Judging Surgical Quality: How to Keep Score?

The first thing that any surgical trainee observes and understands may seem obvious—that some surgeons are better than others, their technique is much more refined and that, consequently, (mostly because of less tissue damage and speed) their outcomes are better. Patients, of course, have little or no way of knowing who has "good hands" and who doesn't unless they have an inside source. That is changing.

Now that bundled payment is moving forward, surgical outcomes are coming more and more into focus. But, a nagging issue is how to keep score:

1. How should we measure risk-adjusted outcomes?

2. Who should do the measuring? Doctors, independent third parties, payers, patients?

3. How accurate is the data?

4. How valid are the measurements and reported results?

5. How do we factor in things like surgical skill, intra-operative events (prolonged low BP during cardiothoracic surgery), surgical volume that affects outcomes, peri-operative care, and hand off issues?

6. Does bundled payment improve outcomes or does it lead to unintended consequences?

7. How transparent should we make the results?

8. Should 100% surgical outcomes reporting be mandatory and who will pay for doing it?

9. What are the appropriate carrots and sticks for getting to the "real" value equation i.e. quality/price?

10. How will this impact postgraduate education and training?

It is inevitable that stakeholders will game the system and teach to the test. Hint: Don't operate on lonely patients.

Value driven care is forcing all sick care players to focus on the numerator as well as the denominator. Unfortunately, it will take more than just plugging in the numbers to interpret the results.