Quality, safety, and value — a triad of related and interdependent components — together form the fundamental basis of providing optimal patient care. This is the precept that drives the work of Michael G. Vitale, MD, MPH, Chief Quality Officer for the Department of Orthopedic Surgery at NewYork-Presbyterian/Columbia. Dr. Vitale, in collaboration with William N. Levine, MD, Orthopedic Surgeon-in-Chief, and Kevin Wang, Quality Officer for Columbia Orthopedics, is vigorously pursuing the development of protocols and processes that will improve the overall outcomes of patients who seek out orthopedic care.
“I have long had an interest in quality, but had been primarily focused on pediatric orthopedics,” says Dr. Vitale, who is also Chief of Pediatric Spine and Scoliosis Surgery at NewYork-Presbyterian/Morgan Stanley Children’s Hospital.
In 2013, Dr. Vitale led a nationwide quality effort addressing the variability in perioperative surgical site infection practices following pediatric spine fusion. An expert panel composed of 20 pediatric spine surgeons and three infectious disease specialists from North America, selected for their extensive experience in the field of pediatric spine surgery, developed a consensus-based Best Practice Guideline (BPG) consisting of 14 recommendations for the prevention of SSIs in high-risk pediatric patients undergoing spine fusion. For the purpose of their study, the results of which were published in the Journal of Pediatric Orthopedics, high risk was defined as anything other than a primary fusion in a patient with idiopathic scoliosis without significant comorbidities.
“By implementing these recommendations, we immediately had a drop in infection rates to near zero,” notes Dr. Vitale, who was lead author on the paper. “And even years later, we still maintain infection rates in pediatric spine surgery that are as low as anywhere in the country.”
Dr. Vitale’s Work as Chief Quality Officer
Since becoming Chief Quality Officer for the Department two years ago, Dr. Vitale and his Columbia colleagues have taken a multidisciplinary, coordinated approach to improve both adult and pediatric patient care in a number of areas, including pain management. “We recognize that we can do better at communicating to patients about expectations and about responding quickly to people with discomfort,” says Dr. Vitale. “In combination with medical and nonmedical treatment, it is critical that patients have perioperative comfort.”
Another safety initiative focuses on radiation exposure. “We are reviewing the rational use of X-rays,” says Dr. Vitale. “While a single X-ray generates a limited amount of radiation exposure, a patient diagnosed as a child experiences radiation exposure that is cumulative. So we’ve paid a lot more attention to ordering as few X-rays as needed, being careful about the timing and dosing, and limiting CT scans.”
Achieving high value for patients is another overarching goal of the Department. “Value in health care means making sure that everything we do — what we order, everything we purchase, and every orthopedic implant we use — is appropriate and absolutely needed,” says Dr. Vitale. “We’re also constantly reevaluating the amount of lab work required.”
Dr. Vitale also calls on the expertise of Henry H. Ting, MD, Chief Quality Officer for NewYork-Presbyterian, and utilizes the well-established quality and patient safety infrastructure of the Hospital’s Value Institute. “It’s truly a team effort,” says Dr. Vitale. “But it requires a combination of a systems approach – a look at institutional and network and infrastructure issues – as well as some on the ground, front-line work with surgeons. Ultimately it’s the surgeons who are in the position to most quickly effect change.”
Dr. Vitale cites the Hawthorne effect — the alteration of behavior by the awareness of being observed — to describe efforts to improve quality, safety, and value. “The reality is that if you observe a situation, it gets better; if you shine a light on a problem, it gets better,” says Dr. Vitale, who regularly meets with the Department’s orthopedic surgical team, providing feedback on data.
“We start out every meeting as a group with a safety vignette that’s volunteered by a resident or staff member who shares a concern about patient safety,” notes Dr. Vitale. “Part of my role is to follow up on that concern to prevent that particular incident from happening again. Oftentimes it’s just a matter of awareness by the people who are involved that enables us to correct it. Everyone wants to improve their patients’ outcomes, so once you start showing that there is the opportunity to make improvements in so many areas — antibiotic utilization, prophylaxis for deep vein thrombosis, average time to do an operation, or wait time before a patient enters the OR — it almost universally results in a shift in the right direction.”
Dr. Vitale allows that there has been emphasis and focus of attention on improving the quality, safety, and value of care in medical centers across the country. “We are certainly not alone in this; there are a number of centers that have a dedicated and similar infrastructure and focus,” he says. “We learn from each other. If a group elsewhere is doing something that works well, you learn from their experiences. I also try to share our experiences, for better or worse. Fundamentally we have an opportunity to make a difference. We’re all very much on the same team.”
Vitale MG, Riedel MD, Glotzbecker MP, Matsumoto H, Roye DP, et al. Building consensus: development of a Best Practice Guideline (BPG) for surgical site infection (SSI) prevention in high-risk pediatric spine surgery. Journal of Pediatric Orthopaedics. 2013 Jul-Aug;33(5):471-78.