ABC | Volume 114, Nº4, April 2020

Short Editorial How Do We Know a Change is an Improvement? The (Not So) New Scientific Knowledge Every Physician Should Learn, Master and Lead Alexandre Siciliano Colafranceschi 1,2, 3 Universidade Federal do Estado do Rio de Janeiro, 1 Rio de Janeiro, RJ - Brazil Instituto Nacional de Cardiologia, 2 Rio de Janeiro, RJ - Brazil Hospital Pró Cardíaco, 3 Rio de Janeiro, RJ – Brazil Short Editorial related to the article: Analysis of >100,000 Cardiovascular Surgeries Performed at the Heart Institute and a New Era of Outcomes Mailing Address: Alexandre Siciliano Colafranceschi • Instituto Nacional de Cardiologia - Cirurgia Cardíaca - Rua das Larangeiras, 374. CEP 22240-002, Rio de Janeiro, RJ – Brazil E-mail: alexandre.siciliano@gmail.com keywords Cardiovascular Surgical Procedures/trends; Quality Improvement; Patient Safety; Hospital Mortality; Database. Cardiothoracic surgeons have a rich history of quality improvement and a strong ethos of transparency and innovation allowing for the rapid diffusion of standards, techniques, and benchmarks worldwide. Nationally, fewmedical specialties have contributed as much to the development of knowledge as the Brazilian cardiac surgery. From the hard work developed during decades by pioneering surgeons such as Euryclides Zerbini and Adib Jatene to the most contemporaneous leaders in the field, the Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo – InCor – is definitely at the heart of this journey. 1 In this issue of Arquivos Brasileiros de Cardiologia the work by Mejia et al. 2 has the merit of taking into account the evolution of the number of cardiovascular surgeries performed at InCor during a 35-year period. The total number is a remarkable one: over 100,000 open heart procedures were analyzed. After all, themean number of procedures/year is 2,964, - or more than 11 procedures per workday. It is noteworthy the fact that the total number of procedures has been increasing, especially due to an increase in valvular operations and the correction of congenital cardiopathies. Also, of note, there is a 7% decrease in coronary artery bypass graft surgery volume in the most recent period studied. Besides describing the volume of disease-specific open-heart surgical procedures throughout five different periods of time over the 35 years of data, another objective of the study byMejia et al. 2 was to evaluate the impact of the actions taken froma continuous quality improvement program on mortality from cardiovascular surgery. It is not clear, however, how the periods of time were selected for the analyses. The quality improvement initiative at InCor, called Programa de Melhoria Contínua da Qualidade (PMCQ), was consolidated in 2016 with a clear mission to decrease the cardiovascular surgical operative mortality. It is hosted at the Unidade Cirúrgica de Qualidade e Segurança do Paciente Cirúrgico (UCQSP) as a department of the Cardiovascular Surgical Division at InCor. According to the authors, this unit aims to support the construction of the safety culture, promote transparency, standardize training, improve the work of the teams andmonitor the surgical performance. 2 When InCor aims to support the construction of a safety culture, it is clear that they head toward the right direction. As stated by Robert Lloyd, 3 Vice President at the Institute for Healthcare Improvement, “Quality” is not a department. An organization will only make meaningful and sustainable improvements when people at every level feel a shared desire and responsibility for making processes and outcomes better every day. After analyzing the data, the authors concluded that there was a significant decrease in operativemortality (closer to international standards) in the studied groups after the implementation of the quality improvement programat InCor. The question that remains is how do we know that the changes made after the PMCQ consolidation resulted in an improvement in surgical mortality? Directing efforts in collecting, analyzing and applying data of the surgical results in order to improve quality and reassess conducts and procedures is critical to quality improvement initiatives. Mixing accountability or researchmeasures with those for improvement, however, is counterproductive. 4 ModernQuality Improvement (QI) concepts had their origins in the Statistical Process Control (SPC) measurements developed byWalter Shewart in the 1920s. Themarriage of those techniques with an overall management philosophy by Edwards Deming, Joseph Juran, and others has resulted in the quality movement as it is known through various terms and acronyms (TQM – Total Quality Management, CQI – Continuous Quality Improvement, and so on). Although arriving later in health care than in other fields, QI concepts have rapidly proliferated here through the efforts of Berwick and others. 5 Quality improvement requires using data to learn and to predict future performance (as opposed to what happened in the past, as stated by accountability and research data). Regarding improvement, it is critical to understand that every process has an inherent variation that one wants to understand. Understanding the terms process and variation, besides developing process thinking, are fundamental to an understanding of how to improve anything. Contemporary cardiothoracic surgical care is a complex process, involving sophisticated techniques and equipment, health care professionals with varying levels of skills, and high- risk patients. Surgeons work in a safety-critical environments where the complexity of care and the patients’ risk factors exponentially increase the potential for significant harm. The designed system of caring for surgical patients deliver DOI: https://doi.org/10.36660/abc.20200249 613