Superlative performance in cardiovascular surgery (2024)

Abstract

Achieving excellence in surgery is an ongoing endeavor, gained through experience, observation, and practice. It is difficult to evaluate enterprise excellence, but attempts include the ratings of the Society of Thoracic Surgeons. The surgery team at Baylor University Medical Center has achieved three-star ratings for 9 of the past 10 evaluations for coronary artery bypass. This accomplishment is a result of many factors, including teamwork, multidisciplinary conferences, application of the latest evidence, continuous efforts at quality improvement, and effective governance. Some aspects of the latter include individual excellence, enjoying the work, being bold, having psychological safety, and employing meritocracy. Discernment of contemporary issues, a clear vision of the common good, and virtuous service to all must be attained while preserving the highest level of patient-centered service to patients and the institution.

Keywords: Cardiovascular surgery, leadership, outcomes, quality improvement, teamwork

“Wisdom is wasted on the old; youth is wasted in the young.”—George Bernard Shaw

Superlative surgical performance is laudable yet capricious.

Performing surgery is a technical exercise accomplished in a necessarily variable, sometimes ill prepared and messy biological milieu. Diagrams and models and flow charts are but guides. The contemporary principles of surgery are founded upon a few paradigms that “work,” though our true understanding of the molecular level may be incomplete. These principles1 (deliberation, accuracy, precision, and gentle handling) are delineated in training and then honed again and again. Ultimately, each surgeon makes her own rules and develops her own skills through personal experience, careful observation, and practice.2 The technical skills are then practiced and practiced again3 like “Fur Elise.” Without compelling new knowledge, we are loath to change.4

Defining case-specific success, though seemingly obvious, remains debatable to the beholders. Consequently, excellence is necessarily biased, flawed, and perhaps artificial. There are some accepted metrics, and they are useful.5

Individual case success does not equate to nor cause enterprise excellence.6^,7 Rather, departmental excellence encompasses the composite product production and operations of many people in their niche. People often are in different locations doing different things; their coordination requires attention, respect, and patience. Actions are intentional, and effective communication is required.8 Surgery is a team sport.

Governing a department of surgeons is the management of people. People sometimes have different goals—stated or otherwise. Competing factions, however, must be melded into a single voice with authority. Still, members all must feel purposeful, safe, and free to express themselves without reproach. Both high-quality routine work and original creative ideas must be encouraged within these walls. Still, we all are subject to agreed-upon boundaries and rules of exploration lest anarchy and chaos ensue.

Success depends on juggling reliable surgery, smooth departmental operations, and fair and encouraging governance. Superlative departmental performance is as slippery as an eel; happily, we have some experience fishing these waters.9

SURGICAL PERFORMANCE

Cases of isolated coronary artery bypass surgery (CAB) comprise half of the volume performed by cardiac surgeons at Baylor University Medical Center (BUMC); this is true nationally.10 Recently, with great advances and the availability of percutaneous tools, heart assist devices, and reflection upon meaningful use, the array of operations performed by surgeons at BUMC has broadened (Figure 1). Advances in percutaneous aortic valve implants and techniques have made it the standard of care11 with an incipient shift in procedural location. Improved tools, judgment, and skills have led to the use of more circulatory assist devices, both temporary and permanent. Still, we are generally measured by “bread and butter” isolated CAB outcomes.

Marks, grades, or scores, for want of concrete measures, have long ascribed the air of “excellence” to the skilled professions.12 Not dissimilar from points in sport, they are logical but contrived markers of “mostly good” work.13 The sentiments and statements ascribed to these “scores” are not new and are ubiquitous. Sadly, creative ideas and hard work are rarely celebrated; in America we celebrate opulence, change, and audacity.

The Society of Thoracic Surgeons’ model of operative success is used to measure success for the purpose of self-improvement.14 Data collection commenced in 1987 (Clark and Grover) and has changed many times over 20+ years. The database now collects roughly 230,000 cases per year, employing 40 million data points for individual case risk adjustment and Bayesian statistical modeling.15 Though flawed, the tool is useful.16

Twice yearly, the Society of Thoracic Surgeons issues a comparison star rating (with 3 indicating Best) of a given program versus other like programs for that specific category of case. Generally, three stars correlates with the top 12%. BUMC has attained a 3-star rating for 9 of the last 10 evaluation periods (Table 1). Our sister program in Plano has as well. Achieving this over 5 years is uncommon and is testimony to judgment, skill, performance, and departmental management.

Table 1.

Society of Thoracic Surgeons ranking of coronary artery bypass grafting procedures at Baylor University Medical Center, 2018 to 2023

Harvest date	STS rating	Program rank percentile
12/31/2018		Top 10th
6/30/2019		Top 10th
12/31/2019		Top 10th
6/30/2020		Top 10th
12/31/2020		10th–90th
6/30/2021		Top 10th
12/31/2021		Top 10th
6/30/2022		Top 10th
12/21/2022		Top 10th
6/30/2023		Top 10th

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Generally, cardiologists, internists, surgeons, and teams all improve year over year and the metric is readjusted annually. The only way to continue excellence is through programmatic, emphatic, continual self-improvement.¹⁰ Departmental performance impacts this achievement by embracing feedback in all aspects of care delivery.

Many facets have improved during CAB. The technique of cardioplegia (the cardiac arrest technique) simplified by Dr. del Nito has allowed for a more complete and longer period of protected cardiac arrest, thereby reducing the need for repeat and distracting cardioplegia dosing into the heart. The operation is simpler.

Locally developed and nationally recognized data show the value of graft evaluation in real time in the operating room using ultrasound and Doppler flow analysis. This technique generally leads to the revision of 1% to 3% of graft distal anastomoses with obvious improvement. This assessment is used in all questioned anastomoses and is available in all the CAB cases performed at BUMC. Our technique is tested.

Surgeons at BUMC and internationally have observed the long-term survival benefit of employing arterial conduits where indicated and when the conduit is available, normal, and the harvest is free from unintended consequences like harvest organ ischemia or steal. Some improvements in harvest technique using lower energy are honed here. We have increased the frequency of artery grafts from the standard and well-known left internal mammary artery only to left anterior descending artery anastomosis (7%) to mostly multiple arterial grafts (>20%). The CAB is more durable.

Recognizing the true expertise of all members and colleagues, CAB at BUMC enjoys extensive programmatic review before patients go to the operating room. Other cases, indeed any unusual or informative case, are discussed in the forum. Cases of patients who have a high predicted mortality, who are transferred from outside hospitals, or who have known mitigating but perhaps not measurable comorbidities are reviewed regularly in a fully staffed multidisciplinary conference. Participants in these conferences include surgeons, cardiologists, nurses, advanced practitioners, perfusionists, and administrators. All enjoy a safe and secure space. In the last year, 250 cases were presented. Once the plans were amended, more than two-thirds proceeded as reviewed. The meetings are marked by attention, decorum, and creativity. Recommendations are not binding and are free from retribution. Follow-up on the subsequent events is presented in a later meeting for review and education. Participation is active; attendance is high.

STRUCTURAL HEART

Because one-fourth of cardiovascular surgery cases are “structural” cases, the most common case—surgical aortic valve replacement with or without CAB—is also star rated. These cases differ in pathology and technique from CAB, requiring some artistry for success. Advances in cardiac imaging pioneered often by our colleagues17 have illuminated the nongeometric nature of previously perceived round or angled structures. Because transcatheter aortic valves are so successful,18 surgical aortic valves are now less common; however, open valve surgery remains essential, if not existential, to the required menu of cardiovascular services.19

Because of the lower number of these cases and their attendant high-risk profile, nationally and at BUMC the ratings require a greater number of data points gathered over a much longer term (3-year evaluation period) and change less quickly. In the most recent star ratings, we have achieved very high two-star ratings in both categories; achieving three stars is statistically nearly impossible given our robust yet small volume.

Hand in hand with the honing of transcatheter aortic valve replacement and routine straight open surgical aortic valve replacement skills and judgment is the development of techniques addressing aortic valve preservation and programs for surgery for aortic dissection and aortic aneurysm. Department members with experience are now routinely performing aneurysm surgery with preservation of the aortic valve leaflets, thus allowing patients to keep their native valve without anticoagulation or fear of implant deterioration. Some patients also undergo other operations (head vessel debranching) to prepare the aortic arch for percutaneous operations.

Aortic dissections remain a vexing problem of uncontrolled hypertension. Under surgeon leadership at BUMC and Plano, the Baylor Scott & White Health system has implemented a program of designated and specific aortic dissection call teams for addressing these cases, which are often true emergencies involving cardiology and vascular surgery colleagues. The surgeons at the Dallas campus have managed over 300 aortic dissections in 8 years20 and have operated on over 150 ascending aortic dissections with a <9% mortality. Published mortality elsewhere is up to 20%. A similar experience is reported by our surgeons in infective endocarditis.21

Elective aortic issues including aneurysms, repeat operations, endovascular leaks, and some chronic dissections, among others, are complex problems that are best treated in a team setting. Again, under our surgeons’ leadership, these cases are generally directed to the Aortic Center for expert and experienced management of these often complex structural heart syndromes. A team led by bona fide expert surgeons22 is present, and each case is presented for review and comment at the aortic conference on Thursday mornings.

Department members have pioneered techniques to reduce sternal wounds and to accelerate sternum bone healing. In 2010, the sternum wound infection rate for CAB exceeded 2%. With the development of vancomycin paste combined with the use of platelet-rich plasma, the rate of CAB sternal wound infection in this department has plummeted to <0.3%.23 Others have followed to validate the technique nationally, so the national rate has fallen too. Infection cases now principally occur in patients with uncontrolled diabetes mellitus, immunosuppression, more than one sternotomy, ventricular assist devices leading to transplantation, or other assist device changes.24 Together with early treatment of suspicious wounds using wound suction techniques, the management of sternal wounds has dramatically improved.

Collaborative improvements in care have come from our anesthesia colleagues as well. Over the last 10 years, we have collaboratively developed a designated team of cardiac anesthesiologists with expertise in transesophageal echocardiography and the acute management of complex acute systolic and diastolic heart failure. All “pump” cases employ transesophageal echocardiography and right heart catheter monitoring unless contraindicated. Almost all cases are handled in a collaborative way, particularly in the induction and recovery phase. Expert continuous monitoring greatly improves our collective judgment and myocardial health immediately before, during, and after the operation.

Our intensivist team members have improved greatly. The intensive care unit (ICU, 4Roberts) is now staffed continuously with physician attendings (plural), certified nurse practitioners leading the team of over 20 certified ICU nurse technicians, and other professionals. Training, collaborating, and teaching are constant and emphasized. Multidisciplinary rounds are held daily with 8 to 20 partners, including pharmacists, nutritionists, physical therapists, critical care attendings, and others. The attending physicians staffing the ICU direct an Accreditation Council for Graduate Medical Education–accredited critical care fellowship. Advanced therapies for rescue are immediately available, including real-time expert multidisciplinary review for surgery at the bedside and extracorporeal membrane oxygenation. We are a Platinum Center of Excellence, the highest level of extracorporeal membrane oxygenation management attainable. From this, numerous protocols that include checklists for administration of medicines and progression and/or escalation of care have been derived, resulting in consistently more uniform care. The advanced practice nurses administer an American Nurses Credentialing Center–accredited nurse practitioner fellowship. BUMC has been redesignated Magnet status for the fifth consecutive period, an achievement attained by only nine hospitals nationally.

DEPARTMENT OFFICE OPERATIONS

Operations of the department are managed by a staff of 20 to 22 professionals. They include but are not limited to surgeons, advanced practice nurses, a manager, administrators, assistants, and nurse practitioners.

Over the last 5 years, the office moved to the Baylor Scott & White Heart and Vascular Hospital. This move allows simple staffing of the aortic center, valve clinic, and numerous conferences and easy access to cardiologists and patients’ families. Physical proximity facilitates personal interaction with fellows, staff, and administrators. With these changes and expert management, the office has enjoyed an exceedingly low 11% turnover rate in the last 5 years.

Inviting colleagues to view, visit, and comment on our program is a healthy departmental activity. It costs time, effort, and money. A visiting professor program at BUMC downtown has allowed a robust program of visiting professors to visit BUMC’s cardiovascular surgery department in conjunction with Baylor Scott & White Heart and Vascular Hospital’s cardiology department and the vascular surgery department. Over the last 3 years, we have hosted 13 visiting professors for collegial review and advice (Table 2).

Department members continue to engage in research and development, with all members publishing in peer-reviewed journals over the past 5 years.

Breadth of knowledge in the arts and sciences is important for patient relations. Department members’ expertise is diverse and deep. Department members participate in recognized and unrecognized pro bono surgical care, international outreach, and training—principally in Central America and England. In addition, they have authored several books and lay press articles regarding history, philosophy, art, and avocations and in their spare time host numerous intellectual organizations within our community.

FAIR AND ENCOURAGING GOVERNANCE

In any just and steady governance, three concerted goals must be attained: discernment of contemporary issues, clear vision of the common good, and virtuous service to all. All must be attained while preserving the continual exemplar patient-centered service to patients and to the institution.

The US founding fathers had a not dissimilar problem when designing the functionality and governance of this new great country composed of widely disparate people. Mankind has long recognized that drive must be bounded by rules. Through great consternation and deep historical examination, they recognized that drive fueled necessarily by personal liberty must be balanced with the boundaries for the common good. Neither concept was new. Opulence, change, and audacity are antithetical to good parenting or good management. So departmental management problems are not new.

Departmental representative democracy is the preferred form of governance. Preserving liberty, surgeons are encouraged to pursue individual expertise and skills. Creation of a beautiful functional unique operation is enormously fulfilling. As long as the therapy is not injurious, there is only benefit and celebration of the intervention. Surgeons are to improve technically and strategically on existing paradigms, and they are to serve as many patients and referrals as is prudent.

Striving for equipoise, there is a goal to have one voice on shared issues while allowing members to, within boundaries, change their world for the better. To maintain equality, the safety of all professionals and staff members from aggression from an overzealous member is maintained. Further, the department itself maintains protection from outside aggression and distraction while maintaining an environment full of fertile educational opportunity.

These goals are only accomplished with true administrative professionals at the helm of governance. The impartial party is principally concerned with preserving the excellent outcomes and productivity of the department as a unit and also as an arm of the overarching healthcare system. This is a necessary component of governance that may not always please an individual member or worker, but upon reflection it will please one who remains interested in the common good.

With these “boundaries” and “protections,” the department can confidently develop and deliver its work. In the milieu of a large, vibrant, and progressive medical center, this form of departmental governance allows every member to pursue his or her chosen endeavor avidly and confidently. Liberty, equanimity, and fraternity are preserved.

CONCLUSION

An outside view is often superior to introspection. I was physically away for 2 years, and now I see the Baylor Scott & White Dallas unit with fresh eyes. All departments run in a somewhat kluge way; we are no different. However, because our team members have boundaries and excel in some areas, our relational coordination is high and our administrators handle the department intentionally and emphatically well. I take license to identify points that codify how we have accomplished this (Table 3).

We all must be very good at what we do. To be good, one must continually repeat and practice. Volume solves most statistical problems, but high quality speaks for itself. With sufficient volume, we can compare ourselves to the standard. Still, surgeons’ teams must have fun and enjoy their work; it is quite stressful and difficult. Without joy, there is only toil.

To foster professional bravery, department leaders must encourage the necessarily selfish creative energy, accepting that some individuals will push the boundaries. Bumpers must be identifiable, gentle but firm. Yet reproducibility is crucial. Surgeon administrators must create an environment that is fair and safe for surgeons and staff members to strive for excellence while ensuring equality of opportunity. Only fair play persists.

Finally, meritocracy promotes excellence. Governors must subscribe to meritocratic advancement. The individual is the basic unit of merit, fairness, and equality. His or her advancement is based on merit. Excellence in outcomes is the highest merit.

I am pleased to be a longtime associate of the department.

References