Seeing is Believing When it Comes to
Video Evaluation of Surgery

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Gathering accurate data related to clinical performance in healthcare is critical to optimal outcomes. Heretofore, most measures of adverse outcomes (financial, retrospective, incident review, quality measure compliance) have failed to achieve broad acceptance from clinicians because of inaccuracies in the basic dataset, inadequate risk adjustment, and blind attribution of the outcome to the physician without regard to the impact of the hospital system or the natural course of the patient’s disease. Case complexity is neglected in favor of simple cost-accounting models, post hoc reviews (frequently devoid of physician input) or bundle compliance. The classic Morbidity & Mortality forum, where detailed critical reviews can be achieved, have been eschewed in favor of these objective but less meaningful processes. Clearly, quality is an outcome driven by optimum cognitive input by the physician (diagnosis, judgment, communication), system proficiency and technical expertise. Of the three, evaluation of technical expertise may be the most amenable to advances in technological innovation.

The aeronautical industry is replete with data on the value of repetitive training in the context of critical review (the instrument check ride), simulator skill evaluation and constructive feedback. Many surgical researchers have developed algorithms to evaluate technical skill in surgery and have been able to show skill improvement with simulator training, video game exercises and structured technical skill training (Rosser et al). In fact, video review of surgical cases has been used by many surgeons as a self-critique method for years, but the benefit achieved may be skewed by the inherent biases accompanying the obviously ‘non-objective’ review. However, the C-SATS video methodology of deconstructing procedures into critical components and crowd-sourcing technical parameters to a numerical scale may be a practical way to accurately measure technical skill. Broad use of this technology would establish a baseline of performance, identify areas for improvement, and in combination with the measurement of adverse outcomes and volume, increase transparency throughout the health system.

Currently, improvement gains in surgical skill are achieved primarily by performing more cases on patients; first as an apprentice during residency and subsequently, in one’s practice. Occasionally, improvements are made, but in some cases, pre-existing deficits are simply perpetuated because of the lack of critical review. To add complexity to the situation, when it comes to robotic surgery, institutions haven’t had the bandwidth or financial resources to support the infrastructure required to rigorously evaluate technical skills. Fortunately, C-SATS can help, because its video evaluation methodology is both efficient and cost-effective. Identified skill deficits can be remediated with simulation and improvement measured again with a C-SATS review. Thus, surgeons are offered not only critique, but a path to improvement.

This is so much more constructive than pointing out deficiencies and leaving improvement to individual unstructured practice on patients. With C-SATS and a coordinated improvement curriculum, surgeons actually get to see areas where they need to improve and how they’ve improved. The tracking and reporting of progress is critical.

This approach may frighten some in healthcare. Some practitioners, for example, may believe that if nothing goes obviously wrong during a case, they’re doing well. However, efficiency of resource utilization, anesthesia time, and length of stay may tell a different story. There’s also a sense held by many physicians that organizations are not qualified to critique physician performance and that gathering data and reviewing videos, may threaten physician autonomy and independence. However, the reality is that the world of medicine is moving towards optimized, evidence-based outcomes and on-going performance review is firmly embedded within the fabric the evolving culture.

The C-SATS approach fits well in the new culture because it allows physicians to self-assess, optimize performance and enhance outcomes.

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C-SATS is used in areas such as...

Surgery, Pathology, Nursing, Device Usage, Homecare, Psychology, and Simulation

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Results in days; a fraction of the time of traditional peer review.


Highly accurate performance scores equivalent to gold standards.



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...the whole exercise was an outstanding, confidential self-assessment tool that will help me improve my technique so that I can offer better care to my patients.”
— James Greenberg, MD, Chief Division of Gynecology, Brigham & Women's Hospital, Associate Professor, Harvard