Objective To evaluate the association between hospital penalization in the US Hospital Acquired Condition Reduction Program (HACRP) and subsequent changes in clinical outcomes. Design Regression discontinuity design applied to a retrospective cohort from inpatient Medicare claims. Setting 3238 acute care hospitals in the United States. Participants Medicare fee-for-service beneficiaries discharged from acute care hospitals between 23 July 2014 and 30 November 2016 and eligible for at least one targeted hospital acquired condition (n=15 470 334). Intervention Hospital receipt of a penalty in the first year of the HACRP. Main outcome measures Episode level count of targeted hospital acquired conditions per 1000 episodes, 30 day readmissions, and 30 day mortality. Results Of 724 hospitals penalized under the HACRP in fiscal year 2015, 708 were represented in the study. Mean counts of hospital acquired conditions were 2.72 per 1000 episodes for penalized hospitals and 2.06 per 1000 episodes for non-penalized hospitals; 30 day readmissions were 14.4% and 14.0%, respectively, and 30 day mortality was 9.0% for both hospital groups. Penalized hospitals were more likely to be large, teaching institutions, and have a greater share of patients with low socioeconomic status than non-penalized hospitals. HACRP penalties were associated with a non-significant change of −0.16 hospital acquired conditions per 1000 episodes (95% confidence interval −0.53 to 0.20), −0.36 percentage points in 30 day readmission (−1.06 to 0.33), and −0.04 percentage points in 30 day mortality (−0.59 to 0.52). No clear patterns of clinical improvement were observed across hospital characteristics. Conclusions Penalization was not associated with significant changes in rates of hospital acquired conditions, 30 day readmission, or 30 day mortality, and does not appear to drive meaningful clinical improvements. By disproportionately penalizing hospitals caring for more disadvantaged patients, the HACRP could exacerbate inequities in care.

Objective:To assess risk-adjusted outcomes and participant perceptions following a statewide coaching program for bariatric surgeons.Summary of Background Data:Coaching has emerged as a new approach for improving individual surgeon performance, but lacks evidence linking to clinical outcomes.Methods:This program took place between October 2015 and February 2018 in the Michigan Bariatric Surgery Collaborative. Surgeons were categorized as coach, participant, or nonparticipant for an interrupted time series analysis. Multilevel logistic regression models included patient characteristics, time trends, and number of sessions. Risk-adjusted overall and surgical complication rates are reported, as are within-group relative risk ratios and 95% confidence intervals. We also compared operative times and report risk differences and 95% confidence intervals. Iterative thematic analysis of semi-structured interviews examined participant and coach perceptions of the program.Results:The coaching program was viewed favorably by most surgeons and many participants described numerous technical and nontechnical practice changes. The program was not associated with significant change in risk-adjusted complications with relative risks for coaches, participants, and nonparticipants of 0.99 (0.62–1.37), 0.91 (0.64–1.17), and 1.15 (0.83–1.47), respectively. Operative times did improve for participants, but not coaches or nonparticipants, with risk differences of –14.0 (–22.3, –5.7), –1.0 (–4.5, 2.4), and –2.6 (–6.9, 1.7). Future coaching programmatic design should consider dose-complexity matching, hierarchical leveling, and optimizing video review.Conclusions:This statewide surgical coaching program was perceived as valuable and surgeons reported numerous practice changes. Operative times improved, but there was no significant improvement in risk-adjusted outcomes.

Background: The ''surgical personality'' is a mostly negative academic and cultural image of the surgeon as egotistical, paternalistic, and inflexible. Because of this image, surgeons have been viewed as resistant to change and some behaviors, vulnerability, for example, are viewed as ''suspect'' because they seemingly threaten professional competency. We report on exit interviews of surgeons who participated in a coaching program and demonstrate how their narratives challenge the surgical ''personality'' and forge an evolving and more open professional surgical identity. Methods: We interviewed n ¼ 34 bariatric surgeons at the end of a 2-year surgical coaching program. Transcribed interviews were analyzed in NVivo, computer-assisted qualitative data analysis software. Coding of transcripts was approached through iterative steps. We utilized an exploratory method; each member of our team independently examined 3 transcripts to evaluate emergent themes early in the investigation. The team met to discuss our independent themes and develop the codebook collectively. We created a descriptive framework for our first round of coding based on emerging themes and employed an interpretive framework to arrive at our themes. Results: Three major themes emerged from our data. Participants in this study discussed the ways that participation in the coaching program initially conflicted with their identity as a competent professional. Surgeons were acutely aware of how participation might have destabilized their surgical identity because they might be viewed as vulnerable. Despite these concerns about image, surgeons found impetus for improvement because of poor outcome scores or because they desired early career affirmation. Finally, surgeons report that the safe spaces of intentional coaching contributed to their ideas about how surgeons, and ultimately surgery, can change. Conclusions: Participation in a coaching program challenged how surgeons thought of themselves in relationship to social and peer expectations. Our results indicate that surgeons do feel peer and social pressures related to identity but are much more complex and nuanced than has been previously discussed. The safe space of intentional coaching allowed participants to practice vulnerability without the pressures of sometimes caustic professional norms. Participants in this study viewed coaching as the way to improve the culture of surgery.

urgical coaching is a partnership between a trained surgeon coach and a surgeon coachee. Together, they use collaborative analysis and constructive feedback to set goals and make action plans to promote performance improvement in technical and nontechnical skills. 1 Successful surgical coaching programs have been implemented for medical students, residents, and practicing surgeons. [1][2][3][4][5][6][7][8] This success has added to the growing enthusiasm for creating surgical coaching programs for professional development.While there is rising interest in building surgical coaching programs, it remains unclear how to select effective surgical coaches. The selection of coaches is a crucial step in the creation of a coaching program as the program's success relies on the effectiveness of its coaches. 8 The Wisconsin Surgical Coaching Framework identifies important characteristics of coaches that include strong interpersonal and communication skills, adaptability, advanced experience and skill level, and the ability to get into the coaching mindset. 1,8 While these qualities provide insight into basic coaching skills, there is no objective method to select effective surgical coaches.Consequently, the objective of this study was to identify an objective measure to determine who will be an effective surgical coach. Given that interpersonal and communication skills are important for surgical coaches, we hypothesized existing behavioral assessments, including the Myers-Briggs Type Indicator (MBTI) and the Life Styles Inventory (LSI), could be used to identify effective surgical coaches. [9][10][11][12][13][14] We had the following specific hypotheses: (1) the MBTI profile for an individual coach would not be associated with coach performance as all types are considered equal, (2) higher LSI IMPORTANCE While interest in surgical coaching programs is rising, there is no objective method for selecting effective surgical coaches.OBJECTIVE To identify a quantitative measure to determine who will be an effective surgical coach. DESIGN, SETTING, AND PARTICIPANTSThis prospective cohort study included coaches and coachees from 2 statewide peer surgical coaching programs: the Wisconsin Surgical Coaching Program and the Michigan Bariatric Surgical Collaborative coaching program. Data were collected from April 2014 to February 2018, and analysis began August 2018. INTERVENTIONSThe Myers-Briggs Type Indicator was administered to coaches and coachees, and the Life Styles Inventory was administered to surgical coaches before their first coaching session. MAIN OUTCOMES AND MEASURESCoach performance in the first coaching session and all coaching sessions using the Wisconsin Surgical Coaching Rubric.RESULTS Twenty-three surgical coaches and 38 coachees combined for a total of 65 unique pairs and 106 coaching sessions. Overall, 22 of 23 coaches (96%) and 32 of 38 coachees (84%) were men. An increase in a coach's Life Styles Inventory constructive style score correlated with an increase in overall coach performance for the first coaching s...