Exporting excellence for Whipple resection to refine the Leapfrog Initiative

The Leapfrog Group is a consortium of Fortune 500 corporations and healthcare purchasers whose intent is to harness their purchasing power to improve the quality of care by regionalizing high complexity operations at high volume hospitals (HVH). The Whipple resection has been designated a "Leapfrog" procedure and the recommendation issued that it be performed at HVH. However, alternatives to the Leapfrog Initiative are likely necessary because regionalization has been difficult to implement, as the number of Leapfrog sites is low in rural areas, and the initiative's relevance to facilities that care for the uninsured is unclear. We hypothesized that defining exportable elements of the Whipple resection could allow a low volume hospital (LVH) to improve upon its processes of care to safely attempt these procedures.

We describe the surgical experience of the University of California, San Francisco at the San Mateo Medical Center (SMMC) from 2002 to 2004. A quality improvement program was introduced at this LVH, focusing on enhancing structure and processes of care. High-volume UCSF pancreas surgeons were polled to define exportable elements of Whipple resection. A senior pancreas consultant assisted in the perioperative preparation of SMMC.

Of the nine patients who underwent exploratory surgery for an intended Whipple resection, four had a successful resection, and five were unresectable. Morbidity was minimal and 30-d mortality was zero.

Whipple resections can be safely performed at a LVH after exporting surgical excellence. The structure and process changes allowed the LVH to improve its quality of care. Alternatives to the Leapfrog Initiative are feasible and can extend its original intent.