Technical performance scores in congenital cardiac operations: a quality assessment initiative.
BACKGROUND
Technical performance in congenital cardiac operations and its association with clinical outcomes was previously examined in infants and neonates. The purpose of this study was the development and implementation of a system for measuring technical performance in the majority of congenital cardiac operations to be used as a surgeon's self-assessment tool.


METHODS
Using the methodologic framework piloted at our institution, measures of technical performance were created for more than 90% of all congenital cardiac operations. Each operation was divided into multiple subprocedures to be assessed separately. Criteria for technical scores were created using a consensus panel of senior clinicians and were based primarily on the predischarge echocardiographic findings and need for early postoperative reinterventions. This system of procedure modules was then piloted by prospectively assigning technical scores to all patients undergoing operations.


RESULTS
Thirty modules were created covering more than 90% of the cardiac operations performed. One hundred eighty-five patients were enlisted. One hundred one (54.6%) cases were scored as class 1 (highest), 46 (24.9%) cases as class 2, 22 (11.9%) cases as class 3 (lowest); 16 cases (8.6%) could not be scored. The results were further analyzed by RACHS (Risk Adjustment for Congenital Heart Surgery) categories and outcomes. Valve-procedure-specific criteria were calibrated to reflect specific echocardiographic measurements.


CONCLUSIONS
The development and implementation of a broad technical performance self-assessment system for congenital cardiac operations is possible. Based on this scoring system, the impact of a less than optimal (2 or 3) technical score depends on case risk category, with higher mortality in the higher risk group, and increased resource use for lower risk procedures.
Department of Cardiac Surgery, Children's Hospital Boston and Harvard Medical School, Boston, Massachusetts, USA. john.karamichalis@ucsfmedctr.org
John M
JM
Karamichalis
Steven D
SD
Colan
Meena
M
Nathan
Frank A
FA
Pigula
Christopher
C
Baird
Gerald
G
Marx
Sitaram M
SM
Emani
Tal
T
Geva
Francis E
FE
Fynn-Thompson
Hua
H
Liu
John E
JE
Mayer
Pedro J
PJ
del Nido
D006348:Cardiac Surgical Procedures / Q000379:methods / Q000401:mortality / Q000592:standards*; D002675:Child, Preschool; D002983:Clinical Competence; D005260:Female; D005500:Follow-Up Studies; D006330:Heart Defects, Congenital / Q000401:mortality / Q000601:surgery*; D017052:Hospital Mortality / Q000639:trends; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D007902:Length of Stay / Q000639:trends; D008297:Male; D008404:Massachusetts / Q000453:epidemiology; D010865:Pilot Projects; D011785:Quality Assurance, Health Care; D018570:Risk Assessment; D012720:Severity of Illness Index