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Codman, Hawthorne, and End Results of a Watched System.

Ever since Ernest A. Codman first advocated measuring outcomes of patients through End Results Cards,1 the goal of surgical quality has been to study the results of operative intervention and improve those results through systematic analysis. The article by Massarweh et al2 clearly documents that the Veterans Administration (VA) Surgical Quality Improvement Program and, with a nod to Codman, the American College of Surgeons National Surgical Quality Improvement Program have systemically advanced the quality of care for millions of surgical patients both in and outside of the VA. The unique aspect of this article that deserves particular focus is the trends in failure to rescue (FTR). Failure to rescue is defined as in-hospital death after a complication and is considered to be an important indicator of hospital quality. While postoperative mortality is affected by numerous patient characteristics, FTR is thought to be influenced by structural characteristics and safety culture in hospitals through timely recognition and treatment of severe complications. Failure to rescue as a measure is rapidly gaining acceptance as a key metric for assessing surgical quality, with the 2015 adoption by the Agency for Healthcare Research and Quality as a patient safety indicator.3 The authors show how mortality and FTR rates after complications have significantly declined in all hospitals and differed by hospital performance as stratified by quintiles, with a reduced risk of mortality and FTR of 40% to 50% (odds ratio, 0.53; 95% CI, 0.46-0.60 and odds ratio, 0.59; 95% CI, 0.50-0.69; respectively). The unanswered question the Massarweh et al article2 poses is what ultimately has driven the marked improvements seen over time. The multifactorial nature of surgical care precludes an easy answer, and some have questioned whether participation in a registry is the driving initiative for quality improvement.4,5 Regardless of the mechanism, one cannot discount the Hawthorne effect6 at the VA, with a congressional mandate to measure surgical quality and the scrutiny of public opinion through the fourth estate. The Massarweh et al article2 serves notice that the quality and safety of surgical care in the VA system are on par with if not better than other large integrated health care systems. The important message from these studies is that surgery as a community, especially within the VA, continuously monitors outcomes and continues the work of improving the end result.