E-QUALITY, complex IBD surgery and dishwashers

Seventeen years ago I went to Toronto for a month to further improve my understanding of pouch surgery. I went to meet one of the ‘superheroes’ of the time. He represented a member of an elite group of master pouch surgeons who had pioneered this complex operation as well as the decision-making that underpins it. His unit undertook huge volumes and in one month I observed more pouches than I had seen in my entire ten-year surgical training in the United Kingdom up to that point. Not only did those high volumes enable him to gain essential surgical skills but when you saw his theatre – it was different. An ileoanal pouch was not an occasional occurrence as in so many theatres. There was one on every list. I watched my new surgical hero in clinic, too. His questioning was similar to that of the dishwasher engineer: precise, with clear understanding of which information was vital. In theatre the scrub team even arranged the bespoke kit that would be necessary in much the same way that the dishwasher guy had. When working I would watch him slow down at certain points – his experience had taught him the moments when this operation can fail. It had become intuitive, just as with the ‘dishwasher guy’, to whom a particular churning noise gave away the problem as well as the solution. Years doing the same thing had led both craftsmen to a place where quality just exuded from the work that they did.

For the last two years, colleagues at ECCO have been contributing to the E-QUALITY project. The workplan is expected to run for 3–5 years. The project is likely to deliver an understanding of the current gap between actual practice in European centres and recommended ECCO Standards. Clearly, the UR-CARE database will be an essential tool to measure performance and monitor its improvement. The intention of the project is to bridge those gaps that are identified. What, however, does this mean in IBD surgery? Quality improvement projects almost always break down to metrics that describe the Donabedian components of quality: structural factors (the resource components of the host institution), process factors (the way that we do things) and outcome (the results of what we do). These are the measurable components of quality. High performance should ultimately describe the functioning of expert high-volume surgical IBD specialists working within IBD centres. These surgeons will be craftsmen just like the ‘superhero’ that I met in Toronto. They will work as super-specialists dedicated to a very narrow case mix, delivering outstanding outcomes, participating in research and pioneering new surgical techniques. This is, however, not easy to deliver in practice. It requires health systems to dedicate resource to super-specialist areas and redirect cases to a particular ‘favoured’ institution. Major healthcare reorganisation at a regional level is often required to centralise particular services to certain locations. There are numerous political and economic barriers to such reconfiguration. The latter is often unpopular with surgeons and patients and it is easier and cheaper to perpetuate a ‘plural’ general surgical approach where surgeons don’t specialise to any great extent. Similarly, in many healthcare systems surgeons themselves don’t want to become too ‘pigeon-holed’ for fear that they might lose other interesting case mix or private referrals for other conditions. As such, centralisation is not easy to make happen in practice. Centralised surgical services undertaking high complexity work do, however, define quality in surgery. Despite this, many national professional bodies have been slow to demand centralisation of complex IBD surgery. This is understandable to some extent, as to do so would likely cause dissatisfaction amongst these bodies’ surgical members.

ECCO does not have a direct mandate within participating countries. It does, however, have a powerful expert voice that can overcome parochial national attitudes and professional self-interest. I hope that the E-QUALITY agenda will succeed in ensuring that the bar in surgery is set high. After all, patients requiring complex IBD surgical procedures, just like those requiring complex cancer or cardiac operations, should expect to encounter surgeons who just exude experience and expertise and can show you their own outcome data – i.e. genuine quality.  

If anybody living in south west London should have a faulty Zanussi dishwasher and need a true expert craftsman within the field, get in touch and I will pass on my man’s number. Should you require a pouch in many places in the United Kingdom, or elsewhere, you are less likely to find such expert craftmanship locally or even regionally. That would be okay if this ‘gap’ were acknowledged, and patients were just referred on to an expert centre elsewhere in the country. Unfortunately, this often doesn’t happen and patients live out their lives with an unwanted stoma, or worse still, with the consequences of poorly performed pouch surgery. I hope that one day in the future I will similarly be able to offer you a contact for an expert pouch craftsman near you. In 2022 we are, however, still sadly a long way away from that situation in many countries.