well it's it's a great pleasure to be here and I'm delighted to have this relationship to Pee and I you know um I started two years ago uh and I came in as a neurosurgeon with P. And I with a very small clinical practice. I was I was charged with working on innovation and quality within P. And I and I gotta roll it's sort of a manufactured role almost a role uh with the regional neuroscience Institute neurology neurosurgery that covers all 11 hospitals in southern California roll. Um to work on improving the programs and over over the next couple of years with a lot of great colleagues and a lot of involvement from P. And I we saw quite dramatic improvements in the system of care for brain tumors. We saw improvements in the acute treatment of stroke with thrombin, ectomy and and T. P. A. Um And so as as Chester said I was asked to become the chief medical officer for each of the institute's G. I. Cardiac oncology, behavioral health even. And you know it really it sort of was the result of a broad misconception of what I had done. I was indirectly because I was affiliated with attributed um a lot of the improvements in neuroscience and they said wow that's really amazing everything that's being done in neuroscience. And so I was the indirect beneficiary of that. They thought I had done it. It was dan and Chester and and Garnie Barcode Aryan and our great neurology team who really had done it because he and I is unique amongst all the medical groups and providence Because it has, it covers stroke in four different hospitals, it covers neuro oncology in seven of the 11 hospitals. Um It's really taken over not only ST jOHn's which has outstanding performance metrics, but also a little company of mary which is rapidly approaching the same quality level as uh ST john's. So um you know, I was, I was the fortunate beneficiary of this broad misconception, but I'd like to, I'd like to talk about some of the things that have been done, actual projects that we've worked on uh in providence over the last couple of years, talk a little bit about some of my past experience and try to provide a few guidelines on how to do. The one thing that uh we like everybody else in any line of work has to do and that is constantly get better, constantly improve if you're in business and you're not constantly improving, you're gone pretty quickly and we have to, we have to assume we have to adopt that same kind of attitude and many people in healthcare have and I'll talk a little bit about some of those opportunities. So I don't have any relevant disclosures here. Um but you know, in neurosurgery, it's, it's a high stakes endeavor, but all of health care really is, it all affects the lives of patients and their families and their communities. Uh And so, you know, shouldn't we be aspiring for perfection, perfection is perfection is the absence of flaws and flaws have negative consequences on people's lives. Um, and the concept of perfection is really adopted in professional sports. So this is from Vince Lombardi, after whom the Super Bowl trophy is named. We're going to relentlessly chase perfection knowing full well that we won't catch it, You can't be paralyzed by the concept of perfection because nothing is perfect, but we're gonna chase it because in the process will catch excellence. So you have to envision what perfection might be. You have to do everything reasonable to approach perfection, but there is a flip side to perfection. Um you hear, um Good today is better than perfection tomorrow. Well, I would agree with that. Don't be paralyzed by constantly overthinking how you're going to get to perfection and not do anything. It's got to be coupled with action now because the lessons associated with action as you aspire to approach perfection, those lessons are critically important and you have to be out there in the world working acting to learn those lessons, but this is not an uncommon thing in a lot of different areas. So Professor Chengji at the capitol University in Beijing, um he was one of their iconic department shares wrote this because as we, because we work as though on the brink of an abyss and walk as though on thin ice that's neurosurgery in the operating room almost every day. We go all out to seek ultimate perfection. It's the same general concept that um it's a high stakes endeavor. Try to figure out how to be flawless and avoid the things that are going to compromise the outcome for the patient. So it's not uncommon and and uh, you know, a tool go one day and his book better has written this better is possible. It doesn't require genius. It takes diligence, it takes moral clarity and ingenuity. And above all it takes a willingness to try. So action is critical. Um, and and diligence means, you know, baby steps Taking a step one step forward every day. Uh not trying to hit the Grand slam home run, but working on all those elements that contribute to a flawless outcome. And then Pat Riley, you know, Pat Pat Riley used to be the coach of the L. A. Lakers, but Pat Riley is the only guy who's won the NBA championship as a player, as a coach and as a team president. And so he knows something about excellence. He did it with the Lakers, he did it with Miami heat and still is excellence is a gradual result of always striving to do better. So again, it's an envisioning where you want to go to be as flawless as possible, continuing to work on it. So here's here's the key things in healthcare that that I think um enable us to pursue perfection. It's that relentless focus on progress. You have to measure your results, metrics are critical. You can't walk around a unit in the hospital, you can't talk to the people on a particular service line and and fully grasp what their performance level is. Um, so you gotta measure it measurements. Key. None of the measurements are perfect. A lot of them are controversial. You still have to measure and and constantly work on getting the best possible measurements. I'll show you some simple examples of how powerful that really is. You have to acknowledge and reflect on failure. You know, I was presenting a case one time at morbidity and mortality rounds. It didn't turn out the way I wanted. And one of the, one of the, one of the empathetic colleague neurosurgeons said don't beat yourself up over it. If you're going to get better, you have to administer yourself with beating after every bad outcome. You've got to be able to take it and be honest about the mistakes. You may not point the finger at somebody else not make a lot of excuses. That's wasted energy. It's what did I do? What could I have done differently? How would this turned out? And that endeavor is really critical and it it applies in a broader sense when you're looking at improving whole service lines or improving an entire hospital and as you identify the flaws, you have to come up with specific interventions to deal with the individual flaws and you have to work to improve every element. We'll talk a little bit about that, all of these, all of these things lead to the development of a plan that is a result of measurements and a result on the reflection of failures and flaws and the ingenuity to come up with plans to improve every element. So you do have to have a plan and a protocol really ought to be the last bullet point of a plant. That's not cookbook medicine protocols aren't cookbook medicine planning is essential. A plan doesn't fit every single play patient. That's where the skill and experience of an individual clinician is and that is to how to massage and modify a standardized best practice evidence based plan for the patient sitting in front of you. But you've got to have a plan. Planning is essential and um this, this is a story that I find interesting. Sir David Brailsford, anybody here know who he is? Probably not. You got to read about this guy, you got to read this story. It's the most amazing story In about 2003. Sir. David Brailsford became the Director of Silence, National Director of Cycling for great Britain for the UK which had as its history 100 years of failure. They had one like 1 Olympic gold medal, never won the Tour de France mired in mediocrity and he came on board and his fundamental concept was, we have to look at every possible element that impacts performance of our cyclists And improve them just a little bit as much as possible, but even 1% is going to count. You know, if you, if you get better by 1% every day of a year, You're 30 times 37 times better by the end of the year. So that little bit of improvement is critical because it's like compound interest. So he, what did he do? He um he changed the mattresses and pillows for all the cyclists. He took, he took away so they would get good rest, he took away their uniforms and gave them skin tight aerodynamic uniforms. He observed that often the van where they repaired, the cyclist was dirty, so he had them all painted pure white so that the smallest speck of dust would turn up and they could, they could clean it out. He found out the tires on the bicycles got better traction if they rubbed them with alcohol. He developed more comfortable seats for the riders, but he also paired this with some innovations, they develop force measurement devices, they had aerodynamic wind tunnels to check things, but he looked at every possible element. I mean, he changed the gel used for the massage, is that the cyclists had and six years later in Beijing, they want more gold medals in cycling than any other country country And another five years later they won the Tour de France and over the period of 10 years, they dominated cycling at every level The 15 Tour de Frances and continued winning World Championships and gold medals through through this approach. And you know, maybe part of this, in fact, almost certainly part of this is the fact that as everybody gets engaged in looking for these opportunities to improve, you develop a contagious enthusiasm that spreads throughout the team and that positive energy uh is the, is the incredible halo effect of this kind of approach. And I've seen the same thing when we work with medical teams to improve their performance and we start looking at all the different things that we can do to improve. And people start getting up uh encouraged when they see measurable improvements, then they start getting the pride of their team and they can't wait to tell you about the exciting things they're doing. And once you get to that level it becomes self sustaining, as long as as long as they get appropriate encouragement and support so that you can search that right there at James Clear dot com. He's the guy who wrote about this. Um but if you look up David Brailsford, you'll find marginal gains everywhere. So is is improving improving possible? Well, we've seen dramatic improvement in, in the airline industry. You know, it's been years since there's been a commercial airline accident with loss of life in the US years. Uh huh flat panel TVs, you know, when I first looked at flat panel TVs in the early two thousand's at circuit city, a 40 inch crappie five panel tv was $10,000. A TV that is 10 times better in performance and resolution at Walmart now is $200. Have we seen that kind of improvement in health care Over the last 20 years? Well, you know, human biology is a lot more complicated than a flat panel tv granted. But we should be making some kind of equivalent improvement and in many areas in health care, we are seeing dramatic improvements, but we should be aspiring to that kind of transformative improvement because if you're making flat panel TVs and you're not improving at that rate, you're out of business, you're gone. And uh you know, we have made some improvements. If we look at a brain tumor surgery, you know, in 19, in 1889 I found a meta analysis, they didn't call it that that term hadn't been invented yet. That reported brain tumor surgery mortality 49%. So it was 5050 that you were going to survive the operation at that point. Then came some incremental improvements over the next 10 years. And um, you know, 20 years later, Harvey cushing who, who was the david Brailsford of neurosurgery. He looked at every element of what he was doing and improved everything. They, you know, some people say that harvey cushing is famous because he closed the Galia. So no longer were the wounds falling apart tiny little the Galia doesn't seem like the least important part of the whole operation but that in addition to everything else. He dropped he dropped the mortality to 14% Walter Danny. A fantastic surgeon dropped it down to 2.5%. Today. It's It's well under 1% in most places it's around 1% or less in most places including in our hospitals and providence. But we're not only you know we're not only working on patients surviving. We also want we want to preserve function. In fact we even want cosmetic results that look as if you never had surgery whatsoever. And and we'll talk about this in a minute. We want people to go home on the first or second day after surgery and we want them back to their life with no interruption In 6 to 12 weeks. Don't always achieve it. But we should be we should be figuring out given our current capabilities what's a perfect operation looks like. We'll talk about that in a minute. And you know, you should read Michael Porter. If you haven't you can find abstracts of Michael Porter's work all over the internet. You can find power points. He's a he's a Harvard business school. Um Professor written a lot about health care, mainly value based healthcare but you know value based healthcare is good health care. And these are some there's some of the strategic agenda. You know it is organizing around patient conditions. Well that's what P. And I has done. We've organized around neurological conditions that are all intersecting. So you know E. N. T. Works with neurosurgery to treat pituitary tumors by doing incision list surgery right up the nostril to take out a pituitary tumor. We're working with DR Volcker's um to restore hearing so that the people in our brain health program have something to offer to the patients who have deafness that is compounding their dementia uh measure outcomes and costs. You know, that's a that's a fundamentally critical thing. Bundle payments causes you to think more globally um integrating across all the different environments of care from home to hospital to skilled nursing facility and rehab etcetera. And um affiliate across geography is to reinforce excellence. That's a fundamental thing that we're trying to do with providence right now. Not every one of the 11 hospitals in the providence providence southern California, which is the biggest providence region. Not every hospital has to have a quaternary skull based cochlear implant plant program. And and not every hospital can but we need it in the system. So we need to be integrating across the hospitals and in fact we're doing that with brain tumors and ST johN's is one of is one of the comprehensive brain tumor centers because of the high experience because of the high quality because of the efforts to continuously improve everybody has heard this I don't need to really deal with this too much. We you know everybody used to talk in neurosurgery and probably almost every surgical specialty about their volume of cases, the more you did, the better your program. But that doesn't always translate. And so value is critically important to look at. You know, what are you, what are the outcomes of your patients and and how efficient are you? What's your clinical effectiveness for carrying those those patients in an efficient and cost conscious manner. When you when you want to get better, we're going to talk about improving your operational strategies, improving your effectiveness. I'm not gonna go into innovation in any huge amount of detail because that's really what most people talk about in advance service lines is innovation. The latest device, the latest therapy, the latest um ah newest medication. You know we've seen a lot. Here's here's a diagram of brain tumor surgery and the way we did it. When I started in training would make a big opening. We'd retract on the brain, find an aneurysm and put a put a clip across it like this. A spring loaded titanium clip would squeeze shut the aneurysm and close it off. It's very effective. But it does take a big operation that can can have its own consequences until at U. C. L. A. Back in the eighties and nineties uh a trans arterial endovascular approach was taken where coils were put in the aneurysms. You drove right up the freeway of the artery into the aneurysm. You filled it with titanium coils and blocked it off from the inside with no external incisions other than a puncture wound for the angiography. And this really has over the last 20 years has become the technique that's used in anywhere from 80 to 90% of the cases now didn't exist when I started. So innovation is extremely powerful. I'm not gonna I'm not gonna focus in on innovation here today because we have we have opportunities every single day right now to focus on improving our effectiveness. You know 111 other thing people have talked about in in in improving health care is that is access. It used to be that 40 million plus people had no meaningful access to healthcare. Um and now it's it's under about 10%. The country's made uh made some pretty good progress in providing access to healthcare for people across the spectrum covered California and other programs like that no matter where you are in the political spectrum whether you like obamacare or not, that's one of the net effects of it. And it helped a lot of people. Ah we developed a robot. So our intensive list could be on call 24 7 but didn't have to live in the hospital and he could drive up to the bedside and evaluate a patient using this robot. He drove it like with with game controllers and could see the patient, the patient could see him and he could see new admissions to the ICU at three a.m. Without getting out of bed driving to the hospital night after night after night we We had the first robot in the icu anywhere in 2007. There's thousands of them in I. C. U. S. Around the world. Now I'm gonna talk about surgical care redesign. I want to focus on the importance of data for a second. You know, this is from Michael Porter's work. He he pointed out what in the in the timeframe of 87 89, what the kidney transplant survival rate one year kidney survival rate was across all the transplant programs. Um and you can see that there's a broad spread And the average is around 80%. That kind of data was mandated reporting that I was mandated and um what was the effect of that? Well two things happen years later after everybody saw the data and started working. Especially if they're on the lower end. They worked really hard. This is what it looked like in 2011, the average went up tremendously because keep people carefully tracking their results and they were learning from the programs that we're doing it the best and who improved the most the worst centers improved the most because they saw that they were the worst centers and they knew they had a big opportunity and they worked it hard or they were dropped from the kidney transplant capable uh conditions. So data is powerful. Um and data alone can precipitate this kind of improvement. Here's a here's a personal story I this is work I did with Nancy Mclaughlin who was a fellow trained by dan kelly uh at ST john's um and an extremely dedicated and smart neurosurgeon who helped me. And around that time I started getting interested in quality II appointed a quality director in our department, Native Parady and I said Nader take a look at all the operations, find us the opportunities that are there for us to improve. Where were our results aren't where we want them to be, where there are too many complications. Three months later after intensively studying our our dad, he came back to me and said, well dr martin, we do have, we did find, you know one glaring opportunity. It's your operations for microvascular decompression, for trigeminal neuralgia. You have too many. You have far too many CSF leaks. The patients are in the hospital too long. There's too many readmissions. That wasn't exactly what I sent him off to find, but that's what it was. So with nancy Mclaughlin's help, we reviewed all of our cases and uh we found flaws in the closure of the dura and and how we sealed everything up with with how we closed it. We we found that patients would stay in the hospital too long for reasons that weren't clear. So we carefully went through the preoperative phase, the interpretive phase and the postoperative phase and we did a David Brailsford on it. We said what can we improve in each one of these categories? What we found was in the patients where everything went well they would go home in two days sometimes. And I was saying when the patients asked me how long will I be in the hospital? Was saying the patient, well you know I don't know three or 3 to 5 days because that's sort of what it felt like to me when we measured it, you could go home in two days. So I started telling patients You're gonna go home in two days. And I did it with a little bit of trepidation because I thought you know if they have to stay four days they're going to say to me you didn't tell me how serious an operation this was. You, you undersold this whole thing. They never said that most of them would go home in two days. Their families accepted it, they accepted it. If they had a little bit of a headache or a little bit of nausea, it wasn't gonna get any better line in a hospital bed. So they would go home in two days. We did not have increased numbers of readmissions because we had redesigned the operation to be more effective and have fewer complications. Uh And if they did have to stay here is what they said. If I said you know you're gonna have to stay another day because you just have a little too much nausea and you're still unsteady. They said thank you every time. So and when I share that story to surgeons and other disciplines it often cut 12 or three days off the hospital ST just telling the patient you're going home in whatever two days, three days best possible scenario in intra operatively. Um We introduced a serious time out so that we can make sure that the patients got exactly what they needed to get. We had all the equipment ready, everybody on the team was together it formed a lot of team spirit by having that discussion and then we made some technical improvements on how we closed the dura which was critical. We injected the incision at the end of the operation with marc cain so the patients wouldn't wake up in pain and we gave a considerable amount of nausea reducing medications. So in the old days the patients wake up in a lot of pain thrashing, thrashing around in bed and and retching which only made their headaches worse after we did this they would be sitting up in the in the recovery room as if nothing had happened because we'd really relieve the pain and post operatively. Probably the most important thing was um that we uh started actively mobilizing the patients uh to the point where sometimes we take the gurney from the recovery room to the patient's room on the ward and have them get off the gurney day of surgery, walk to their bed with the nurse guarding them and they had to get out of bed at seven o'clock in the morning for breakfast. They had to walk 50 ft by noon. They had to walk 100 ft by five PM. And in the vast majority of cases when they did that they went home on postoperative day too. So all these things, you know, these are the marginal gains which which when added up dramatically transformed the results. And so basically what we found in a careful study of these was that the ultimate outcomes were fine. We reduced the rate of complications. We had no mortality in those groups. Uh and here's the here's the percent of patients who went home on postoperative day. It went from 15% to 55% with these modifications. That's a big change. Ah We almost eliminated re emissions only had one in the in the post redesigned group. And then we then we decided, okay, what's up? What's a perfect operative experience? Well, it's no mortality, no complications, resolution of symptoms, discharged home Two days in the hospital, no readmissions, no reprieve surgery before redesigned. 5% of patients had a perfect outcome. You know, this is a relative perfection. Obviously they still had to have an incision in the scalp. Could just wave a wand but 5%. And after resign It wasn't 100 You know, hitting every one of those targets is hard but that's what that's what envisioning perfection is all about. It was 31%. Well that's You know, 600% improvement in a relative sense. So it's pretty impactful and and and it can be improved from that point on. I think I think you know, in the world of metrics we probably should be measuring that that parameter because it forces you to focus on all the other things to get to that parameter. And I don't think we do that enough. We also looked at cost. It's difficult but the surrogates for cost really is how long you're in the ICU, how long you're in the hospital. What the re operation of readmission rate were And our costs went down 25%. If we reduced the cost of everything in healthcare by 25%, which is probably achievable. You know, health care costs this year crossing the threshold of $4 trillion dollars worth of tea every year. We could save a trillion dollars. We do a lot with a trillion dollars in this country. And So that's project # one. Project # two. Uh it was carried out by Dr. Kelly and colleagues here in P&I they did a very careful analysis of 500 pituitary cases and they came up with strategies to address every possible complication. So they looked at their data and they looked for those marginal gains in every domain. And this is what they found that um They they with with dr griffiths assistance implemented these specific changes. Um Changing the nasal flap, used the Doppler probe to avoid the carotid, changed the dissection technique for the tumor. They redesigned the closure And this was the effect um years later. Now in the providence system. P. And I. Does more pituitary tumors than any other of the hospital of the 52 hospitals. And little company. You married down there halfway down does fewer cases but growing rapidly that's staffed by P. And I. Physicians. Uh the ICU stay down at the bottom. That's that's ST john's very few patients go to the ICU. Because they redesigned the care, they make sure the patient stays a little longer in the recovery room. They get a cT scan and make sure everything's okay. And they've trained the nurses to accept the patients. Um Outside of the ICU. They and little company of mary is making progress. Most hospitals in the providence system just as a knee jerk response send the patients to the ICU. That's that's like $1000 more a day. That's almost always unnecessary. If you evaluate the patient's carefully length of stay. Ot that's the that's the observed the real length of stay compared to what's expected based on the medical comorbidities and age of the patient. Little company and and ST john's are best in the system and this is what the length of stay has looked like. Uh it's been it's been good and low and dropped even lower. We'll talk a little bit about that recent drop and and and how that's going on. But that's that's the that's the effect of looking for every opportunity to improve. Readmission rates also also has come down so a lot of careful thought. A lot of measurement. A lot of redesign of protocols has gone into these kinds of improvements in the course of the pandemic. The covid 19 crisis. The I. C. U. Beds were filling up with covid patients and it was beginning to threaten um the ability to do craniotomy ease and and elective surgical cases at ST john's and dr kelly and dr barker derry. And you know the whole team Therese Hammond in the ICU. Uh Amy Eisenberg the nurse practitioner. The whole team took a careful look at what could be done so that we would avoid ICU admissions and keep the hospital stay as short as possible so the patient can go home and get out of the covid environment in the hospital during this recent recent crisis. And this is what they did mm hmm. So uh these top things had already been done in the in the uh in the interest of improving but then he enhanced the protocol more extensive patient preparation. Like I was talked about um worked with the I. C. U. So that fewer patients needed to go to the I. C. U. Worked with the care team to promote early discharge home so that the case managers were on top of this early mobilization. The things I just talked about post discharge called by the nurses. So there was a dramatic change and again none of these required invention of a new device or drug. This is this is just this is just performance improvement 101. This is David Brailsford 101. And this is what happened. You can see that the most common day of discharge became postoperative day one instead of day two. Dramatic number of patients going home after one day in the hospital. And this is really what's happened with a brain tumor with a brain tumor population. You know again ST john's in southern California is the busiest and little company which is which is very close is the third busiest length of stay is far and away shorter than all the other hospitals in southern California. The length of stay observed to affected is expected is lower. The ICU. Stay rate is lower than all the other hospitals. All the other hospitals for brain tumor cases. Now these are brain tumors, not pituitary tumors. All the other hospitals just automatically admit everybody to the I. C. U. Which is probably unnecessary and almost half the cases nothing's gonna happen. The patients are gonna be stable because they've been evaluated in the recovery room. The C. T. Scan was done in the recovery room and those patients are fine to go to a non ICU status. I see a length of stay dramatically shorter. The number discharged home is the highest for ST john's 82% by the way. That's one of the quality parameters for US News. Uh And even in the providence system as a whole, Our two hospitals are near the top 265 brain tumor cases at ST. John's and and a high number of little company Median length of stay 2.23. The only one that's above us is a is a is a place that does very few cases and only the simplest of cases. This is against 52 hospitals out there and and those are all the ones that do a significant number of brain tumor cases. Uh And this is the length of stay trended over time. You can see that we've seen dramatic improvements at uh ST jOHn's and that little company using all of these principles that we just talked about. So this is another story. I encourage you to take a look at this. This is this is the story of mcallen texas where there Medicare expand spend per patient was twice as high as it was of the national average and far higher than an equivalent community in el paso take a look at a tool rwandese article called the cost conundrum. and 10 years after the Costco number because it talks about how this community which was spending way more money than anybody else on Medicare patients engaged in some hard self analysis and reflection and may think made a change, quite a, quite a good story. So thank you. We'll take questions now for dr martin, but we are gonna limit to only two questions for the sake of time. Thanks. Okay, thank you. So that is really uh just inspiring. Thank you so much Neil. Um so we're gonna skip the breaking and move on.
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