeframe N Observed
Blood Use
Expected
Blood Use
O/E
ratio
Jan 2016 – Sep 2016 17 88% 43% 2.0
Timeframe N Observed
Operative
Time
Expected
Operative
Time
Jan 2016 – Sep 2016 17 355 min 309 min
MORTALITY
MAJOR COMPLICATIONS
BLOOD USE
OPERATIVE TIME
0
10
20
30
40
50
60
5% 10% 15% 20% 25% 30% 35% 40% 45% 50% 55% 60% 65% 70% More
0
5
10
15
20
25
Mortality Mortality and Morbidity
Outcomes for Heart
Surgery at Mt. View
Dec ‘16 – Dec ‘17 (n=202)
17%
16.5
16
15.5
15
14.5
14
13.5
13
12.5
12
11.5
11
10%
8
6
4
2
0
Observed Expected
O/E
0.75
O/E
0.83
Histogram of M&M Risk for CT Patients at Mt. View
frequency
Morbidity and Mortality Risk
Time
Performance
Low
High
Rapid Improvements
1st case …Nth case
Robotic program
introduced
Trial and error
Status quo
Team Learning of Less Invasive Surgery
Novice Proficient Expert
Expectations
Time
Low
High
1st case …Nth case
Status quo
Organizational Learning of Less Invasiveness
Novice Proficient Expert
Expectations
Low
High
Status quo
“The minimally invasive…much less traumatic. By the time you go home, you're
pretty much ready to go back to work.“ LA Times, story by T Maugh
Sept 2011May 1997 May 1999
“…backed away from minimally invasive after poor outcomes,
concerns about difficulty, and high cost of the equipment.”
Wall Street Journal, story by Ralph King
“Our experience with the DaVinci robot…
continues to be positive and satisfying,
encompassing more than 200 patients with
1 death and 2 permanent strokes.”
Editorial, Mayo Clinic Proceedings
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
STEP 1: Uncovering the Expectations – Reality Gap
Expectations-
reality gap
Concerns about the Safety of Less Invasive
1. Limited field of view slows response to
adverse events
2. Case selection is both challenging and
critical to success
3. Existing training does not address # 1
and #2
http://www.roboticctsurgery.com/2016/02/07/the-scandal-of-robotic-heart-surgery-training-and-what-to-do-about-it/
Learning Curve Challenges
• Communication
• Learning from failures
• Teamwork
• Prepare for safety threats
Edmondson, Amy et al. Speeding Up Team Learning. Harvard Business Review 2001: 125-132.
Less costly More costly
More Costly Categories
Inhaled nitric oxide/flolan
Intraop mentoring for TEE
Anesthesia assistants for CT cases
ECMO (two CT surgeons/perfusionists)
Less Costly Categories
Employee training: HRO
Time-outs/OR briefings
Debriefings in OR, ICU and IMC
Participate in the STS database
Safety Investments
Improvements
• IT issues
• Margo/Robin: Angiograms
• Margo: Echo images sent via text
• Matt: vital signs in robotic console
• Equipment/supplies
• Tim/Ray: IABP (cables, helium, working with cath
lab), EKG troubleshooting
• Carla/Melinda: esophageal pacing, fibrilator box,
vital signs screen, cerebrox, cinch Medtronic MV,
aortic cannula without stopcock, two iron
interns
• Jennifer: ABG vs. lab Hct, hemolyzed samples
• Bob: Factor VII dosing
• Tim: pleurovac/cell saving
• Robin/Chelsie: abx dosing for wound infection
• Communication
• Mark: implicit vs. explicit (closed loop), safety of open RA/RV
while on CPB
• Chad: cerebral oximetry
• Deannette: pacing wire/CO2 in the field
• Robin: postop issues (SBP, reintubating)
• Anesthesia: one-lung and pulm HTN
• Dee: sterility, sponge counts, motherly advice
• Matt: expertise with Everest patch, looking for bleeding sites
• Tim/Roberto: reminders about unique patient issues
(subclavian occlusion, femoral disease, IVC filter)
• Becky: difficult airway
• Safety
• Matt/Carla: groin a-line
• Tim: emergency bypass pack
• Margo: new habits (time outs x 2 and at 6 hr)
• Rhiana, Ann: TEE support
• Robin/Chelsea: risk assessments
• David: routine on-table CXR
• Pericardial effusion prior to TEE removal, extubation checklist
• Jim/Pat/Katt: flolan
• David: de facto ICU director
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
STEP 2: DILEMMA OF INFORMATION ASYMMETRY
Stakeholders outside the robotic OR:
Administrators
Referring physicians
ICU nurses/managers
Ancillary staff
QA/Peer review
Surgeon colleagues/competitors
Perfect Information
CABG
Imperfect Information
Robotic CABG
George A. Akerlof. The Market for "Lemons": Quality Uncertainty and the Market Mechanism. The Quarterly Journal of Economics, 1970; 84(3):488-500.
Improvements: ICU RN in the Operating Room
• Rationale
• Improve ICU nurse performance in the early postop phase
• Provide assistance to anesthesia in high workload period
• Metrics of success
• Evaluate hemodynamics and ischemia effectively
• Troubleshoot drips and lines
• Give protamine, fluid and blood products and describe response
• Empathy
• Announce their arrival
• Give them a break at 30 minutes
Near Misses
• Severe protamine reaction
• Off CPB without awareness
• Low AUC for cerebral oximetry
• Off CPB with ongoing surgical bleeding
• Occlude coronary with no heparin
• Large ptx noted after extubation
• Retained heartstring
Dealing with Conflict
• Administering protamine
• Responding to intraop critique
• Scheduling cases/room assignment
• Changes in the arrangement of the room
• Overreact to equipment problems
• Staffing of valve cases
• OR extubations
• SBAR – “poor respiratory status”
• Concerns about doing cases robots/off-pump
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
STEP 3: ADAPTING TO A NEW WAY
1940 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000
CHANGE IN FATAL AIRLINE ACCIDENTS OVER TIME
1940 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000
CHANGE IN FATAL AIRLINE ACCIDENTS OVER TIME
Things to Watch Out For
• Old habits
• Noise in the OR (ventilation, too many people)
• Work overload (anesthesia, perfusion)
• Accountability (echo training, high risk cases)
• Situational awareness
• Cognitive tunneling/High stress decisions
• Administration
• Follow-up: TEG, CVVH machine
• Involvement in clinical decisions
Robotics Increases the Risk of Blame
• Adverse event: Loss vs. foregone gain
• Poor morale – judgment calls go the wrong way
Criteria for Blame Before Adverse Event After Adverse Event Blameworthy
Planning
Safety
Risk unforeseeable
Persistence = grit
Negligent planning
Persistence = disregard of
safety
Could’ve
Type of program
Type of surgeon
Program is innovative
Highly skilled
Program is unsafe
Skills are idiosyncratic
Should’ve
Cause of event
Accountability
Pioneering effort
Team learning curve
Reckless behavior
Surgeon unable to learn
Didn’t
https://robpostonblog.wordpress.com/2017/12/26/the-real-reason-most-cardiac-surgeons-dont-use-robotics-its-not-about-patients/
Unique value
of less invasiveness
OPCAB results

More Related Content

Similar to Cardiac Surgery at Mountain View Medical Center 2017

Radiation Safety: The Nuts & Bolts of an Effective Program
Radiation Safety: The Nuts & Bolts of an Effective ProgramRadiation Safety: The Nuts & Bolts of an Effective Program
Radiation Safety: The Nuts & Bolts of an Effective Program
Triumvirate Environmental
 
POLY TRAUMA Management strategies .ppt
POLY TRAUMA Management  strategies .pptPOLY TRAUMA Management  strategies .ppt
POLY TRAUMA Management strategies .ppt
DR FIAZ FAZILI MUBARAK HOSPITAL SRINAGAR KASHMIR
 
Surgical safety
Surgical safetySurgical safety
Surgical safety
Man Mohan Harjai
 
Surgical safety
Surgical safetySurgical safety
Surgical safety
Batubo Nimi
 
Technology Assessment/Outcome & Cost-Effectiveness Analysis 2016
Technology Assessment/Outcome & Cost-Effectiveness Analysis 2016Technology Assessment/Outcome & Cost-Effectiveness Analysis 2016
Technology Assessment/Outcome & Cost-Effectiveness Analysis 2016
evadew1
 
Structured Problem Solving (Correction, Corrective Action, Preventive Action ...
Structured Problem Solving (Correction, Corrective Action, Preventive Action ...Structured Problem Solving (Correction, Corrective Action, Preventive Action ...
Structured Problem Solving (Correction, Corrective Action, Preventive Action ...
Lallu Joseph
 
The invasion of Robotics in Theatre
The invasion of Robotics in TheatreThe invasion of Robotics in Theatre
The invasion of Robotics in Theatre
DrNikhilVasdev
 
Abdominal Surgeries during Covid 19 Pandemic - Literature Review & Current Gu...
Abdominal Surgeries during Covid 19 Pandemic - Literature Review & Current Gu...Abdominal Surgeries during Covid 19 Pandemic - Literature Review & Current Gu...
Abdominal Surgeries during Covid 19 Pandemic - Literature Review & Current Gu...
Vishal Soni
 
Technology Assessment, Outcomes Research and Economic Analyses
Technology Assessment, Outcomes Research and Economic AnalysesTechnology Assessment, Outcomes Research and Economic Analyses
Technology Assessment, Outcomes Research and Economic Analyses
evadew1
 
Clinical quality assurance in Radiotherapy
Clinical quality assurance in RadiotherapyClinical quality assurance in Radiotherapy
Clinical quality assurance in Radiotherapy
Bharti Devnani
 
Workplace accidents and_human_error_by_isti
Workplace accidents and_human_error_by_istiWorkplace accidents and_human_error_by_isti
Workplace accidents and_human_error_by_isti
SYED HAIDER ABBAS
 
Wyatt 1b
Wyatt 1bWyatt 1b
Why jonny cant operate
Why jonny cant operateWhy jonny cant operate
Why jonny cant operate
fgetty01
 
STEMI Training
STEMI TrainingSTEMI Training
STEMI Training
cm6157
 
Nursing ppt by myassignmenthelp.net
Nursing ppt by myassignmenthelp.netNursing ppt by myassignmenthelp.net
Nursing ppt by myassignmenthelp.net
www.myassignmenthelp.net
 
Electronic Medical Records Systems & Interdisciplinary Services
Electronic Medical Records Systems & Interdisciplinary ServicesElectronic Medical Records Systems & Interdisciplinary Services
Electronic Medical Records Systems & Interdisciplinary Services
Association of University Centers on Disabilities
 
Estado actual del cierre de orejuela, por Juan Miguel Ruiz Nodar
Estado actual del cierre de orejuela, por Juan Miguel Ruiz NodarEstado actual del cierre de orejuela, por Juan Miguel Ruiz Nodar
Estado actual del cierre de orejuela, por Juan Miguel Ruiz Nodar
Fundacion EPIC
 
Radiology Department Quality (SPO- Structure, Process, Outcome)
Radiology Department Quality (SPO- Structure, Process, Outcome)Radiology Department Quality (SPO- Structure, Process, Outcome)
Radiology Department Quality (SPO- Structure, Process, Outcome)
Srishti Bhardwaj
 
Lean, Six Sigma and Emotional Intelligence
Lean, Six Sigma and Emotional IntelligenceLean, Six Sigma and Emotional Intelligence
Lean, Six Sigma and Emotional Intelligence
Ian R. Lazarus
 
Barach.Human factors HMA talk Sept 4
Barach.Human factors  HMA talk Sept 4Barach.Human factors  HMA talk Sept 4
Barach.Human factors HMA talk Sept 4
Wayne State University School of Medicine
 

Similar to Cardiac Surgery at Mountain View Medical Center 2017 (20)

Radiation Safety: The Nuts & Bolts of an Effective Program
Radiation Safety: The Nuts & Bolts of an Effective ProgramRadiation Safety: The Nuts & Bolts of an Effective Program
Radiation Safety: The Nuts & Bolts of an Effective Program
 
POLY TRAUMA Management strategies .ppt
POLY TRAUMA Management  strategies .pptPOLY TRAUMA Management  strategies .ppt
POLY TRAUMA Management strategies .ppt
 
Surgical safety
Surgical safetySurgical safety
Surgical safety
 
Surgical safety
Surgical safetySurgical safety
Surgical safety
 
Technology Assessment/Outcome & Cost-Effectiveness Analysis 2016
Technology Assessment/Outcome & Cost-Effectiveness Analysis 2016Technology Assessment/Outcome & Cost-Effectiveness Analysis 2016
Technology Assessment/Outcome & Cost-Effectiveness Analysis 2016
 
Structured Problem Solving (Correction, Corrective Action, Preventive Action ...
Structured Problem Solving (Correction, Corrective Action, Preventive Action ...Structured Problem Solving (Correction, Corrective Action, Preventive Action ...
Structured Problem Solving (Correction, Corrective Action, Preventive Action ...
 
The invasion of Robotics in Theatre
The invasion of Robotics in TheatreThe invasion of Robotics in Theatre
The invasion of Robotics in Theatre
 
Abdominal Surgeries during Covid 19 Pandemic - Literature Review & Current Gu...
Abdominal Surgeries during Covid 19 Pandemic - Literature Review & Current Gu...Abdominal Surgeries during Covid 19 Pandemic - Literature Review & Current Gu...
Abdominal Surgeries during Covid 19 Pandemic - Literature Review & Current Gu...
 
Technology Assessment, Outcomes Research and Economic Analyses
Technology Assessment, Outcomes Research and Economic AnalysesTechnology Assessment, Outcomes Research and Economic Analyses
Technology Assessment, Outcomes Research and Economic Analyses
 
Clinical quality assurance in Radiotherapy
Clinical quality assurance in RadiotherapyClinical quality assurance in Radiotherapy
Clinical quality assurance in Radiotherapy
 
Workplace accidents and_human_error_by_isti
Workplace accidents and_human_error_by_istiWorkplace accidents and_human_error_by_isti
Workplace accidents and_human_error_by_isti
 
Wyatt 1b
Wyatt 1bWyatt 1b
Wyatt 1b
 
Why jonny cant operate
Why jonny cant operateWhy jonny cant operate
Why jonny cant operate
 
STEMI Training
STEMI TrainingSTEMI Training
STEMI Training
 
Nursing ppt by myassignmenthelp.net
Nursing ppt by myassignmenthelp.netNursing ppt by myassignmenthelp.net
Nursing ppt by myassignmenthelp.net
 
Electronic Medical Records Systems & Interdisciplinary Services
Electronic Medical Records Systems & Interdisciplinary ServicesElectronic Medical Records Systems & Interdisciplinary Services
Electronic Medical Records Systems & Interdisciplinary Services
 
Estado actual del cierre de orejuela, por Juan Miguel Ruiz Nodar
Estado actual del cierre de orejuela, por Juan Miguel Ruiz NodarEstado actual del cierre de orejuela, por Juan Miguel Ruiz Nodar
Estado actual del cierre de orejuela, por Juan Miguel Ruiz Nodar
 
Radiology Department Quality (SPO- Structure, Process, Outcome)
Radiology Department Quality (SPO- Structure, Process, Outcome)Radiology Department Quality (SPO- Structure, Process, Outcome)
Radiology Department Quality (SPO- Structure, Process, Outcome)
 
Lean, Six Sigma and Emotional Intelligence
Lean, Six Sigma and Emotional IntelligenceLean, Six Sigma and Emotional Intelligence
Lean, Six Sigma and Emotional Intelligence
 
Barach.Human factors HMA talk Sept 4
Barach.Human factors  HMA talk Sept 4Barach.Human factors  HMA talk Sept 4
Barach.Human factors HMA talk Sept 4
 

More from Robert Poston

SUNY-Downstate CT Surgery Results
SUNY-Downstate CT Surgery ResultsSUNY-Downstate CT Surgery Results
SUNY-Downstate CT Surgery Results
Robert Poston
 
Surgery Grand Rounds - Downstate 2018
Surgery Grand Rounds - Downstate 2018Surgery Grand Rounds - Downstate 2018
Surgery Grand Rounds - Downstate 2018
Robert Poston
 
Invited Presentation at the Eastern Cardiothoracic Surgical Society 2018
Invited Presentation at the Eastern Cardiothoracic Surgical Society 2018Invited Presentation at the Eastern Cardiothoracic Surgical Society 2018
Invited Presentation at the Eastern Cardiothoracic Surgical Society 2018
Robert Poston
 
Outcomes for cardiac surgery at Mt. View 2017
Outcomes for cardiac surgery at Mt. View 2017Outcomes for cardiac surgery at Mt. View 2017
Outcomes for cardiac surgery at Mt. View 2017
Robert Poston
 
Team training for robotic heart surgery at Downstate
Team training for robotic heart surgery at DownstateTeam training for robotic heart surgery at Downstate
Team training for robotic heart surgery at Downstate
Robert Poston
 
Dr. Poston's surgical laser training
Dr. Poston's surgical laser trainingDr. Poston's surgical laser training
Dr. Poston's surgical laser training
Robert Poston
 
Dr. Poston's robotic training
Dr. Poston's robotic trainingDr. Poston's robotic training
Dr. Poston's robotic training
Robert Poston
 
Culture of safety for Downstate ct surgery
Culture of safety for Downstate ct surgeryCulture of safety for Downstate ct surgery
Culture of safety for Downstate ct surgery
Robert Poston
 
Data.sts.sfmc2016
Data.sts.sfmc2016Data.sts.sfmc2016
Data.sts.sfmc2016
Robert Poston
 
Pima society
Pima societyPima society
Pima society
Robert Poston
 
Support group at St. Francis
Support group at St. FrancisSupport group at St. Francis
Support group at St. Francis
Robert Poston
 
Grand Rounds: Univ of Chicago Cardiology
Grand Rounds: Univ of Chicago CardiologyGrand Rounds: Univ of Chicago Cardiology
Grand Rounds: Univ of Chicago Cardiology
Robert Poston
 
Invited Presentation: Hybrid coronary revascularization, ISMICS
Invited Presentation: Hybrid coronary revascularization, ISMICSInvited Presentation: Hybrid coronary revascularization, ISMICS
Invited Presentation: Hybrid coronary revascularization, ISMICS
Robert Poston
 
Abstract presentation - Bleeding and patient satisfaction
Abstract presentation - Bleeding and patient satisfactionAbstract presentation - Bleeding and patient satisfaction
Abstract presentation - Bleeding and patient satisfaction
Robert Poston
 
Society of Laparoscopic Surgery, Invited Presentation, Aug 2015
Society of Laparoscopic Surgery, Invited Presentation, Aug 2015Society of Laparoscopic Surgery, Invited Presentation, Aug 2015
Society of Laparoscopic Surgery, Invited Presentation, Aug 2015
Robert Poston
 
Summary of UA CT Surgery 2011-14
Summary of UA CT Surgery 2011-14Summary of UA CT Surgery 2011-14
Summary of UA CT Surgery 2011-14
Robert Poston
 
Invited Presentation: Ex Vivo Storage of Vein Grafts
Invited Presentation: Ex Vivo Storage of Vein GraftsInvited Presentation: Ex Vivo Storage of Vein Grafts
Invited Presentation: Ex Vivo Storage of Vein Grafts
Robert Poston
 
Sfmc.2015results
Sfmc.2015resultsSfmc.2015results
Sfmc.2015results
Robert Poston
 
Ems.presentation
Ems.presentationEms.presentation
Ems.presentation
Robert Poston
 

More from Robert Poston (19)

SUNY-Downstate CT Surgery Results
SUNY-Downstate CT Surgery ResultsSUNY-Downstate CT Surgery Results
SUNY-Downstate CT Surgery Results
 
Surgery Grand Rounds - Downstate 2018
Surgery Grand Rounds - Downstate 2018Surgery Grand Rounds - Downstate 2018
Surgery Grand Rounds - Downstate 2018
 
Invited Presentation at the Eastern Cardiothoracic Surgical Society 2018
Invited Presentation at the Eastern Cardiothoracic Surgical Society 2018Invited Presentation at the Eastern Cardiothoracic Surgical Society 2018
Invited Presentation at the Eastern Cardiothoracic Surgical Society 2018
 
Outcomes for cardiac surgery at Mt. View 2017
Outcomes for cardiac surgery at Mt. View 2017Outcomes for cardiac surgery at Mt. View 2017
Outcomes for cardiac surgery at Mt. View 2017
 
Team training for robotic heart surgery at Downstate
Team training for robotic heart surgery at DownstateTeam training for robotic heart surgery at Downstate
Team training for robotic heart surgery at Downstate
 
Dr. Poston's surgical laser training
Dr. Poston's surgical laser trainingDr. Poston's surgical laser training
Dr. Poston's surgical laser training
 
Dr. Poston's robotic training
Dr. Poston's robotic trainingDr. Poston's robotic training
Dr. Poston's robotic training
 
Culture of safety for Downstate ct surgery
Culture of safety for Downstate ct surgeryCulture of safety for Downstate ct surgery
Culture of safety for Downstate ct surgery
 
Data.sts.sfmc2016
Data.sts.sfmc2016Data.sts.sfmc2016
Data.sts.sfmc2016
 
Pima society
Pima societyPima society
Pima society
 
Support group at St. Francis
Support group at St. FrancisSupport group at St. Francis
Support group at St. Francis
 
Grand Rounds: Univ of Chicago Cardiology
Grand Rounds: Univ of Chicago CardiologyGrand Rounds: Univ of Chicago Cardiology
Grand Rounds: Univ of Chicago Cardiology
 
Invited Presentation: Hybrid coronary revascularization, ISMICS
Invited Presentation: Hybrid coronary revascularization, ISMICSInvited Presentation: Hybrid coronary revascularization, ISMICS
Invited Presentation: Hybrid coronary revascularization, ISMICS
 
Abstract presentation - Bleeding and patient satisfaction
Abstract presentation - Bleeding and patient satisfactionAbstract presentation - Bleeding and patient satisfaction
Abstract presentation - Bleeding and patient satisfaction
 
Society of Laparoscopic Surgery, Invited Presentation, Aug 2015
Society of Laparoscopic Surgery, Invited Presentation, Aug 2015Society of Laparoscopic Surgery, Invited Presentation, Aug 2015
Society of Laparoscopic Surgery, Invited Presentation, Aug 2015
 
Summary of UA CT Surgery 2011-14
Summary of UA CT Surgery 2011-14Summary of UA CT Surgery 2011-14
Summary of UA CT Surgery 2011-14
 
Invited Presentation: Ex Vivo Storage of Vein Grafts
Invited Presentation: Ex Vivo Storage of Vein GraftsInvited Presentation: Ex Vivo Storage of Vein Grafts
Invited Presentation: Ex Vivo Storage of Vein Grafts
 
Sfmc.2015results
Sfmc.2015resultsSfmc.2015results
Sfmc.2015results
 
Ems.presentation
Ems.presentationEms.presentation
Ems.presentation
 

Recently uploaded

Medicard presentation for companies 2024
Medicard presentation for companies 2024Medicard presentation for companies 2024
Medicard presentation for companies 2024
FrancescaAlainaDeGuz
 
Mohali Call Girls 7742996321 Call Girls Mohali
Mohali Call Girls  7742996321 Call Girls  MohaliMohali Call Girls  7742996321 Call Girls  Mohali
Mohali Call Girls 7742996321 Call Girls Mohali
Digital Marketing
 
3. User Guide Activity Budget Tracking App Steps to apply.pptx
3. User Guide Activity Budget Tracking App Steps to apply.pptx3. User Guide Activity Budget Tracking App Steps to apply.pptx
3. User Guide Activity Budget Tracking App Steps to apply.pptx
habtegirma
 
PPT DDTK 2 untuk balita dan prasekolah, deteksi dini tumbuh kembang pada anak
PPT DDTK 2 untuk balita dan prasekolah, deteksi dini tumbuh kembang pada anakPPT DDTK 2 untuk balita dan prasekolah, deteksi dini tumbuh kembang pada anak
PPT DDTK 2 untuk balita dan prasekolah, deteksi dini tumbuh kembang pada anak
woelan1
 
PPT on Embryological and fetal development
PPT on Embryological and fetal developmentPPT on Embryological and fetal development
PPT on Embryological and fetal development
smileysharma63
 
Exploring Stem Cell Solutions for Parkinson's Disease with Dr. David Greene A...
Exploring Stem Cell Solutions for Parkinson's Disease with Dr. David Greene A...Exploring Stem Cell Solutions for Parkinson's Disease with Dr. David Greene A...
Exploring Stem Cell Solutions for Parkinson's Disease with Dr. David Greene A...
Dr. David Greene Arizona
 
GORDON'S 11 FUNCTIONAL PATTERN-Health Assessment.pptx
GORDON'S 11 FUNCTIONAL PATTERN-Health Assessment.pptxGORDON'S 11 FUNCTIONAL PATTERN-Health Assessment.pptx
GORDON'S 11 FUNCTIONAL PATTERN-Health Assessment.pptx
Rommel Luis III Israel
 
THE SPECIAL SENCES- Unlocking the Wonders of the Special Senses: Sight, Sound...
THE SPECIAL SENCES- Unlocking the Wonders of the Special Senses: Sight, Sound...THE SPECIAL SENCES- Unlocking the Wonders of the Special Senses: Sight, Sound...
THE SPECIAL SENCES- Unlocking the Wonders of the Special Senses: Sight, Sound...
Nursing Mastery
 
Test bank advanced health assessment and differential diagnosis essentials fo...
Test bank advanced health assessment and differential diagnosis essentials fo...Test bank advanced health assessment and differential diagnosis essentials fo...
Test bank advanced health assessment and differential diagnosis essentials fo...
rightmanforbloodline
 
ASSESSMENT OF THE EYE (1)-Health Assessment.ppt
ASSESSMENT OF THE EYE (1)-Health Assessment.pptASSESSMENT OF THE EYE (1)-Health Assessment.ppt
ASSESSMENT OF THE EYE (1)-Health Assessment.ppt
Rommel Luis III Israel
 
一比一原版(UoA毕业证)昆士兰科技大学毕业证如何办理
一比一原版(UoA毕业证)昆士兰科技大学毕业证如何办理一比一原版(UoA毕业证)昆士兰科技大学毕业证如何办理
一比一原版(UoA毕业证)昆士兰科技大学毕业证如何办理
xkute
 
Test bank clinical nursing skills a concept based approach 4e pearson educati...
Test bank clinical nursing skills a concept based approach 4e pearson educati...Test bank clinical nursing skills a concept based approach 4e pearson educati...
Test bank clinical nursing skills a concept based approach 4e pearson educati...
rightmanforbloodline
 
English Drug and Alcohol Commissioners June 2024.pptx
English Drug and Alcohol Commissioners June 2024.pptxEnglish Drug and Alcohol Commissioners June 2024.pptx
English Drug and Alcohol Commissioners June 2024.pptx
MatSouthwell1
 
Sunscreens, IP-I, Dr. M.N.CHISHTI, Asst Prof. Dept of Pharmaceutics, YBCCPA
Sunscreens, IP-I, Dr. M.N.CHISHTI, Asst Prof. Dept of Pharmaceutics, YBCCPASunscreens, IP-I, Dr. M.N.CHISHTI, Asst Prof. Dept of Pharmaceutics, YBCCPA
Sunscreens, IP-I, Dr. M.N.CHISHTI, Asst Prof. Dept of Pharmaceutics, YBCCPA
ssuser555edf
 
Psychological Safety as a Foundation for Improvement 12-06-24.pdf
Psychological Safety as a Foundation for Improvement 12-06-24.pdfPsychological Safety as a Foundation for Improvement 12-06-24.pdf
Psychological Safety as a Foundation for Improvement 12-06-24.pdf
Healthcare Improvement Support
 
𝔹hopal Call Girls 7023059433 High Profile Independent Escorts 𝔹hopal
𝔹hopal Call Girls 7023059433 High Profile Independent Escorts 𝔹hopal𝔹hopal Call Girls 7023059433 High Profile Independent Escorts 𝔹hopal
𝔹hopal Call Girls 7023059433 High Profile Independent Escorts 𝔹hopal
garge6804
 
05 CLINICAL AUDIT-ORTHO done at a peripheral.pptx
05 CLINICAL AUDIT-ORTHO done at a peripheral.pptx05 CLINICAL AUDIT-ORTHO done at a peripheral.pptx
05 CLINICAL AUDIT-ORTHO done at a peripheral.pptx
Santhosh Raj
 
Electrocardiogram_20240614_173859_0000.pdf
Electrocardiogram_20240614_173859_0000.pdfElectrocardiogram_20240614_173859_0000.pdf
Electrocardiogram_20240614_173859_0000.pdf
Elackkiya Balamurugan
 
Solution manual for managerial accounting 18th edition by ray garrison eric n...
Solution manual for managerial accounting 18th edition by ray garrison eric n...Solution manual for managerial accounting 18th edition by ray garrison eric n...
Solution manual for managerial accounting 18th edition by ray garrison eric n...
rightmanforbloodline
 
STERILIZATION AND DISINFECTION PRACTICES IN HOSPITAL.pptx
STERILIZATION AND DISINFECTION PRACTICES IN HOSPITAL.pptxSTERILIZATION AND DISINFECTION PRACTICES IN HOSPITAL.pptx
STERILIZATION AND DISINFECTION PRACTICES IN HOSPITAL.pptx
Ritikachoudhary69
 

Recently uploaded (20)

Medicard presentation for companies 2024
Medicard presentation for companies 2024Medicard presentation for companies 2024
Medicard presentation for companies 2024
 
Mohali Call Girls 7742996321 Call Girls Mohali
Mohali Call Girls  7742996321 Call Girls  MohaliMohali Call Girls  7742996321 Call Girls  Mohali
Mohali Call Girls 7742996321 Call Girls Mohali
 
3. User Guide Activity Budget Tracking App Steps to apply.pptx
3. User Guide Activity Budget Tracking App Steps to apply.pptx3. User Guide Activity Budget Tracking App Steps to apply.pptx
3. User Guide Activity Budget Tracking App Steps to apply.pptx
 
PPT DDTK 2 untuk balita dan prasekolah, deteksi dini tumbuh kembang pada anak
PPT DDTK 2 untuk balita dan prasekolah, deteksi dini tumbuh kembang pada anakPPT DDTK 2 untuk balita dan prasekolah, deteksi dini tumbuh kembang pada anak
PPT DDTK 2 untuk balita dan prasekolah, deteksi dini tumbuh kembang pada anak
 
PPT on Embryological and fetal development
PPT on Embryological and fetal developmentPPT on Embryological and fetal development
PPT on Embryological and fetal development
 
Exploring Stem Cell Solutions for Parkinson's Disease with Dr. David Greene A...
Exploring Stem Cell Solutions for Parkinson's Disease with Dr. David Greene A...Exploring Stem Cell Solutions for Parkinson's Disease with Dr. David Greene A...
Exploring Stem Cell Solutions for Parkinson's Disease with Dr. David Greene A...
 
GORDON'S 11 FUNCTIONAL PATTERN-Health Assessment.pptx
GORDON'S 11 FUNCTIONAL PATTERN-Health Assessment.pptxGORDON'S 11 FUNCTIONAL PATTERN-Health Assessment.pptx
GORDON'S 11 FUNCTIONAL PATTERN-Health Assessment.pptx
 
THE SPECIAL SENCES- Unlocking the Wonders of the Special Senses: Sight, Sound...
THE SPECIAL SENCES- Unlocking the Wonders of the Special Senses: Sight, Sound...THE SPECIAL SENCES- Unlocking the Wonders of the Special Senses: Sight, Sound...
THE SPECIAL SENCES- Unlocking the Wonders of the Special Senses: Sight, Sound...
 
Test bank advanced health assessment and differential diagnosis essentials fo...
Test bank advanced health assessment and differential diagnosis essentials fo...Test bank advanced health assessment and differential diagnosis essentials fo...
Test bank advanced health assessment and differential diagnosis essentials fo...
 
ASSESSMENT OF THE EYE (1)-Health Assessment.ppt
ASSESSMENT OF THE EYE (1)-Health Assessment.pptASSESSMENT OF THE EYE (1)-Health Assessment.ppt
ASSESSMENT OF THE EYE (1)-Health Assessment.ppt
 
一比一原版(UoA毕业证)昆士兰科技大学毕业证如何办理
一比一原版(UoA毕业证)昆士兰科技大学毕业证如何办理一比一原版(UoA毕业证)昆士兰科技大学毕业证如何办理
一比一原版(UoA毕业证)昆士兰科技大学毕业证如何办理
 
Test bank clinical nursing skills a concept based approach 4e pearson educati...
Test bank clinical nursing skills a concept based approach 4e pearson educati...Test bank clinical nursing skills a concept based approach 4e pearson educati...
Test bank clinical nursing skills a concept based approach 4e pearson educati...
 
English Drug and Alcohol Commissioners June 2024.pptx
English Drug and Alcohol Commissioners June 2024.pptxEnglish Drug and Alcohol Commissioners June 2024.pptx
English Drug and Alcohol Commissioners June 2024.pptx
 
Sunscreens, IP-I, Dr. M.N.CHISHTI, Asst Prof. Dept of Pharmaceutics, YBCCPA
Sunscreens, IP-I, Dr. M.N.CHISHTI, Asst Prof. Dept of Pharmaceutics, YBCCPASunscreens, IP-I, Dr. M.N.CHISHTI, Asst Prof. Dept of Pharmaceutics, YBCCPA
Sunscreens, IP-I, Dr. M.N.CHISHTI, Asst Prof. Dept of Pharmaceutics, YBCCPA
 
Psychological Safety as a Foundation for Improvement 12-06-24.pdf
Psychological Safety as a Foundation for Improvement 12-06-24.pdfPsychological Safety as a Foundation for Improvement 12-06-24.pdf
Psychological Safety as a Foundation for Improvement 12-06-24.pdf
 
𝔹hopal Call Girls 7023059433 High Profile Independent Escorts 𝔹hopal
𝔹hopal Call Girls 7023059433 High Profile Independent Escorts 𝔹hopal𝔹hopal Call Girls 7023059433 High Profile Independent Escorts 𝔹hopal
𝔹hopal Call Girls 7023059433 High Profile Independent Escorts 𝔹hopal
 
05 CLINICAL AUDIT-ORTHO done at a peripheral.pptx
05 CLINICAL AUDIT-ORTHO done at a peripheral.pptx05 CLINICAL AUDIT-ORTHO done at a peripheral.pptx
05 CLINICAL AUDIT-ORTHO done at a peripheral.pptx
 
Electrocardiogram_20240614_173859_0000.pdf
Electrocardiogram_20240614_173859_0000.pdfElectrocardiogram_20240614_173859_0000.pdf
Electrocardiogram_20240614_173859_0000.pdf
 
Solution manual for managerial accounting 18th edition by ray garrison eric n...
Solution manual for managerial accounting 18th edition by ray garrison eric n...Solution manual for managerial accounting 18th edition by ray garrison eric n...
Solution manual for managerial accounting 18th edition by ray garrison eric n...
 
STERILIZATION AND DISINFECTION PRACTICES IN HOSPITAL.pptx
STERILIZATION AND DISINFECTION PRACTICES IN HOSPITAL.pptxSTERILIZATION AND DISINFECTION PRACTICES IN HOSPITAL.pptx
STERILIZATION AND DISINFECTION PRACTICES IN HOSPITAL.pptx
 

Cardiac Surgery at Mountain View Medical Center 2017

  • 1. Mt. View CT Surgery 2017 and in the future
  • 2. Timeframe N Observed Mortality Expected Mortality O/E ratio Jan 2016 – Sep 2016 17 5.9% 2.2% 2.9 Timeframe N Observed Complications Expected Complications O/E ratio Jan 2016 – Sep 2016 17 17% 13% 1.1 Timeframe N Observed Blood Use Expected Blood Use O/E ratio Jan 2016 – Sep 2016 17 88% 43% 2.0 Timeframe N Observed Operative Time Expected Operative Time Jan 2016 – Sep 2016 17 355 min 309 min MORTALITY MAJOR COMPLICATIONS BLOOD USE OPERATIVE TIME
  • 3.
  • 4. 0 10 20 30 40 50 60 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% 55% 60% 65% 70% More 0 5 10 15 20 25 Mortality Mortality and Morbidity Outcomes for Heart Surgery at Mt. View Dec ‘16 – Dec ‘17 (n=202) 17% 16.5 16 15.5 15 14.5 14 13.5 13 12.5 12 11.5 11 10% 8 6 4 2 0 Observed Expected O/E 0.75 O/E 0.83 Histogram of M&M Risk for CT Patients at Mt. View frequency Morbidity and Mortality Risk
  • 5. Time Performance Low High Rapid Improvements 1st case …Nth case Robotic program introduced Trial and error Status quo Team Learning of Less Invasive Surgery Novice Proficient Expert
  • 6. Expectations Time Low High 1st case …Nth case Status quo Organizational Learning of Less Invasiveness Novice Proficient Expert
  • 7. Expectations Low High Status quo “The minimally invasive…much less traumatic. By the time you go home, you're pretty much ready to go back to work.“ LA Times, story by T Maugh Sept 2011May 1997 May 1999 “…backed away from minimally invasive after poor outcomes, concerns about difficulty, and high cost of the equipment.” Wall Street Journal, story by Ralph King “Our experience with the DaVinci robot… continues to be positive and satisfying, encompassing more than 200 patients with 1 death and 2 permanent strokes.” Editorial, Mayo Clinic Proceedings
  • 8. 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 STEP 1: Uncovering the Expectations – Reality Gap Expectations- reality gap
  • 9. Concerns about the Safety of Less Invasive 1. Limited field of view slows response to adverse events 2. Case selection is both challenging and critical to success 3. Existing training does not address # 1 and #2 http://www.roboticctsurgery.com/2016/02/07/the-scandal-of-robotic-heart-surgery-training-and-what-to-do-about-it/
  • 10. Learning Curve Challenges • Communication • Learning from failures • Teamwork • Prepare for safety threats Edmondson, Amy et al. Speeding Up Team Learning. Harvard Business Review 2001: 125-132.
  • 11. Less costly More costly More Costly Categories Inhaled nitric oxide/flolan Intraop mentoring for TEE Anesthesia assistants for CT cases ECMO (two CT surgeons/perfusionists) Less Costly Categories Employee training: HRO Time-outs/OR briefings Debriefings in OR, ICU and IMC Participate in the STS database Safety Investments
  • 12. Improvements • IT issues • Margo/Robin: Angiograms • Margo: Echo images sent via text • Matt: vital signs in robotic console • Equipment/supplies • Tim/Ray: IABP (cables, helium, working with cath lab), EKG troubleshooting • Carla/Melinda: esophageal pacing, fibrilator box, vital signs screen, cerebrox, cinch Medtronic MV, aortic cannula without stopcock, two iron interns • Jennifer: ABG vs. lab Hct, hemolyzed samples • Bob: Factor VII dosing • Tim: pleurovac/cell saving • Robin/Chelsie: abx dosing for wound infection • Communication • Mark: implicit vs. explicit (closed loop), safety of open RA/RV while on CPB • Chad: cerebral oximetry • Deannette: pacing wire/CO2 in the field • Robin: postop issues (SBP, reintubating) • Anesthesia: one-lung and pulm HTN • Dee: sterility, sponge counts, motherly advice • Matt: expertise with Everest patch, looking for bleeding sites • Tim/Roberto: reminders about unique patient issues (subclavian occlusion, femoral disease, IVC filter) • Becky: difficult airway • Safety • Matt/Carla: groin a-line • Tim: emergency bypass pack • Margo: new habits (time outs x 2 and at 6 hr) • Rhiana, Ann: TEE support • Robin/Chelsea: risk assessments • David: routine on-table CXR • Pericardial effusion prior to TEE removal, extubation checklist • Jim/Pat/Katt: flolan • David: de facto ICU director
  • 13. 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 STEP 2: DILEMMA OF INFORMATION ASYMMETRY
  • 14. Stakeholders outside the robotic OR: Administrators Referring physicians ICU nurses/managers Ancillary staff QA/Peer review Surgeon colleagues/competitors
  • 15. Perfect Information CABG Imperfect Information Robotic CABG George A. Akerlof. The Market for "Lemons": Quality Uncertainty and the Market Mechanism. The Quarterly Journal of Economics, 1970; 84(3):488-500.
  • 16. Improvements: ICU RN in the Operating Room • Rationale • Improve ICU nurse performance in the early postop phase • Provide assistance to anesthesia in high workload period • Metrics of success • Evaluate hemodynamics and ischemia effectively • Troubleshoot drips and lines • Give protamine, fluid and blood products and describe response • Empathy • Announce their arrival • Give them a break at 30 minutes
  • 17. Near Misses • Severe protamine reaction • Off CPB without awareness • Low AUC for cerebral oximetry • Off CPB with ongoing surgical bleeding • Occlude coronary with no heparin • Large ptx noted after extubation • Retained heartstring
  • 18. Dealing with Conflict • Administering protamine • Responding to intraop critique • Scheduling cases/room assignment • Changes in the arrangement of the room • Overreact to equipment problems • Staffing of valve cases • OR extubations • SBAR – “poor respiratory status” • Concerns about doing cases robots/off-pump
  • 19. 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 STEP 3: ADAPTING TO A NEW WAY
  • 20.
  • 21. 1940 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 CHANGE IN FATAL AIRLINE ACCIDENTS OVER TIME
  • 22. 1940 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 CHANGE IN FATAL AIRLINE ACCIDENTS OVER TIME
  • 23. Things to Watch Out For • Old habits • Noise in the OR (ventilation, too many people) • Work overload (anesthesia, perfusion) • Accountability (echo training, high risk cases) • Situational awareness • Cognitive tunneling/High stress decisions • Administration • Follow-up: TEG, CVVH machine • Involvement in clinical decisions
  • 24. Robotics Increases the Risk of Blame • Adverse event: Loss vs. foregone gain • Poor morale – judgment calls go the wrong way Criteria for Blame Before Adverse Event After Adverse Event Blameworthy Planning Safety Risk unforeseeable Persistence = grit Negligent planning Persistence = disregard of safety Could’ve Type of program Type of surgeon Program is innovative Highly skilled Program is unsafe Skills are idiosyncratic Should’ve Cause of event Accountability Pioneering effort Team learning curve Reckless behavior Surgeon unable to learn Didn’t https://robpostonblog.wordpress.com/2017/12/26/the-real-reason-most-cardiac-surgeons-dont-use-robotics-its-not-about-patients/
  • 25.
  • 26. Unique value of less invasiveness OPCAB results

Editor's Notes

  1. The next question becomes how much experience that I would want my surgeon to have. Every surgeon that performs robotic CABG is somewhere on the spectrum from a novice to becoming proficient in this procedure to then finally becoming recognized as a true expert. Unfortunately, there are not many have completed this full journey. According to Intuitive’s national marketing database, out of the 372 cardiac programs that have attended training, been credentialed and then performed some robotic CABG cases, only 22 are currently considered experts as defined by performing >50 cases/yr for the last 3 years. So would it be acceptable to consider a novice or someone who is only proficient to perform my procedure?