Operative Reports in Orthopaedic Surgery: The Need for Assessment and Education

ARTICLE IN PRESS ORIGINAL REPORTS

Operative Reports in Orthopaedic Surgery: The Need for Assessment and Education Niall A. Smyth, MD,* Karim G. Sabeh, MD,† Karthik Meiyappan‡, Sheila A. Conway, MD,x and Seth D. Dodds, MDx Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, Florida; †Department of Orthopaedic Surgery, Newton Wellesley Hospital, Newton, Massachusetts; ‡University of Miami, Coral Gables, Florida; and § Department of Orthopaedic Surgery, University of Miami Miller School of Medicine, Miami, Florida

*

BACKGROUND: The ability to complete an operative

KEY WORDS: Resident, Education, Orthopedic surgery,

report is a vital skill for an orthopaedic surgeon. We hypothesized that most programs do not have formal operative report teaching, that resident operative reports at our institution are incomplete, and that a formal teaching program would improve operative reports.

Operative report

METHODS: A survey of residencies in the United States was conducted assessing the state of operative report education. In addition, resident operative reports were collected at our institution both pre and post a formal educational session. Scores were given for each report out of a possible 35 points. RESULTS: Total 54 institutions responded to the survey,

of which 83% indicated that they had no formal resident operative report teaching. Within our institution, 100 resident operative dictations were assessed prior to instituting a formal education session, with a mean score of 24.5. The most commonly missed items in the report were preoperative antibiotics, deep venous thrombosis prophylaxis, and tourniquet time. The mean score of 100 resident operative dictations following the educational session improved to 31.8. CONCLUSION: Most residency programs do not con-

duct formal resident operative report teaching. Formal instruction on how to complete a comprehensive operative report resulted in a significant improvement in their quality. ( J Surg Ed 000:16. Ó 2019 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.) Funding: None. Investigation performed at: Department of Orthopaedic Surgery, University of Miami Miller School of Medicine, 1611 NW 12th Ave, Miami, FL, 33136. Correspondence: Inquiries Niall A. Smyth, MD, University of Miami Miller School of Medicine, Department of Orthopaedic Surgery, 1611 NW 12th Avenue, Miami, FL 33136; e-mail: [email protected]

COMPETENCIES:

Interpersonal and Communication Skills, Practice-Based Learning and Improvement, Medical Knowledge

INTRODUCTION The operative report is a narrative documenting a patient’s operative procedure and serves multiple purposes. It is a medical document which provides critical information to current and future health care providers.1 In the United States where medico-legal issues are commonplace, the operative report acts as a legal document that serves as the surgeon’s best representation of the events of surgery.2,3 The operative report is also a major component of a fee for service billing system. For example, it is used to justify the necessity of a procedure, to detail its execution, and to demonstrate how specific procedure charges relate to the surgery performed.4 The operative report may also serve as a tool for research and quality improvement projects. Given the importance of this singular document, one might imagine that it is a standardized skill taught to orthopaedic surgery residents to prepare them for clinical practice. However, studies in the nonorthopaedic literature have shown that there is a discrepancy between the quality of operative reports between practicing surgeons and residents, and even among academic surgeons who are responsible for resident education.4,5,6 While residency program directors may believe in the importance of operative report teaching, this education is rarely implemented in the formal resident curriculum.7 This problem has been studied in the general surgery and the obstetrics and gynecology literature, but there is an absence of research on

Journal of Surgical Education  © 2019 Association of Program Directors in Surgery. Published by 1931-7204/$30.00 Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jsurg.2019.08.013

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ARTICLE IN PRESS the quality of operative reports by orthopaedic surgeons and the current state of resident education. Analysis of this specific surgical subspecialty is important because orthopaedic surgery has a large variety of surgical procedures, with a multitude of described operative approaches to each anatomic region. In addition, orthopaedic surgeons utilize an extremely wide array of temporary and permanent implants—details of which can be critical to the patients’ current and future surgical care. The first purpose of this study is to understand whether or not orthopaedic surgery residents across the United States receive formal training in generating an operative report and if such educational methods were considered sufficient. The first step was the survey assessment of the current state of operative report education within orthopaedic surgery residencies. The second purpose was to assess the quality of resident operative reports at our institution and to test if the quality could be improved through a formal educational plan. First, we hypothesized that operative report education is not widely implemented across residency programs and that educational efforts are currently insufficient. Second, we hypothesized that the

quality of resident operative reports could be improved with a 1-hour targeted education session.

METHODS A survey intended for orthopaedic surgery program directors and department chairs was developed consisting of 17 queries, which were a mixture of multiple choice and open-ended questions. The items created were developed using a consensus-based approach that included input from all authors. The survey was then tested and was able to be completed within 5 to 10 minutes. A link to the survey was then emailed to all allopathic (MD) orthopaedic surgery residency programs. The data was gathered using Google Forms (Google, Mountain View, CA). For the second stage of the study, approval of our Institutional Review Board was obtained prior to data collection. The authors created the Operative Report Assessment Tool (ORAT), a checklist utilized to score orthopaedic surgery operative reports (Table 1). This simple 35-point checklist was developed with orthopaedic

TABLE 1. Operative Report Assessment Tool Header

Grade

Date of surgery Timing of dictation Pre-op diagnosis Post-op diagnosis Procedures performed Surgeon (attending) Assistants Anesthesia Blood loss Tourniquet time

0, 1 point 0, 1 point (if done within 24 hours) 0, 1, 2 points (none, partial, complete) 0, 1, 2 points (none, partial, complete) 0, 1, 2 points (none, partial, complete) 0, 1 point 0, 1 point 0, 1, 2 points (none, type, name) 0, 1 point 0, 1, 2 points (0 if not mentioned, 0 if tourniquet is used but time is not mentioned, automatic 1 point if no tourniquet used) 1 point (if none used, must state so) 0, 1, 2 points (if soft tissue procedure automatic 2 points) 0, 1, 2 points (must include even if none sent. Type of specimen and analysis) 0, 1 point 0, 1 point 0, 1 point Total 9 points A. 0, 1 point B. 0, 1 point C. 0, 1 point D. 0, 1 point E. 0, 1, 2 points (quality of detail) F. 0, 1 point G. 0, 1 point H. 0, 1 point

Antibiotics Implants Specimens Complications Operative indications Risks vs. benefits Procedure description A. Surgical marking B. Patient position C. Surgical time-out D. Incision location/wound description E. Procedure details F. Skin closure G. Dressings/splint H. Disposition Post-op Plan A. DVT prophylaxis B. Weight bearing status/range of motion Comments

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Total of 4 points A. 0, 1, 2 points (not mentioned, type, duration) B. 0, 1, 2 points (none, partial, complete) Total (out of 35)

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ARTICLE IN PRESS faculty input to ensure inclusion of orthopaedic specific critical data and also incorporates the medical record documentation requirements as stated by the Joint Commission on Accreditation of Healthcare Organizations.8 Items marked with an asterisk are established Joint Commission on Accreditation of Healthcare Organizations requirements. This tool was then applied to randomly selected resident orthopaedic operative reports both prior to and after formal operative report education. A random sample of 100 resident-dictated operative reports were collected prior to edit or signature by the orthopaedic surgery attending at our residency program’s 2 primary educational hospitals. The operative reports were identified by using the surgical schedule to determine which patients had undergone surgery. The operative reports were obtained from the electronic medical record system (Cerner, North Kansas City, MO). Of note, all resident operative reports are completed using an oral dictation system without the use of a template. Following the initial operative report collection, an obligatory educational session for all orthopaedic residents was led by a faculty member (SDD). The educational session highlighted each item of the ORAT individually. In addition, each resident was sent provided with a copy of the ORAT so that they may use it as a reference. Beginning a week after the educational session, we sequentially collected another 100 operative reports from the same institutions. Prior to grading, each operative report was redacted of patient and participating physician information. Two blinded reviewers assessed all of the operative reports utilizing the ORAT and scores were averaged. There were no significant discrepancies between the 2 reviewers. Pre-education and posteducation statistical analysis were performed using SAS software.

RESULTS Total 54 institutions, out of a total of 154, replied to the survey. Of the institutions that replied, 48 were selfdescribed as university/academic, 5 private/community, and 1 military. Total 83% of the respondents indicated that their program provided no formal resident operative report teaching at their institution. However, 50% of the respondents believed that poor resident operative dictations may lead to worse communication within the operative team or between different operative teams and 50% reported that poor resident operative dictations may lead to problems with the postoperative plan or postoperative care. The majority of respondents (72%) noted that poor resident operative reports may present a medico-legal issue. Fifty-six percent of respondents indicated that they did not consider operative report

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teaching a priority in resident education and 65% do not plan to implement any changes to their residency program with regard to resident operative report education. The mean overall pre-education assessment score for our institution was 24.2 § 3.5. The most commonly under reported items were mode of deep venous thrombosis prophylaxis, risks and benefits of the surgery, preoperative antibiotics administered, and implants used. The median postgraduate residency year for the pre-education operative report assessment was 3 (range 1-5). The median postgraduate residency year for the posteducation operative reports was also 3 (range 1-5). There was no difference in the postgraduate residency year between the pre and posteducation operative reports (p = 0.74). The mean overall score of the posteducation operative reports was 31.8 § 2.1, a 22% increase on the 35 point scale. This improvement demonstrated a statistically significant change compared to the pre-education reports (p < 0.01). When looking at the specific metrics within the operative report analysis tool, certain points were noted to be more profoundly impacted by this education effort. For example, the inclusion of deep venous thrombosis (DVT) prophylaxis improved from 8% to 55% (p < 0.01); reporting on preoperative antibiotics administered improved from 27% to 84% (p < 0.01); appropriate description of the risks and benefits of the surgery improved from 15% to 50% (p < 0.01), and implants used improved from 72% to 98% (p < 0.01).

DISCUSSION The results of our survey confirmed our initial hypothesis that little formal education regarding operative reports is currently being offered to orthopaedic surgery residents, despite this report being considered a critical medical document. Half of the respondents believed poor resident operative reports may lead to communication issues or errors among healthcare teams and problems with postoperative care. In addition, the majority of respondents believed that poor operative reports may lead to medico-legal issues. Despite these critical findings, only 17% of institutions indicated that they had any formal resident education on generating operative reports and only 56% believe this to be a teaching priority. With 65% of respondents indicating no plans to change or improve this educational effort, this problem is likely to persist.7 Literature from other specialties indicates that suboptimal operative report education is a challenge for many training programs. In a survey-based publication by Melton et al.9 assessing operative report teaching across all surgical subspecialties, the overall prevalence

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ARTICLE IN PRESS of formal education was only 17%, despite the authors reporting that 67% of program directors consider operative report teaching a priority. Obstetrics and gynecology programs were the most likely to offer operative report instruction, with a rate of 35%. One potential reason for obstetrics and gynecology programs offering increased resident teaching has been attributed to a greater proportion of routine procedures with minimal variation.9 Another possible reason may be that obstetricians and gynecologists are a frequent target for malpractice claims, with 1 physician based survey claiming it to be the most sued specialty.10 The results of our survey revealed that the majority of responders do not consider operative report teaching a priority, nor do they have intentions to change their educational approach to operative reports. However, there are multiple published examples indicating that the completion of a high quality operative report is vital for good clinical practice. From a fee-for-service perspective, inadequate resident operative reports have been shown to result in incorrect coding in up to 28% cases. These deficiencies were shown to have the potential to reduce reimbursement by an average of $18,200.11 While the billing surgeon bears the responsibility for an appropriate operative report, if he or she fails to correct the deficiencies then this may negatively reflect reimbursement. Furthermore, the operative report is the single most important document used to justify the charges associated with a procedure.4 Its importance was highlighted by Novitsky et al.,11 who concluded that the operative report is responsible for validating nearly 90% of charges in general surgery cases. The other important function of the operative report is as a form of medical communication. Operative reports can help guide a patient’s postoperative care and represent a critical medical reference for other practitioners, such as nurses, physical therapists, medical colleagues, and in the event of revision surgerythe orthopaedic surgeon. The operative note from the primary surgery is essential to preoperative planning in revision surgery.11,12 Critical elements of the operative report at the time of revision surgery include surgical approach, variable anatomy, detailed orthopaedic implant and device information, and complications at surgery. Failure to know this information can make revision surgery substantially more challenging. From a medico-legal perspective, a complete operative report is vital when defending against a malpractice claim. Medical malpractice defense attorneys report that inadequate medical documentation is the most common difficulty they encounter.3 Incomplete or inadequately compiled operative reports also affects legal tort cases and lawsuits between patients and employers, insurers, or businesses. Despite the importance of this note in

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medical practice, medical billing, medico-legal investigations, both our national survey results and our institutional assessments indicate there is considerable room for improvement in the approach to operative report education. Common deficiencies encountered in the pre-educational assessments were the mode of DVT prophylaxis, documentation of the risks, and benefits of the surgery, preoperative antibiotics administered, and implants used. The documentation of DVT prophylaxis is a good illustration of how the quality of operative reports can impact medical care, communication, and legal outcomes. The choice of perioperative DVT prophylaxis is impacted by a multitude of factors, including medical co-morbidities, procedure type, and procedure duration. These complex perioperative decisions are often dynamic and formulated by a team of physicians from surgery, anesthesia, hematology, and critical care specialists. Furthermore, the treatment options (medical and pharmacologic) are rapidly expandingintroducing additional treatment algorithms to an already complex medical judgment. In a study reporting the success of malpractice claims regarding venous thromboembolism in surgical patients, an expert witness noted that 89% of claims were successful.13 As the operative report is authored by the surgeon, it represents a straightforward and reproducible opportunity for the orthopaedic surgeon to document their perioperative plan of care. While documenting a clear plan for DVT prophylaxis may not eliminate all concern, and will not address immediate postoperative care, it will certainly improve medical communication and could thereby mitigate some medical and medico-legal risks.14,15 While this study represents the first analysis on the quality of operative reports amongst orthopaedic surgery residents, trainees in other specialties have been noted to be equally deficient. Zwintscher et al. 16 in their assessment of general surgery resident operative reports noted that only 0.2% contained all the items assessed. These findings were further corroborated in a multi-center study evaluating incisional hernia repair operative reports. Those authors concluded that 67.9% of the documents failed to report at least 1 vital operative item.17 Therefore, poor quality and incomplete operative reports is a problem that transcends all surgical specialties. Poor operative reporting is also not solely a problem amongst trainees. Flynn et al.4 used professional coders from a multispecialty academic institution to identify the 10 most common deficiencies for reimbursement of services due to incomplete operative notes. The authors concluded that while only 20% of resident operative reports contained no deficiencies, faculty surgeons did not fare much better with only 29% of their reports deemed adequate. This may highlight the

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ARTICLE IN PRESS need of early and ongoing education, as increased experience does not necessarily translate to a thorough operative report. Our study demonstrates that the standard of resident operative reports can be improved by including teaching on the subject as part of the formal educational curriculum. While the operative reports were not universally complete following the teaching session, there was a significant improvement in the mean score from 24.2 to 31.8 (p < 0.01). The implementation of this change was not overly burdensome, consisting of a single 1-hour long session for all orthopaedic surgery residents. The education was well-received and the residents expressed gratitude for the new educational initiative. It should also be recognized that an additional option to improve the quality of an operative report is to use an electronic medical record generated template. One interesting finding from the survey we performed was the discordance between the apparent value placed on operative reports by residency and departmental leadership and the paucity of current or planned formalized efforts to address this educational need. While the reason for this discrepancy was not addressed by our follow-up study, 1 hypothesis is that this discordance is related to the recent and ongoing changes and trends that specifically impact teaching physicians. Increasing clinical and administrative pressures may lead to decreasing time available for academic effort for teaching faculty.18,19 In combination with the formalized restrictions placed on resident work hours, this may result in less available time for all resident education, including formalized and clinically-based educational efforts. In this challenging environment, efficient educational assessment tools are 1 way to provide such essential activity in a time efficient, targeted, and reproducible manner. In our program, we found the Operative Report Assessment Tool to be easy and quick to use. Similarly, the educational intervention was limited to 1 hour and both the internal assessment and educational intervention will be provided annually to determine if this is adequate for sustainable proficiency in resident performance on operative reports. As our data indicate that there is a great need for improved operative report education, this efficient assessment tool and educational program represents 1 easily implementable educational change. In our institution, this minimal curriculum change demonstrated immediate improvement in resident performance. The principle limitation of this study is the possible influence on the results secondary to the Hawthorne (observer) effect. A phenomenon first described in the 1930’s, it refers to the changes in behavior by subjects of a study due to their awareness of being observed.20 A general increased focus in improving resident operative reports may have influenced the behavior of the residents by pressuring them into bettering their documentation.

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Additionally, it remains unclear if the improvement in resident operative reports will be lasting and applied in future practice. In our institution, the assessments and teaching sessions will be held annually to reinforce the habit of thorough operative report documentation and further study will be completed to assess long-term results. Our study indicates that there is minimal formal education on how to complete an operative report conducted in orthopaedic surgery residency education. Utilizing an assessment tool to analyze the completeness of operative reports, we determined that instituting a 1-hour formal teaching session on the topic can significantly improve the level of operative report dictations by orthopaedic surgery residents. These results have instigated programmatic change and improvement projects on the subject and an operative report educational session has been added to the annual resident education curriculum.

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