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Mastery of Care-toward Communitarian Regulation

Pronovost, Peter MD, PhD; Higgins, Robert. S. D. MD, MSHA

doi: 10.1097/SLA.0000000000001813

Department of Surgery, Johns Hopkins Hospital, Baltimore, MD; Department of Patient Safety and Quality, Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, MD.

Reprints: Robert S. D. Higgins, MD, MSHA, Johns Hopkins School of Medicine, Baltimore, MD. E-mail:

Disclosure: The authors declare no conflicts of interest.

In Malcolm Gladwell's Outliers: The Story of Success,1 the author asserts that achieving “world class expertise” in any skill, is (to a large extent) a matter of practicing the correct way for 10,000 hours. In healthcare, the number of procedures and or accumulated experience (hours) is representative of training and considered as a surrogate for quality. The data linking volume to outcome for surgery is over 25 years old and robust. Though the exact threshold varies by study, there is a consistent and linear relationship between higher volumes with improved outcomes. In the field of transplantation, for instance, there is clear evidence in risk adjusted evaluations of mortality in heart, lung, liver, and kidney procedures that outcomes are correlated with busy surgeons performing at least 10 procedures per year working as leaders of high performance teams.2

Despite the evidence, the healthcare community-particularly hospitals and surgeons, have been slow to adopt standard volume and performance expectations in specialized procedures such as resections of the esophagus, knee, and hip replacements and major pancreas resections (Whipple procedure). Patients are generally not told of the volume of cases the surgeon and hospital performed; surgeons and hospital leaders do not limit who can do specific cases based on experience or volumes. The general thought is that if a surgeon has completed residency training in a field, they are qualified to do all operations in that field; these surgeons, of course, are subject to each hospital's credentialing requirements to perform procedures; however, sustained and regular assessments of competency and performance are not uniform or standardized.

The world of healthcare continues to be measured by metrics that expect extraordinary, almost flawless performance. However as we know, these expectations can only occur as the culmination of outstanding talent, training, preparation, and practice, working together as a coordinated team. Patients undergoing major surgical procedures are subject to risks of surgical intervention and rewards of successful outcomes based upon the combined skills of healthcare practitioners honed over years of training, deliberate practice, progressive skill acquisition, and more often than we like, learning from their mistakes.

The volume and outcome issue came into public light with a USNEWS report suggesting that over 11,000 lives could be saved by addressing this problem; and despite 25 years of evidence, healthcare has been slow to adopt minimum volume thresholds. A recent call to action “Take the Volume Pledge,” a campaign to limit certain surgical procedures to hospitals and surgeons that perform a minimum number of procedures, has stimulated widespread debate and discussion in the surgical, hospital leadership, and quality of care communities. The debate challenges traditional perspectives on surgeon autonomy, practice quality, and patient advocacy.

Administrative leaders, hospital executives, and clinicians from Johns Hopkins, Dartmouth, and the University of Michigan committed to set volume thresholds for 10 common surgery procedures for which the relationship between volume and outcome is strong, believing that physicians with insight and knowledge in these institutions should discuss and resolve these issues. The exact thresholds are admittedly subjective, as the relationship between volume and outcome is often linear and varies by study. Still, we sought to set a minimum standard that had face validity. Although volume thresholds may not be appropriate in rural areas or areas with limited access to care, we believe all patients should be provided information about volume and make an informed decision about what is best for them. Furthermore, the lack of conclusive evidence upon which to set explicit thresholds and the need to account for cumulative and annual experience, challenges the development of consensus in the surgical and broader medical community.

To help advance the discussion, we believe the surgical community can align around some common principles. The first principle is our commitment to optimizing patient outcomes. Our surgical programs need to determine how best to achieve this goal because a surgeon completed a residency, we should not assume life-time competency in performing all procedures in that field. We believe that the establishment of minimum standards suggesting procedural “competency” are a good thing for patients. No matter whether the surgeon is a high volume or a low volume provider in these selected areas, demonstration of acceptable quality outcomes is a must. For low volume surgeons, this could be a challenge, requiring over a decade of patients to provide a precise measure of outcomes.

Second, patients should have information to make an informed choice about where to have surgery. Right now, there is limited information for patients to be informed about surgical volumes and most surgeons do not discuss this with patients. Yet providing this type of information is not as easy as it sounds. Hospitals and surgeons should agree on a description and definition of types of cases, monitor their surgeon's experiences, and share these patients.

Transparency is the key to success in this endeavor. Up until this point, surgeons and hospitals have allowed these issues to be managed in a self-policing approach.3 We support a vigorous program of evaluation and review of surgical outcomes to enhance the patient's best interest. But who pays the price when it fails? Our patients deserve a healthcare system that ensures and or at least enhances their best interests be served. Practice, informed by evidence, can and often does make for better outcomes. This is how surgeons have improved patients outcomes as surgeries inception; volume thresholds are the next step in that journey, recognizing that many details need discussion. And when your surgeon and their team show “mastery of their craft” through minimum volume thresholds and thoughtful risk adjusted reporting of outcomes, we all benefit from the effort—A real Story of Success in health care.

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1. Gladwell M. Outliers: The Story of Success. New York: Little, Brown and Company; 2008.
2. Organ Procurement and Transplantation Network. OPTN Database. Health Resources and Services Administration, U.S. Department of Health and Human Services. Available at:
3. Friedson E. Profession of Medicine: A Study of the Sociology of Applied Knowledge. Chicago: The University of Chicago Press; 1998.
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