Case Study: Objective Surgical Mortality Analysis

Situation:

• A large teaching tertiary care facility wants to objectively review each mortality case for a selected surgical subspecialty
• Focus is on overall program improvement, not just practitioner competency for the evaluation
• Peer review is to be used to "drill down" to commonalities in technical, equipment, process and emergency decision making impacting patient care and safety
• Findings to be used to enhance competitive edge in market share and surgical outcomes

QMCG Team Role:

Conducted an objective and independent review of all mortalities for all surgeons in the target surgical specialty during a specific timeframe using an eight (8) step process:

• Select a nationally recognized surgical leader to conduct the objective retrospective peer review
• Enhance surgical criteria for expanded evaluation capture
• Offsite objective record/film review with planned onsite program visit after peer review completed
• Report (for each surgeon) development
• Opportunity for Committee conference call with Reviewer to review objective peer review findings
• Onsite program evaluation and assessment of subjective program data to make suggestions for program improvements
• Onsite report of program opportunities for improvements and program prioritizations
• Ongoing "as needed" support continues

Peer Review Study Conclusions:

Surgical case selection criteria needed honing and program hardware needed upgrading. One surgeon required proctoring in a specific technique.

Facility Accomplishments:

Since receipt of the reports and conclusion of all conference calls:

• Program is scheduled for fiscal infusion to upgrade equipment
• Multi-disciplinary surgical case selection criteria has been revised
• Surgeons were heard and supported
• Confirmation of sound and safe quality care delivery