Quality Control and Learning Curves at the Heart Center Leipzig

For several years quality assurance has gained growing attention. De Leval was one of the first to outline the importance of analyzing human factors in cardiac surgery and of performing individual failure analyses.[1] [2] However, the usual means of descriptive statistics cannot be regarded sufficient in this field. The low numbers of particular operations per surgeon require additional analyses to detect changes in quality early. In this context, the usefulness of the sequential probability cumulative sum (CUSUM) technique to analyze surgical performance has been shown in recent publications.[3] [4] [5] [6] It allows detection of changes in perioperative mortality and morbidity already during the patient care process. It provides almost real-time monitoring of surgical performance if updated after each procedure. Also, CUSUM analysis acknowledges the importance of individual experience in monitoring performance and allows easy charting of a learning curve with regards to the incidence of perioperative complications. The charts are intuitively readable, but care is needed to avoid misinterpretation.[7] Moreover, the charts can also be used to depict learning curves and are therefore helpful in accompanying new surgeons during their initial training or experienced surgeons in the learning process of a new method.

In this article, we describe the developments in the field of quality control at the Leipzig Heart Center during the past two decades. The foundation for these initiatives was the creation and maintenance of a comprehensive institutional and national database.

• References

• 1 de Leval MR, Carthey J, Wright DJ, Farewell VT, Reason JT. Human factors and cardiac surgery: a multicenter study. J Thorac Cardiovasc Surg 2000; 119 (4 Pt 1): 661-672
• 2 Carthey J, de Leval MR, Reason JT. The human factor in cardiac surgery: errors and near misses in a high technology medical domain. Ann Thorac Surg 2001; 72 (1) 300-305
• 3 Rogers CA, Reeves BC, Caputo M, Ganesh JS, Bonser RS, Angelini GD. Control chart methods for monitoring cardiac surgical performance and their interpretation. J Thorac Cardiovasc Surg 2004; 128 (6) 811-819
• 4 Novick RJ, Fox SA, Stitt LW, Forbes TL, Steiner S. Direct comparison of risk-adjusted and non-risk-adjusted CUSUM analyses of coronary artery bypass surgery outcomes. J Thorac Cardiovasc Surg 2006; 132 (2) 386-391
• 5 Novick RJ, Fox SA, Stitt LW , et al. Assessing the learning curve in off-pump coronary artery surgery via CUSUM failure analysis. Ann Thorac Surg 2002; 73 (1) S358-S362
• 6 Novick RJ, Stitt LW. The learning curve of an academic cardiac surgeon: use of the CUSUM method. J Card Surg 1999; 14 (5) 312-320 , discussion 321–322
• 7 Blackstone EH. Monitoring surgical performance. J Thorac Cardiovasc Surg 2004; 128 (6) 807-810
• 8 Funkat AK, Beckmann A, Lewandowski J , et al. Cardiac surgery in Germany during 2011: a report on behalf of the German Society for Thoracic and Cardiovascular Surgery. Thorac Cardiovasc Surg 2012; 60 (6) 371-382
• 9 Beckmann A, Funkat AK, Lewandowski J , et al. Cardiac surgery in Germany during 2014: A report on behalf of the German society for thoracic and cardiovascular surgery. Thorac Cardiovasc Surg 2015; 63 (4) 258-269
• 10 Gummert JF, Kluge M, Heidrich L, Janke R, Autschbach R, Mohr FW. Weiterentwicklung des medizinischen Dokumentationssystems Medwork im Herzzentrum Leipzig: Erfahrungen und Perspektiven. In: Arno Krian HHS, , ed. Dokumentationsverfahren in der Herzchirurgie. Berlin Heidelberg: Springer-Verlag; 2000
• 11 Gummert JF, Funkat A, Osswald B , et al. EuroSCORE overestimates the risk of cardiac surgery: results from the national registry of the German Society of Thoracic and Cardiovascular Surgery. Clin Res Cardiol 2009; 98 (6) 363-369
• 12 Holzhey DM, Jacobs S, Walther T, Mochalski M, Mohr FW, Falk V. Cumulative sum failure analysis for eight surgeons performing minimally invasive direct coronary artery bypass. J Thorac Cardiovasc Surg 2007; 134 (3) 663-669
• 13 Holzhey DM, Seeburger J, Misfeld M, Borger MA, Mohr FW. Learning minimally invasive mitral valve surgery: a cumulative sum sequential probability analysis of 3895 operations from a single high-volume center. Circulation 2013; 128 (5) 483-491
• 14 Kang N, Tsang VT, Gallivan S , et al. Quality assurance in congenital heart surgery. Eur J Cardiothorac Surg 2006; 29 (5) 693-697 , discussion 697–698