We aim to improve quality of thoracic surgical care by enabling continuous quality improvement through standardized, comprehensive, collegial capturing, classifying, reporting, analyzing and monitoring of the presence and severity of surgical complications.

Objective reporting of post-operative adverse events (AEs) is the basis of surgical quality assurance. As such, data on post-operative AEs are often used as a means of comparing surgical techniques, individual surgeon outcomes, and institutional performance.¹ Unfortunately, proper documentation and monitoring of post-operative AEs is imprecise and lacks objectivity because of often subjective impressions. Furthermore, conclusive assessments of surgical quality have remained limited by the lack of agreement on how to define and classify complications by severity.²

In 1992, Clavien and colleagues were the first to introduce the concept of severity grading of post-operative AEs.³ The principle underlying this classification is that the severity of an AE is proportional to its impact on a patient and the degree of effort to rectify it. The rationale for this approach was to eliminate subjective interpretation of serious AEs and any tendency to down-grade complications, as it is based on data that are well documented and easily verified. The system, now known as the Clavien-Dindo classification of post-operative AEs, was validated in 2004 in a large cohort of general surgical patients,⁴ and has since been used in a number of different surgical sub-specialities.^5-9

In 2008, modeled on the Clavien-Dindo system, The Ottawa Hospital’s Division of Thoracic Surgery developed a standardized approach to identify both presence and severity of Thoracic Morbidity & Mortality (TM&M), with the aim to capture all AEs after all surgeries.¹⁰ The rigorous implementation in clinical practice and evaluation of such a system requires time. Since its inception, supporting studies have shown that the TM&M classification is feasible,10 reliable and reproducible - as demonstrated through a national survey of the Canadian Association of Thoracic Surgeons,¹¹ facilitates objective comparison, identifies burden of specific complications,^12-13 provides an effective method for continuous surgical quality assessment, and serves as a complement to the gold standard, the National Surgical Quality Improvement Program (NSQIP).¹⁴ More recently, the TM&M classification has been adopted by numerous surgical groups internationally.^15-16 We are also aware of randomized trials, which have included the TM&M classification in their end point evaluation.¹⁷

The following organizations have provided funding for the development of this program:

The Ottawa Division of Thoracic Surgery
Grant from the University of Ottawa Department of Surgery
Grant from The Ottawa Hospital Academic Medical Organization (TOHAMO)

The definition of each AE as described by their respective database was reviewed and compatibility was assessed with those defined by the CATS system. Data elements were classified as “Perfect”, “Good”, or “Non-Harmonized based on their degree of harmonization. Harmonization of the CATS system was achieved through the addition of 17 adverse events and 2 complication modifiers.

Recognizing that software was necessary to efficiently record and review TM&M data, as well as to report the data back to surgeons, iterative development led to an evolution of a secure, real-time, web-based, point-of-care, iPad-optimized Thoracic Surgery Quality monitoring, Information management, and Clinical documentation (TSQIC) software system.

TSQIC is divided into three components: i) Mandatory OR, for prospective collection of all thoracic surgical cases within the practice, and TM&M, for tracking all complications associated with the operative procedures performed; ii) automated and dynamic reporting of statistics for surgical volume and quality; and iii) clinical documentation for preoperative clinic consults, operative reports, daily progress notes for admitted patients, and follow-up notes.

Data collection is a continuous, collegial and divisional activity that is comprised of daily reporting (by thoracic surgical residents and fellows), weekly review (by staff surgeons) to facilitate uniform classification of complications, monthly discussion at morbidity & mortality (M&M) rounds (by the entire division), and quarterly analysis.

Accurate measurement of post-operative adverse events is necessary, but not sufficient for quality improvement, without also providing surgeons with information and the infrastructure on how to improve patient outcomes.

Bridging this gap has been a top priority for our quality improvement program. To do so, we have used the TM&M classification and the TSQIC system as a foundation for several quality improvement initiatives. First, the divisional M&M conference has been greatly enhanced by the improved quality of statistical reporting of all surgical cases and all postoperative AEs for the preceding month, allowing the division to follow trends over time, and to distinguish between random variation and a significant increase or decrease in the rate of postoperative AEs.

Second, using the TSQIC platform, we have developed novel and dynamic surgeon-specific adverse event reports (SAERs), allowing surgeons to compare their performance over time and to that of their colleagues through automated, real-time, and risk-adjusted data monitoring.

A priority for the division has been to ensure such monitoring translates into tangible and reproducible improvements in surgical performance, for the benefit of surgeons, and ultimately patients. We have thus, implemented quarterly continuous quality improvement (CQI) seminars to provide an additional forum for discussion regarding collective results, utilizing the technique of positive deviance, to unmask best performers as a catalyst for discussing practice measures to improve specific AEs.

Last, while not a primary objective, embracing a culture of quality has been an important outcome of our program. Because the process of TM&M data collection and analysis is integrated with monthly M&M conferences, SSAERs, and quarterly CQI seminars, it has been viewed as a multifaceted approach for creating a continuous culture of quality improvement that is supportive of teamwork, safety, and open and collegial dialogue regarding the links among structure, process, and outcomes of surgical care.