ACS Surgery - Principles and Practice (WebMD, 2006) WW

2184 Pages·2006·72.06 MB·English

Wiley W. Souba, M.D., SC.D., F.A.C.S.
1
PROFESSIONALISM IN SURGERY

Over the past decade, the American health care system has had to
cope with and manage an unprecedented amount of change. As a
consequence, the medical profession has been challenged along
the entire range of its cultural values and its traditional roles and
responsibilities. It would be difficult, if not impossible, to find
another social issue directly affecting all Americans that has under-
gone as rapid and remarkable a transformation—and oddly, a
transformation in which the most important protagonists (i.e., the
patients and the doctors) remain dissatisfied.1
Nowhere is this metamorphosis more evident than in the field
of surgery. Marked reductions in reimbursement, explosions in
surgical device biotechnology, a national medical malpractice cri-
sis, and the disturbing emphasis on commercialized medicine have
forever changed the surgical landscape, or so it seems. The very
foundation of patient care—the doctor-patient relationship—is in
jeopardy. Surgeons find it increasingly difficult to meet their
responsibilities to patients and to society as a whole. In these cir-
cumstances, it is critical for us to reaffirm our commitment to the
fundamental and universal principles and values of medical
professionalism.
The concept of medicine as a profession grounded in com-
passion and sympathy for the sick has come under serious chal-
lenge.2 One eroding force has been the growth and sovereignty
of biomedical research. Given the high position of science and
technology in our societal hierarchy, we may be headed for a
form of medicine that includes little caring but becomes exclu-
sively focused on the mechanics of treatment, so that we deal
with sick patients much as we would a flat tire or a leaky faucet.
In such a form of medicine, healing becomes little more than a
technical exercise, and any talk of morality that is unsubstantiat-
ed by hard facts is considered mere opinion and therefore car-
ries little weight.
The rise of entrepreneurialism and the growing corporatization
of medicine also challenge the traditions of virtue-based medical
care. When these processes are allowed to dominate medicine,
health care becomes a commodity. As Pellegrino and Thomasma
remark, “When economics and entrepreneurism drive the profes-
sions, they admit only self-interest and the working of the market-
place as the motives for professional activity. In a free-market
economy, effacement of self-interest, or any conduct shaped pri-
marily by the idea of altruism or virtue, is simply inconsistent with
survival.”2
These changes have caused a great deal of anxiety and fear
among both patients and surgeons nationwide. The risk to the
profession is that it will lose its sovereignty, becoming a passive
rather than an active participant in shaping and formulating health
policy in the future.The risks to the public are that issues of cost
will take precedence over issues of quality and access to care and
that health care will be treated as a commodity—that is, as a priv-
ilege rather than a right.

The Meaning of Professionalism

A profession is a collegial discipline that regulates itself by
means of mandatory, systematic training. It has a base in a body

of technical and specialized knowledge that it both teaches and
advances; it sets and enforces its own standards; and it has a ser-
vice orientation, rather than a profit orientation, enshrined in a
code of ethics.3-5To put it more succinctly, a profession has cogni-
tive, collegial, and moral attributes. These qualities are well
expressed in the familiar sentence from the Hippocratic oath: “I
will practice my art with purity and holiness and for the benefit of
the sick.”
The escalating commercialization and secularization of medicine
have evoked in many physicians a passionate desire to reconnect
with the core values, practices, and behaviors that they see as exem-
plifying the very best of what medicine is about. This tension
between commercialism on the one hand and humanism and
altruism on the other is a central part of the professionalism chal-
lenge we face today.6 As the journalist Loretta McLaughlin once
wrote, “The rush to transform patients into units on an assembly
line demeans medicine as a caring as well as curative field, demeans
the respect due every patient and ultimately demeans illness itself
as a significant human condition.”7
Historically, the legitimacy of medical authority is based on
three distinct claims2,8: first, that the knowledge and competence
of the professional have been validated by a community of peers;
second, that this knowledge has a scientific basis; and third, that
the professional’s judgment and advice are oriented toward a set
of values.These aspects of legitimacy correspond to the collegial,
cognitive, and moral attributes that define a profession.
Competence and expertise are certainly the basis of patient
care, but other characteristics of a profession are equally important
[see Table 1]. Being a professional implies a commitment to excel-
lence and integrity in all undertakings. It places the responsibility
to serve (care for) others above self-interest and reward. Accord-
ingly, we, as practicing medical professionals, must act as role
models by exemplifying this commitment and responsibility, so
that medical students and residents are exposed to and learn the
kinds of behaviors that constitute professionalism [see Sidebar
Elizabeth Blackwell: A Model of Professionalism].
The medical profession is not infrequently referred to as a voca-
tion. For most people, this word merely refers to what one does for
a living; indeed, its common definition implies income-generating
activity. Literally, however, the word vocation means “calling,” and
the application of this definition to the medical profession yields a

Table 1—Elements of a Profession

A profession
• Is a learned discipline with high standards of knowledge and
performance
• Regulates itself via a social contract with society
• Places responsibility for serving others above self-interest and reward
• Is characterized by a commitment to excellence in all undertakings
• Is practiced with unwavering personal integrity and compassion
• Requires role-modeling of right behavior
• Is more than a job—it is a calling and a privilege

© 2005 WebMD, Inc. All rights reserved.
ELEMENTS OF CONTEMPORARY PRACTICE

ACS Surgery: Principles and Practice
1
Professionalism in Surgery — 1

© 2005 WebMD, Inc. All rights reserved.
ELEMENTS OF CONTEMPORARY PRACTICE

ACS Surgery: Principles and Practice
1
Professionalism in Surgery — 2

more profound meaning. According to Webster’s Third New
International Dictionary,9 a profession may be defined as

a calling requiring specialized knowledge and often long acade-
mic preparation, including instruction in skills and methods as
well as in the scientific, historical, or scholarly principles under-
lying such skills and methods, maintaining by force of organiza-
tion or concerted opinion high standards of achievement and
conduct, and committing its members to continued study and to
a kind of work which has for its prime purpose the rendering of
a public service[.]

Most of us went to medical school because we wanted to help and
care for people who are ill. This genuine desire to care is unam-
biguously apparent in the vast majority of personal statements
that medical students prepare as part of their application process.
To quote William Osler, “You are in this profession as a calling,
not as a business; as a calling which extracts from you at every
turn self-sacrifice, devotion, love and tenderness to your fellow
man.We must work in the missionary spirit with a breath of char-
ity that raises you far above the petty jealousies of life.”10 To keep
medicine a calling, we must explicitly incorporate into the mean-
ing of professionalism those nontechnical practices, habits, and
attributes that the compassionate, caring, and competent physi-
cian exemplifies. We must remind ourselves that a true profes-
sional places service to the patient above self-interest and above
reward.
Professionalism is the basis of our contract with society. To
maintain our professionalism, and thus to preserve the contract
with society, it is essential to reestablish the doctor-patient rela-
tionship as the foundation of patient care.

The Surgeon-Patient Relationship

The underpinning of medicine as a compassionate, caring pro-
fession is the doctor-patient relationship, a relationship that has
become jeopardized and sometimes fractured over the past
decade. Our individual perceptions of what this relationship is and
how it should work will inevitably have a great impact on how we
approach the care of our patients.2
The fundamental question to be answered is, what should the
surgeon-patient relationship be governed by? If this relationship is
viewed solely as a contract for services rendered, it is subject to the
law and the courts; if it is viewed simply as an issue of applied biol-
ogy, it is governed by science; and if it is viewed exclusively as a
commercially driven business transaction, it is regulated by the
marketplace. If, however, our relationship with our patients is
understood as going beyond basic delivery of care and as consti-
tuting a covenant in which we act in the patient’s best interest even
if that means providing free care, it is based on the virtue of char-
ity. Such a perspective transcends questions of contracts, politics,
economics, physiology, and molecular genetics—all of which
rightly influence treatment strategies but none of which is any
substitute for authentic caring.
The view of the physician-patient relationship as a covenant
does not demand devotion to medicine at the exclusion of other
responsibilities, and it is not inconsistent with the fact that medi-
cine is also a science, an art, and a business.2 Nevertheless, in our
struggle to remain viable in a health care environment that has
become a commercial enterprise, efforts to preserve market share
cannot take precedence over the provision of care that is ground-
ed in charity and compassion. It is exactly for this reason that med-
icine always will be, and should be, a relationship between people.
To fracture that relationship by exchanging a covenant based on

charity and compassion for a contract based solely on the delivery
of goods and services is something none of us would want for our-
selves.The nature of the healing relationship is itself the founda-
tion of the special obligations of physicians as physicians.2

Translation of Theory into Practice

The American College of Surgeons (ACS) Task Force on Pro-
fessionalism has developed a Code of Professional Conduct,11
which emphasizes the following four aspects of professionalism:

1. A competent surgeon is more than a competent technician.
2. Whereas ethical practice and professionalism are closely relat-
ed, professionalism also incorporates surgeons’ relationships
with patients and society.
3. Unprofessional behavior must have consequences.

Elizabeth Blackwell: A Model of Professionalism17

Elizabeth Blackwell was born in England in 1821, the daughter of a sug-
ar refiner. When she was 10 years old, her family emigrated to New York
City. Discovering in herself a strong desire to practice medicine and care
for the underserved, she took up residence in a physician’s household,
using her time there to study using books in the family’s medical library.
As a young woman, Blackwell applied to several prominent medical
schools but was snubbed by all of them. After 29 rejections, she sent her
second round of applications to smaller colleges, including Geneva Col-
lege in New York. She was accepted at Geneva—according to an anec-
dote, because the faculty put the matter to a student vote, and the stu-
dents thought her application a hoax. She braved the prejudice of some
of the professors and students to complete her training, eventually rank-
ing first in her class. On January 23, 1849, at the age of 27, Elizabeth
Blackwell became the first woman to earn a medical degree in the United
States. Her goal was to become a surgeon.
After several months in Pennsylvania, during which time she became
a naturalized citizen of the United States, Blackwell traveled to Paris,
where she hoped to study with one of the leading French surgeons. De-
nied access to Parisian hospitals because of her gender, she enrolled in-
stead at La Maternité, a highly regarded midwifery school, in the summer
of 1849. While attending to a child some 4 months after enrolling, Black-
well inadvertently spattered some pus from the child’s eyes into her own
left eye. The child was infected with gonorrhea, and Blackwell contracted
a severe case of ophthalmia neonatorum, which later necessitated the
removal of the infected eye. Although the loss of an eye made it impossi-
ble for her to become a surgeon, it did not dampen her passion for be-
coming a practicing physician.
By mid-1851, when Blackwell returned to the United States, she was
well prepared for private practice. However, no male doctor would even
consider the idea of a female associate, no matter how well trained.
Barred from practice in most hospitals, Blackwell founded her own infir-
mary, the New York Infirmary for Indigent Women and Children, in 1857.
When the American Civil War began, Blackwell trained nurses, and in
1868 she founded a women’s medical college at the Infirmary so that
women could be formally trained as physicians. In 1869, she returned to
England and, with Florence Nightingale, opened the Women’s Medical
College. Blackwell taught at the newly created London School of Medi-
cine for Women and became the first female physician in the United
Kingdom Medical Register. She set up a private practice in her own
home, where she saw women and children, many of whom were of less-
er means and were unable to pay. In addition, Blackwell mentored other
women who subsequently pursued careers in medicine. She retired at
the age of 86.
In short, Elizabeth Blackwell embodied professionalism in her work. In
1889 she wrote, “There is no career nobler than that of the physician.
The progress and welfare of society is more intimately bound up with the
prevailing tone and influence of the medical profession than with the sta-
tus of any other class.”

© 2005 WebMD, Inc. All rights reserved.
ELEMENTS OF CONTEMPORARY PRACTICE

ACS Surgery: Principles and Practice
1
Professionalism in Surgery — 3

4. Professional organizations are responsible for fostering profes-
sionalism in their membership.

If professionalism is indeed embodied in the principles dis-
cussed [see Table 1], the next question that arises is, how do we
translate theory into practice? That is,what do these principles look
like in action? To begin with, a competent surgeon must possess
the medical knowledge, judgment, technical ability, professional-
ism, clinical excellence, and communication skills required for pro-
vision of high-quality patient-centered care. Furthermore, this
expertise must be demonstrated to the satisfaction of the profes-
sion as a whole.The Accreditation Council on Graduate Medical
Education (ACGME) has identified six competencies that must be
demonstrated by the surgeon: (1) patient care, (2) medical knowl-
edge, (3) practice-based learning and improvement, (4) interper-
sonal and communication skills, (5) professionalism, and (6) sys-
tems-based practice.These competencies are now being integrat-
ed into the training programs of all accredited surgical residencies.
A surgical professional must also be willing and able to take
responsibility. Such responsibility includes, but is not necessarily
limited to, the following three areas: (1) provision of the highest-
quality care, (2) maintenance of the dignity of patients and co-
workers, and (3) open, honest communication. Assumption of
responsibility as a professional involves leading by example, placing
the delivery of quality care above the patient’s ability to pay, and
displaying compassion. Cassell reminds us that a sick person is not
just “a well person with a knapsack of illness strapped to his back”12
and that whereas “it is possible to know the suffering of others, to
help them, and to relieve their distress, [it is not possible] to
become one with them in their torment.”13 Illness and suffering are
not just biologic problems to be solved by biomedical research and
technology: they are also enigmas that can serve to point out the
limitations, vulnerabilities, and frailties that we want so much to
deny, as well as to reaffirm our links with one another.
Most important, professionalism demands unwavering person-
al integrity. Regrettably, examples of unprofessional behavior exist.
An excerpt from a note from a third-year medical student to the
core clerkship director reads as follows: “I have seen attendings
make sexist, racist jokes or remarks during surgery. I have met res-
idents who joke about deaf patients and female patients with facial
hair. [I have encountered] teams joking and counting down the
days until patients die.” This kind of exposure to unprofessional
conduct and language can influence young people negatively, and
it must change.
It is encouraging to note that many instances of unprofessional
conduct that once were routinely overlooked—such as mistreating
medical students, speaking disrespectfully to coworkers, and fraud-
ulent behavior—now are being dealt with. Still, from time to time
an incident is made public that makes us all feel shame. In March
2003, the Seattle Times carried a story about the chief of neuro-
surgery at the University of Washington, who pleaded guilty to a
felony charge of obstructing the government’s investigation and
admitted that he asked others to lie for him and created an atmos-
phere of fear in the neurosurgery department. According to the
United States Attorney in Seattle, University of Washington

employees destroyed reports revealing that University doctors sub-
mitted inflated billings to Medicare and Medicaid.The department
chair lost his job, was barred from participation in Medicare, and,
as part of his plea bargain, had to pay a $500,000 fine, perform
1,000 hours of community service, and write an article in a med-
ical journal about billing errors. The University spent many mil-
lions in legal fees and eventually settled the billing issues with the
Federal government for one of the highest Physicians at Teaching
Hospitals (PATH) settlements ever.
Fortunately, such extreme cases of unprofessionalism are quite
uncommon. Nevertheless, it remains our responsibility as profes-
sionals to prevent such behaviors from developing and from being
reinforced. To this end, we must lead by example. A study pub-
lished in 2004 demonstrated an association between displays of
unprofessional behavior in medical school and subsequent discipli-
nary action by a state medical board.14The authors concluded that
professionalism is an essential competency that students must
demonstrate to graduate from medical school.Who could disagree?

The Future of Surgical Professionalism

It is often subtly implied—or even candidly stated—that no
matter how well we adjust to the changing health care environ-
ment, the practice of surgery will never again be quite as reward-
ing as it once was. This need not be the case. The ongoing
advances in surgical technology, the increasing opportunities for
community-based surgeons to enroll their patients into clinical tri-
als, and the growing emphasis on lifelong learning as part of main-
tenance of certification are factors that not only help satisfy social
and organizational demands for quality care but also are in the
best interest of our patients.
In the near future, maintenance of certification for surgeons will
involve much more than taking an examination every decade.The
ACS is taking the lead in helping to develop new measures of com-
petence.Whatever specific form such measures may take, display-
ing professionalism and living up to a set of uncompromisable
core values15 will always be central indicators of the performance
of the individual surgeon and the integrity of the discipline of
surgery as a whole.
Although surgeons vary enormously with respect to personali-
ty, practice preferences, areas of specialization, and style of relating
to others, they all have one role in common: that of healer. Indeed,
it is the highest of privileges to be able to care for the sick. As the
playwright Howard Sackler once wrote, “To intervene, even
briefly, between our fellow creatures and their suffering or death,
is our most authentic answer to the question of our humanity.”
Inseparable from this privilege is a set of responsibilities that are
not to be taken lightly: a pledge to offer our patients the best care
possible and a commitment to teach and advance the science and
practice of medicine. Commitment to the practice of patient-cen-
tered, high-quality, cost-effective care is what gives our work
meaning and provides us with a sense of purpose.16We as surgeons
must participate actively in the current evolution of integrated
health care; by doing so, we help build our own future.

© 2005 WebMD, Inc. All rights reserved.
ELEMENTS OF CONTEMPORARY PRACTICE

ACS Surgery: Principles and Practice
1
Professionalism in Surgery — 4

1. Fein R:The HMO revolution. Dissent, spring 1998,
p 29

2. Pellegrino ED,Thomasma DC: Helping and Heal-
ing. Georgetown University Press,Washington, DC,
1997

3. Brandeis LD:
Familiar medical quotations.
Business—A Profession. Maurice Strauss, Ed. Little
Brown & Co, Boston, 1986

4. Cogan ML: Toward a definition of profession.
Harvard Educational Reviews 23:33, 1953

5. Greenwood E: Attributes of a profession. Social
Work 22:44, 1957

6. Souba W, Day D: Leadership values in academic
medicine. Acad Med (in press)

7. McLaughlin L:The surgical express. Boston Globe,

April 24, 1995

8. Starr PD: The social transformation of American
medicine. Basic Books, New York, 1982

9. Webster’s Third New International Dictionary of
the English Language, Unabridged. Gove PB, Ed.
Merriam-Webster Inc, Springfield, Massachusetts,
1986, p 1811

10. Osler’s “Way of Life” and Other Addresses, with
Commentary and Annotations. Hinohara S, Niki
H, Eds. Duke University Press, Durham, North
Carolina, 2001

11. Gruen RI, Arya J, Cosgrove EM, et al: Profession-
alism in surgery. J Am Coll Surg 197:605, 2003

12. Cassell EJ: The function of medicine. Hastings
Center Report 7:16, 1977

13. Cassell EJ: Recognizing suffering. Hastings Center
Report 21:24, 1991

14. Papadakis M, Hodgson C, Teherani A, et al: Un-
professional behavior in medical school is associat-
ed with subsequent disciplinary action by a state
medical board. Acad Med 79:244, 2004

15. Souba W: Academic medicine’s core values: what
do they mean? J Surg Res 115:171, 2003

16. Souba W: Academic medicine and our search for
meaning and purpose. Acad Med 77:139, 2002

17. Speigel R: Elizabeth Blackwell: the first woman
doctor. Snapshots In Science and Medicine,
http://science-education.nih.gov/snapshots.
nsf/story?openform&pds~Elizabeth_Blackwell_
Doctor

References

© 2005 WebMD, Inc. All rights reserved.
ELEMENTS OF CONTEMPORARY PRACTICE

ACS Surgery: Principles and Practice
1
Professionalism in Surgery — 5

John D. Birkmeyer, M.D., F.A.C.S.

2
PERFORMANCE MEASURES IN
SURGICAL PRACTICE

With the growing recognition that the quality of surgical care
varies widely, there is a rising demand for good measures of surgi-
cal performance. Patients and their families need to be able to
make better-informed decisions about where to get their surgical
care—and from whom.1 Employers and payers need data on
which to base their contracting decisions and pay-for-performance
initiatives.2 Finally, clinical leaders need tools that can help them
identify “best practices”and guide their quality-improvement efforts.
To meet these different needs, an ever-broadening array of perfor-
mance measures is being developed.
The consensus about the general desirability of surgical perfor-
mance measurement notwithstanding, there remains considerable
uncertainty about which specific measures are most effective in
measuring surgical quality. The measures currently in use are
remarkably heterogeneous, encompassing a range of different ele-
ments. In broad terms, they can be grouped into three main cate-
gories: measures of health care structure, process-of-care measures,
and measures reflecting patient outcomes. Although each of these
three types of performance measure has its unique strengths, each
is also associated with conceptual, methodological, or practical
problems [see Table 1]. Obviously, the baseline risk and frequency
of the procedure are important considerations in weighing the
strengths and weaknesses of different measures.3 So too is the un-
derlying purpose of performance measurement; for example, mea-
sures that work well when the primary intent is to steer patients to
the best hospitals or surgeons (selective referral) may not be opti-
mal for quality-improvement purposes.
Several reviews of performance measurement have been pub-
lished in the past few years.3-5 In what follows, I expand on these
reviews, providing an overview of the measures commonly used to
assess surgical quality, considering their main strengths and limi-

tations, and offering recommendations for selecting the optimal
quality measure.

Overview of Current Performance Measures

The number of performance measures that have been devel-
oped for the assessment of surgical quality is already large and
continues to grow. For present purposes, it should be sufficient to
consider a representative list of commonly used quality indicators
that have been endorsed by leading quality-measurement organi-
zations or have already been applied in hospital accreditation, pay-
for-performance, or public reporting efforts [see Table 2]. A more
exhaustive list of performance measures is available on the
National Quality Measures Clearinghouse (NQMC) Web site,
sponsored by the Agency for Healthcare Research and Quality
(AHRQ) (http://www.qualitymeasures.ahrq.gov).
To date, the National Quality Forum (NQF), the Joint Com-
mission on Accreditation of Healthcare Organizations (JCAHO),
and the Center for Medicare and Medicaid Services (CMS) have
focused primarily on preventive care and hospital-based medical
care, with an emphasis on process-of-care variables. In surgery,
these groups have all endorsed one process measure—appropriate
and timely use of prophylactic antibiotics [see Table 2]—in partner-
ship with the Centers for Disease Control and Prevention (CDC).
In 2006, CMS, as part of its Surgical Care Improvement Program
(SCIP), is also endorsing process measures related to prevention of
postoperative cardiac events, venous thromboembolism, and res-
piratory complications.
The AHRQ has focused primarily on quality measures that take
advantage of readily available administrative data. Because little
information on process of care is available in these datasets, these

Table 1
Primary Strengths and Limitations of Structural, Process, and Outcome Measures

Examples

Procedure volume
Intensivist-managed ICU

Appropriate use of
prophylactic antibiotics

Risk-adjusted mortalities
for CABG from state or
national registries

Type of
Measure

Structural

Process of
care

Direct
outcome

Strengths

Measures are expedient and inexpensive
Measures are efficient—a single one may relate to
several outcomes
For some procedures, measures predict subse-
quent performance better than process or out-
come measures do

Measures reflect care that patients actually
receive—hence, greater buy-in from providers
Measures are directly actionable for quality-improve-
ment activities
For many measures, risk adjustment is unnecessary

Face validity
Measurement may improve outcomes in and of
itself (Hawthorne effect)

Limitations

Number of measures is limited
Measures are generally not actionable
Measures do not reflect individual performance and are consid-
ered unfair by providers

Many measures are hard to define with existing databases
Extent of linkage between measures and important patient
outcomes is variable
High-leverage, procedure-specific measures are lacking

Sample sizes are limited
Clinical data collection is expensive
Concerns exist about risk adjustment with administrative data

CABG—coronary artery bypass grafting

© 2006 WebMD, Inc. All rights reserved.
ELEMENTS OF CONTEMPORARY PRACTICE

ACS Surgery: Principles and Practice
2
PERFORMANCE MEASURES IN SURGICAL PRACTICE — 1

© 2006 WebMD, Inc. All rights reserved.
ELEMENTS OF CONTEMPORARY PRACTICE

ACS Surgery: Principles and Practice
2
PERFORMANCE MEASURES IN SURGICAL PRACTICE — 2

measures are mainly structural (e.g., hospital procedure volume)
or outcome-based (e.g., risk-adjusted mortality).
The Leapfrog Group (http://www.leapfroggroup.org), a coali-
tion of large employers and purchasers, developed perhaps the
most visible set of surgical quality indicators for its value-based
purchasing initiative.The organization’s original (2000) standards
focused exclusively on procedure volume, but these were expand-
ed in 2003 to include selected process variables (e.g., the use of
beta blockers in patients undergoing abdominal aortic aneurysm
repair) and outcome measures.

Structural Measures

The term health care structure refers to the setting or system in
which care is delivered. Many structural performance measures
reflect hospital-level attributes, such as the physical plant and
resources or the coordination and organization of the staff (e.g.,
the registered nurse–bed ratio and the designation of a hospital as
a level I trauma center). Other structural measures reflect physi-
cian-level attributes (e.g., board certification, subspecialty train-
ing, and procedure volume).

STRENGTHS

Structural performance measures have several attractive fea-
tures. A strength of such measures is that many of them are
strongly related to outcomes. For example, with esophagectomy
and pancreatic resection for cancer, operative mortality is as much
as 10% lower, in absolute terms, at very high volume hospitals
than at lower-volume centers.6,7 In some instances, structural
measures (e.g., procedure volume) are better predictors of subse-
quent hospital performance than any known process or outcome
measures are [see Figure 1].8
A second strength is efficiency. A single structural measure may
be associated with numerous outcomes. For example, with some
types of cancer surgery,higher hospital or surgeon procedure volume
is associated not only with lower operative mortality but also with
lower perioperative morbidity and improved late survival.9-11 In-
tensivist-staffed intensive care units are linked to shorter lengths of
stay and reduced use of resources, as well as to lower mortality.12,13
The third, and perhaps most important, strength of structural
measures is expediency. Many such measures can easily be as-
sessed with readily available administrative data. Although some
structural measures require surveying of hospitals or providers,
such data are much less expensive to collect than data obtained
through review of individual patients’ medical records.

LIMITATIONS

Relatively few structural performance measures are strongly
linked to patients and thus potentially useful as quality indicators.
Another limitation is that most structural measures, unlike most
process measures, are not readily actionable. For example, a small
hospital can increase the percentage of its surgical patients who
receive antibiotic prophylaxis, but it cannot easily make itself a
high-volume center. Thus, although some structural measures
may be useful for selective referral initiatives, they are of limited
value for quality improvement.
Whereas some structural measures can identify groups of hospi-
tals or providers that perform better on average, they are not ade-
quate discriminators of performance among individuals. For ex-
ample, in the aggregate, high-volume hospitals have a much lower
operative mortality for pancreatic resection than lower-volume
centers do. Nevertheless, some individual high-volume hospitals may
have a high mortality, and some individual low-volume centers may

have a low mortality (though the latter possibility may be difficult to
confirm because of the smaller sample sizes involved).14 For this rea-
son, many providers view structural performance measures as unfair.

Process Measures

Processes of care are the clinical interventions and services pro-
vided to patients. Process measures have long been the predomi-
nant quality indicators for both inpatient and outpatient medical
care, and their popularity as quality measures for surgical care is
growing rapidly.

STRENGTHS

A strength of process measures is their direct connection to patient
management. Because they reflect the care that physicians actually
deliver, they have substantial face validity and hence greater “buy-
in” from providers. Such measures are usually directly actionable
and thus are a good substrate for quality-improvement activities.
A second strength is that risk adjustment, though important for
outcome measures, is not required for many process measures.
For example, appropriate prophylaxis against postoperative venous
thromboembolism is one performance measure in CMS’s ex-
panding pay-for-performance initiative and is part of SCIP. Be-
cause it is widely agreed that virtually all patients undergoing open
abdominal procedures should be offered some form of prophy-
laxis, there is little need to collect detailed clinical data about ill-
ness severity for the purposes of risk adjustment.

Table 2
Performance Measures Currently
Used in Surgical Practice

Diagnosis or Procedure

Critical illness

Any surgical procedure

Abdominal aneurysm repair

Carotid endarterectomy

Esophageal resection
for cancer

Coronary artery bypass grafting

Pancreatic resection

Pediatric cardiac surgery

Hip replacement

Craniotomy

Cholecystectomy

Appendectomy

Performance Measure
Developer/Endorser

Staffing with board-certified intensivists (LF)

Appropriate antibiotic prophylaxis (correct
approach: give 1 hr preoperatively, discon-
tinue within 24 hr) (NQF, JCAHO, CMS)

Hospital volume (AHRQ, LF)
Risk-adjusted mortality (AHRQ)
Prophylactic beta blockers (LF)

Hospital volume (AHRQ)

Hospital volume (AHRQ)

Hospital volume (NQF, AHRQ, LF)
Risk-adjusted mortality (NQF, AHRQ, LF)
Use of internal mammary artery (NQF, LF)

Hospital volume (AHRQ, LF)
Risk-adjusted mortality (AHRQ)

Hospital volume (AHRQ)
Risk-adjusted mortality (AHRQ)

Risk-adjusted mortality (AHRQ)

Risk-adjusted mortality (AHRQ)

Laparoscopic approach (AHRQ)

Avoidance of incidental appendectomy (AHRQ)

AHRQ—Agency for Healthcare Research and Quality
CMS—Center for Medicare and
Medicaid Services
JCAHO—Joint Commission on Accreditation of Healthcare
Organizations
LF—Leapfrog Group
NQF—National Quality Forum

© 2006 WebMD, Inc. All rights reserved.
ELEMENTS OF CONTEMPORARY PRACTICE

ACS Surgery: Principles and Practice
2
PERFORMANCE MEASURES IN SURGICAL PRACTICE — 3

Another strength is that process measures are generally less con-
strained by sample-size problems than outcome measures are.
Important outcome measures (e.g., perioperative death) are rela-
tively rare, but most targeted process measures are relevant to a
much larger proportion of patients. Moreover, because process
measures generally target aspects of general perioperative care,
they can often be applied to patients who are undergoing numer-
ous different procedures, thereby increasing sample sizes and, ulti-
mately, improving the precision of the measurements.

LIMITATIONS

At present, a major limitation of process measures is the lack of a
reliable data infrastructure. Administrative datasets do not have the
clinical detail and specificity required for close evaluation of process-
es of care. Measurement systems based on clinical data, including
that of the National Surgical Quality Improvement Program
(NSQIP) of the Department of Veterans Affairs (VA),15 focus on
patient characteristics and outcomes and do not collect information
on processes of care.Currently,most pay-for-performance programs
rely on self-reported information from hospitals, but the reliability of
such data is uncertain (particularly when reimbursement is at stake).
A second limitation is that at present, targeted process measures
in surgery pertain primarily to general perioperative care and often
relate to secondary rather than primary outcomes. Although the
value of antibiotic prophylaxis in reducing the risk of superficial
surgical site infection (SSI) should not be underestimated, super-
ficial SSI is not among the most important adverse events of major
surgery (including death).Thus, improvements in the use of pro-
phylactic antibiotics will not address the fundamental problem of
variation in the rates of important outcomes from one hospital to
another and from one surgeon to another. Except, possibly, in the
case of coronary artery bypass grafting (CABG), the processes
that determine the success of individual procedures have yet to be
identified.

Outcome Measures

Direct outcome measures reflect the end result of care, either
from a clinical perspective or from the patient’s viewpoint. Mor-
tality is by far the most commonly used surgical outcome mea-
sure, but there are other outcomes that could also be used as qual-

ity indicators, including complications, hospital readmission, and
various patient-centered measures of satisfaction or health status.
Several large-scale initiatives involving direct outcome assess-
ment in surgery are currently under way. For example, proprietary
health care rating firms (e.g., Healthgrades) and state agencies are
assessing risk-adjusted mortalities by using Medicare or state-level
administrative datasets. Most of the current outcome-measure-
ment initiatives, however, involve the use of large clinical registries,
of which the cardiac surgery registries in New York, Pennsylvania,
and a growing number of other states are perhaps the most visible
examples. At the national level, the Society for Thoracic Surgeons
and the American College of Cardiology have implemented sys-
tems for tracking the morbidity and mortality associated with car-
diac surgery and percutaneous coronary interventions, respective-
ly. Although the majority of the outcome-measurement efforts to
date have been procedure-specific (and largely limited to cardiac
procedures), NSQIP has assessed hospital-specific morbidities
and mortalities aggregated across surgical specialties and proce-
dures. Efforts to apply the same measurement approach outside
the VA are now being implemented.16

STRENGTHS

Direct outcome measures have at least two major strengths.
First, they have obvious face validity and thus are likely to garner a
high degree of support from hospitals and surgeons. Second, out-
come measurement, in and of itself, may improve performance—
the so-called Hawthorne effect. For example, surgical morbidity
and mortality in VA hospitals have fallen dramatically since the
implementation of NSQIP in 1991.15 Undoubtedly, many surgical
leaders at individual hospitals made specific organizational or
process improvements after they began receiving feedback on their
hospitals’ performance. However, it is very unlikely that even a full
inventory of these specific changes would explain such broad-
based and substantial improvements in morbidity and mortality.

LIMITATIONS

One limitation of hospital- or surgeon-specific outcome mea-
sures is that they are severely constrained by small sample sizes.
For the large majority of surgical procedures, very few hospitals
(or surgeons) have sufficient adverse events (numerators) and
cases (denominators) to be able to generate meaningful, proce-

Mortality (%), 1998–99

Unadjusted Mortality for
Resection of Esophageal
Cancer, 1994–1997

Hospital Volume,
1994–1997

Highest Lowest Lowest Highest

12.0

16.0

20.0

4.0

8.0

0

Mortality (%), 1998–99

Unadjusted Mortality for
Resection of Pancreatic
Cancer, 1994–1997

Hospital Volume,
1994–1997

Highest Lowest Lowest Highest

12.0

16.0

20.0

4.0

8.0

0

b
a

Figure 1
Illustrated is the relative ability of historical (1994–1997) measures of hospital volume and risk-
adjusted mortality to predict subsequent (1998–1999) risk-adjusted mortality in Medicare patients undergoing
(a) esophageal or (b) pancreatic resection for cancer.8

© 2006 WebMD, Inc. All rights reserved.
ELEMENTS OF CONTEMPORARY PRACTICE

ACS Surgery: Principles and Practice
2
PERFORMANCE MEASURES IN SURGICAL PRACTICE — 4

dure-specific measures of morbidity or mortality. For example, a
2004 study used data from the Nationwide Inpatient Sample to
study seven procedures for which mortality was advocated as a
quality indicator by the AHRQ.17 For six of the seven procedures,
only a very small proportion of hospitals in the United States had
large enough caseloads to rule out a mortality that was twice the
national average. Although identifying poor-quality outliers is an
important function of outcome measurement, to focus on this goal
alone is to underestimate the problems associated with small sam-
ple sizes. Distinguishing among individual hospitals with interme-
diate levels of performance is even more difficult.
Other limitations of direct outcome assessment depend on
whether the assessment is based on administrative data or on clin-
ical information abstracted from medical records. For outcome
measures based on clinical data, the major problem is expense. For
example, it costs more than $100,000 annually for a private-sec-
tor hospital to participate in NSQIP.
For outcome measures based on administrative data, a major
concern is the adequacy of risk adjustment. For outcome mea-
sures to have face validity with providers, high-quality risk adjust-
ment may be essential. It may also be useful for discouraging gam-
ing of the system (e.g., hospitals or providers avoiding high-risk
patients to optimize their performance measures). It is unclear,
however, to what extent the scientific validity of outcome measures
is threatened by imperfect risk adjustment with administrative
data. Although administrative data lack clinical detail on many
variables related to baseline risk,18-21 the degree to which case mix
varies systematically across hospitals or surgeons has not been
determined. Among patients who are undergoing the same surgi-
cal procedure, there is often surprisingly little variation. For exam-
ple, among patients undergoing CABG in New York State, unad-
justed hospital mortality and adjusted hospital mortality (as derived
from clinical registries) were nearly identical in most years (with
correlations exceeding 0.90) [see Figure 2].22 Moreover, hospital
rankings based on unadjusted mortality and those based on ad-
justed mortality were equally useful in predicting subsequent hos-
pital performance.

Matching the Performance Measure to the Underlying Goal

Performance measures will never be perfect. Certainly, over
time, better analytic methods will be developed, and better access
to higher-quality data may be gained with the addition of clinical
elements to administrative datasets or the broader adoption of
electronic medical records. There are, however, some problems
with performance measurement (e.g., sample-size limitations) that
are inherent and thus not fully correctable. Consequently, clinical
leaders, patient advocates, payers, and policy makers will all have
to make decisions about when imperfect measures are nonetheless
good enough to act on.
A measure should be implemented only with the expectation
that acting on it will yield a net improvement in health quality. In
other words, the direct benefits of implementing a particular mea-
sure cannot be outweighed by the indirect harm. Unfortunately,
benefits and harm are often difficult to measure. Moreover, mea-
surement is heavily influenced by the specific context and by
who—patients, payers, or providers—is doing the accounting. For
this reason, the question of where to set the bar, so to speak, has
no simple answer.
It is important to ensure a good match between the perfor-
mance measure and the primary goal of measurement. It is par-
ticularly important to be clear about whether the underlying goal
is (1) quality improvement or (2) selective referral (i.e., directing

patients to higher-quality hospitals or providers). Although some
pay-for-performance initiatives may have both goals, one usually
predominates. For example, the ultimate objective of CMS’s pay-
for-performance initiative with prophylactic antibiotics is to im-
prove quality at all hospitals, not to direct patients to centers with
high compliance rates. Conversely, the Leapfrog Group’s efforts in
surgery are primarily aimed at selective referral, though they may
indirectly provide incentives for quality improvement.
For the purposes of quality improvement, a good performance
measure—most often, a process-of-care variable—must be action-
able. Measurable improvements in the given process should trans-
late into clinically meaningful improvements in patient outcomes.
Although quality-improvement activities are rarely actually harm-
ful, they do have potential downsides, mainly related to their op-
portunity cost. Initiatives that hinge on bad performance measures
siphon away resources (e.g., time and focus) from more productive
activities.
For the purposes of selective referral, a good performance mea-
sure is one that steers patients toward better hospitals or physicians

Risk-Adjusted Mortality (%)
Mortality (%), 2002

Correlation = 0.95

Observed Mortality (%)

Unadjusted Mortality Ratings,
New York State Hospital
Risk-Adjusted Mortality Ratings,
New York State Hospitals, 2001

a

b

0.5

4.0

3.0

2.0

1.0

3.5

2.5

1.5

0.5

4.0

3.0

2.0

1.0

Best
Middle
Worst
Best
Middle
Worst
0

0
1
1.5
2
2.5
3
3.5
4
4.5

Figure 2
Shown are mortality figures from CABG in New York
State hospitals, based on data from the state’s clinical outcomes
registry. (a) Depicted is the correlation between adjusted and
unadjusted mortalities for all state hospitals in 2001. (b) Illus-
trated is the relative ability of adjusted mortality and unadjusted
mortality to predict performance in the subsequent year.