High Performance in IBD Surgery

A lacking evidence base, little political will and absent measurement tools have all hampered the Quality Agenda in IBD surgery. Undoubtedly, other surgical disciplines are further ahead. Cardiac surgery, oncological surgery and even joint surgery are examples where performance is now monitored routinely. In fact, it’s 25 years since cardiac surgeons’ mortality rates were reported publicly in the state of New York [2]. These tactics were/are uncomfortable. The impact on performance was, however, immediate. The consequences resonated across every discipline. Surgical specialties where poor performance results in mortality and where large numbers of patients are affected are the most likely early targets for performance measurement by policy-makers. Unfortunately, IBD surgery meets neither of these criteria and this may explain why performance investigation and initiatives are lagging.

Performance science has been an area of general interest in recent years. In his book Bounce: the myth of talent and the power of practice [3], Matthew Syed, the table tennis world champion and author, investigated performance in sport. Syed suggests that practice is a major prerequisite to achieving high performance in just about any discipline.  Malcolm Gladwell, the Canadian best-selling author of Outliers [4] describes in his chapter 10,000 hours that this number represents the necessary time invested by brilliantly successful stars (outliers) from the worlds of sport, entertainment and business to ‘master’ their skill. 10,000 hours is now so commonly used that it has entered the global lexicon. The concept of ‘repeated practice’ underpins the most frequently used method of quality improvement in surgery – centralisation. Consolidation of surgical services seeks to exploit the volume–outcome relationship. In effect, the more one does, the better one gets. High volume has been associated with better outcome in many aspects of surgery, especially complex procedures like ileo-anal pouch formation surgery [5]. Without doubt, technical craft improves when caseload is enhanced but so, too, does decision-making as clinical patterns are more easily discerned. Our judgement regarding who to select for a pouch and, conversely, who not to select, gets better when it becomes a regular question. The benefits don’t stop there. Institutional volume and research, innovation and the operational management of a service are likely to improve, too. Moreover, institutional volume may confer benefit to clinicians other than surgeons, such as endoscopists, radiologists and pathologists, who become expert in a given area. Policy-makers usually appreciate consolidation of services as efficiencies may be greater, costs reduced and patient experience improved.

It is important to note that neither Syed nor Gladwell needed to dwell on measurement. They use subjects who are sportsmen and industrialists, for whom championships and net worth unequivocally define success. Our first challenge in IBD surgery is to clearly define what high performance, or quality, looks like. After all – if we can’t measure it, we can’t improve it! Efforts have been made in recent years to define benchmarks. In the United Kingdom we investigated and defined, through an expert consensus study, key performance indicators (KPIs) of quality in IBD surgery [6]. At a national level we have developed a comprehensive set of IBD Standards to define expectations on performance across services [7]. Efforts have been made to measure and benchmark data at a national level also. The Association of Coloproctology of Great Britain and Ireland (ACPGBI) Ileal Pouch Registry, Surgical Workload Outcomes Audit Database (SWORD) and Amplitude databases [8] are examples of national IBD surgical activity and quality outputs. Such datasets can enable quality appraisal and monitoring at an institutional and a national level. Important lessons have been learnt from these databases regarding the prerequisites for data collection to be effective if used for benchmarking purposes.

Shining a light on performance in IBD surgery is long overdue. This process starts with building an evidence base for relevant quality metrics. Quality measurement and benchmarking should follow. Ultimately, quality improvement programmes (QIPs) are initiated and reconfiguration of services may result. It will be up to us collectively, as invested clinicians, to work with our patients to develop measurement tools, standards and quality initiatives in order to achieve high performance in IBD surgery. ECCO is the pre-eminent organisation that embraces all IBD-related disciplines. It is possibly the only organisation that is capable of universally and authoritatively defining quality, delivering QIPs and creating a multidisciplinary environment that underpins high performance in IBD services. It is the opportunity of a lifetime and the timing is perfect.

References

1. Accessed on October 14, 2020. https://en.wikipedia.org/wiki/Shaggy_dog_story
2. Hannan EL, Kumar D, Racz M, Siu AL, Chassin MR. New York State's Cardiac Surgery Reporting System: four years later. Ann Thorac Surg 1994;58:1852–7.
3. Syed M. Bounce: the myth of talent and the power of practice. New York: HarperCollins, 2010.
4. Gladwell M. Outliers: the story of success. Boston, Mass: Little, Brown and Company, 2008.
5. Burns EM, Bottle A, Aylin P, et al. Volume analysis of outcome following restorative proctocolectomy. Br J Surg. 2011;98:408–17.
6. Morar PS, Hollingshead J, Bemelman W, et al. Establishing key performance indicators [KPIs] and their importance for the surgical management of inflammatory bowel disease – results from a pan-European, Delphi Consensus Study. J Crohns Colitis. 2017;11:1362–8.
7. https://ibduk.org/ibd-standards Accessed October 14, 2020.
8. https://www.acpgbi.org.uk/research/audits/ Accessed October 14, 2020.