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We appreciate Dr Atik's kind comments and thoughtful questions. Additionally, his efforts are to be recognized and commended. Our quality improvement program (QIP)¹, ² was developed to address opportunities to reduce mortality and mitigate the risk of major morbidity (nosocomial infections, acute renal failure, hemorrhage, reoperations, etc) through elimination of variation while reliably applying the best available evidence as well as best practices. Regarding the comment about severity scores, The Society of Thoracic Surgeons (STS)–National Cardiac Database allowed us to compare our performance to national averages and guided our efforts. STS developed definitions for key data elements, providing a common language and standards. STS also developed risk-adjusted mortality and morbidity algorithms to provide benchmark measures that helped in the construction of our standard operating procedure. STS risk scores were routinely recorded in our QIP efforts and used to calculate expected mortality and compare it with the national average. However, reporting risk scores was beyond our focus. The most important finding of our article was that by building a QIP, a measurable and significant decrease in mortality can be accomplished, and on that regard, our article was among the first to report such a finding.

We tend to disagree with Dr Atik's comments that QIPs follow institutional or regional/national initiatives. A QIP can follow both national/regional initiatives and at the same time be tailored to each institution's needs and particularities. Our QIP was structured based on STS guidelines and best evidence practices but was also adjusted to our institution's particular goals.

An important finding of our work is that a QIP did not improve dramatically the outcomes on diabetic patients, as previously reported.³ Similarly, Van Den Berghe and colleagues³ demonstrated that with their intensive insulin therapy protocol, they were able to reduce mortality of all medical/surgical intensive care unit patients, except those with a prior history of diabetes. Our investigation corroborated this finding that diabetics are a high-risk subset of patients on which future QIP efforts should focus. The presence of small target vessels (diffuse coronary artery disease) frequently encountered in diabetic patients, the higher risk for wound infection, and the higher risk of mortality compared with nondiabetic patients as well as the resistance of diabetic patients to improve with QIP initiatives provided the rationale for our proposition.

We tend to agree with Dr Atik's statement that “because processes of care vary widely among cardiac surgery programs, there are no recipes' that can be universally applied, due to system-based particularities.” However, common denominators of successful QIP efforts include a dedicated multidisciplinary team with common goals, a systems-based approach, accurate communication, adherence to strict protocols, and monitoring compliance. In this respect, some universally applied rules may apply. Regarding the reasons for the change in outcomes, we believe there is a multifactorial etiology: mainly the absence of a dedicated multidisciplinary team, the lack of a monitoring tool to measure compliance to the protocols, and individualized rather than a team approach to clinical problem solving during the initial period before development of QIP. In contradistinction, our systems-based approach, standardization, team building, consistent and accurate communication, and active management of change and quality accounted for a recent decline of 48% in mortality.

The financial impact (investment and savings) of QIP is indeed crucial. We previously demonstrated that by implementing QIP, a significant increase in the early extubation rates, a decrease in intensive care unit stay, and resource utilization can be accomplished.² We are in the process of analyzing the specific financial impact of our QIP, and this will be the focus of a future publication. We believe that by using a unique database linking clinical and financial outcomes through a focus on quality, cost containment in cardiac surgical care can be achieved by identifying and reducing costly complications, improving efficiencies of care, and reducing resource utilization.

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References 

1. Stamou SC, Camp SL, Stiegel RM, et al. Quality improvement program decreases mortality after cardiac surgery. J Thorac Cardiovasc Surg. 2008;136:494–499
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2. Turner SL, Stamou SC, Stiegel RM, et al. Quality improvement program increases early tracheal extubation and decreases pulmonary complications and resource utilization after cardiac surgery. J Card Surg. In press.
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3. Van den Berghe G, Wilmer A, Milants I, Wouters PJ, Bouckaert B, Bruyninckx F, et al. Intensive insulin therapy in mixed medical/surgical intensive care units: benefit versus harm. Diabetes. 2006;55:3151–3159
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