Professor Department of Surgery School of Public Health Hong Kong.
A quality assurance programme in surgical practice is quite simply a mechanism to ensure that the patient (consumer) is subjected to the least threatening journey through the hospital during a period of treatment, with an outcome that is deemed acceptable by international standards. This process inherently incorporates data collection and outcome analysis, but is in fact conceptually broader and includes assessment not only of patient outcomes, but institutional processes, appropriateness of care and patient and healthcare provider satisfaction. All of these variables inherently, but not exclusively, affect the patient journey.
The concept of developing ‘quality assessment’ in surgery is historically attributed to the American surgeon Ernest Codman.1 In the 1900s, he suggested that hospitals in general, and surgeons in particular, should collect their results sequentially over time, in order to provide comparative data on ‘end-results’. His suggestion was that these outcomes be made public, allowing patients to use the information and ‘choose’ their place of treatment and individual surgeon. It was his lifelong pursuit to establish an "end results system" to track the outcome of treatments, as an opportunity to identify and resolve clinical misadventures thus providing the foundation for improving the care of future patients.1 It was a recognition that both institutional and individual measures of ‘performance’ need to be recorded, aspects which are now widely recognised as being an important part of the provision of quality assurance in surgery. But, for surgical specialties in Asia, why do we need this process and how can it be achieved?
Quality assurance programmes in surgery are essential for patients, doctors, hospitals and healthcare providers (financiers) worldwide for a variety of reasons.
Patients need to be reassured that the process of surgical treatment to which they have agreed is appropriate, will be administered effectively, and results in an outcome acceptable by international standards. In order to achieve this, individual surgeons and individual hospitals should be able to provide information regarding outcomes after surgical treatment which is based upon validated data and also ‘risk-adjusted’ for case-mix. For example, in cardiac surgery in the UK, a speciality which has led the way in providing outcome data and analyses, each centre providing cardiac surgical treatments submits data regarding patient risk profiles and outcomes to the UK Society of Cardiothoracic Surgeons. These are subsequently collated by the National body, published and made available to the public.2This process has evolved more recently and in collaboration with the Healthcare Commission in the UK, institutional and individual surgeons' results are now published on the Internet.3The quality assurance process is important for individual surgeons globally. Advances in risk-stratification allow them to compare their case-loads and outcomes with other practitioners both locally and internationally, and ensure that the facility within their institution is enabling them to perform to an appropriate level. It is important for hospitals to be able to look at individual and group surgical outcomes, ensuring that their overall institutional process meets published standards. It is important that healthcare providers are reassured that their financial support of surgical programmes within institutions is being used effectively, not only in terms of patient outcome, but also in resource utilisation.
All of the above issues are pertinent and relevant to the provision of surgical care in Asia in view of the rapid rise of treatment availability, and importantly, the associated financial burden. Whilst it is perceived that all of the above processes can by default lead to consequential quality ‘improvement’, there are still many areas which require investigation and resolution.
Presenting information regarding outcome to the public (patients) requires an ongoing ‘educational’ aspect as there needs to be general understanding of the important differences between ‘crude’ and ‘risk-adjusted’ outcomes. A surgeon or institute with a comparatively high mortality for a given procedure may actually be performing exceptionally well when case-mix is considered. This represents a challenge in Asia.
The ‘risk-stratification’ process is well developed in cardiac surgery, but has accepted limitations and is more complicated to establish and consequently less developed in other surgical disciplines. Despite this, the Veterans Affairs Medical Centers in the US has produced risk-adjustment models for 30-day mortality and morbidity rates for both non-cardiac and associated surgical specialities.4The ability of this model to detect variations in the quality of care has also been shown in a validation study.5There are still, however, complexities to be resolved when defining ‘outcome’.
In cardiac surgery, mortality is routinely used as a measured ‘outcome’. For surgical specialities where this is unlikely to be a useful marker—e.g. plastic surgery—clinical indices which reflect quality in that particular service need to be identified. Mortality alone may not be sensitive enough as a ‘quality’ outcome tool and recently, the concept of recording and analysing ‘near-miss’ episodes rather than death has been suggested as being a more useful mechanism to identify rectifiable performance problems at an early stage2. It seems obvious that, despite apparent difficulties in defining surgical outcomes and applying risk-stratification, embracing the concept of quality assurance in Asia would be of benefit to all parties involved in the patient journey. But how could it be achieved?
The essential element for a successful quality assurance programme is without question, the determination and commitment of healthcare professionals (providers of direct clinical care as well as financiers) to embrace the concept. The most important practical aspect is the provision of an appropriate institutional infrastructure (system) which allows collection of relevant, validated data. Without this, any attempt to provide information regarding patient outcome is doomed to fail. Computerised systems and information technology are globally available, which provide the facility for clinical data storage and complex outcome analysis. It is essential that along with these systems, data validation procedures are undertaken. This will allow confidence in the accuracy of outcome reporting. The provision for these facilities should be given priority by healthcare providers. The natural progression of having these resources in place would be the development of national databases for different surgical specialties within the region, enabling institutional comparisons and ‘benchmarking’ exercises appropriate to the local population. The concept of quality assurance within surgery is not new. The process will continue to be driven by patients, professionals and healthcare providers alike. The provision of comparative systems in Asia, facilitating quality assurance, is a moral obligation of the whole healthcare community involved in the surgical treatment of patients and represents an ongoing challenge within the region.
1) Spiegelhalter DJ. Surgical audit:statistical lessons from Nightingale and Codman. J.R.Stat.Soc A 1999;162:45-58.
2) Keogh BE, Kinsman R. Fifth National Adult Cardiac Surgical Database Report 2003. London: The Society of Cardiothoracic Surgeona of Great Britain and Ireland 2003.
3) Available from URL: www.healthcarecommission.org.uk
4) Participants in the National VA Surgical Quality Improvement Program. The Department of Veterans Affairs’ NSQIP. Annals of Surgery 1998;228:491-507.
5) Khuri SF, Daley J, Henderson W et al. The National Veterans Administration Surgicla Risk Study: risk adjustment for the comparitive assessment of the quality of surgical care. J Am Coll Surg 1995;180:519-531.