The Stick and Bigger Stick Approach to Health Outcomes Publication

The Bulletin of the Annals of the Royal College of England (RCSEng)is this month dedicated to the thorny issue of surgical outcomes reporting. The editorial team should be commended for publishing 2 very opposing views of the reporting of surgeon specific mortality data.

Events that should Never Occur

Patient safety and healthcare quality initiatives started in earnest in the USA in the late 1990s/early 2 noughties. Similar initiatives introduced in the NHS over the past 10 years have migrated from across the pond. One such initiative is the compulsory reporting of what is termed a 'never event'.

The peculiarly termed never event is exactly that - something that, in the eyes of someone somewhere should never ever happen. As with many healthcare safety initiatives, the concept of a never event has been borrowed from the aviation industry. Good examples of never events include a surgeon operating on a wrong limb and accidental retention of a gauze swab inside a body cavity after surgery.

Comparing the English list to the American list makes very interesting reading -The most obvious difference is that the American list is much longer and that many items on one list do not exist on the other. The other big difference is the consequence of a never event happening. In the US where there is a predominantly private competitive healthcare system, publication of a list of never events by a hospital will very likely lead to less business and therefore less income. In the UK, a carrot and stick approach is used to manage the occurrence of never events in hospitals. The response is designed to ensure that processes are put into place to ensure those never events do not occur again.

The number of possible events that should never happen in hospital are innumerable. Different wards and specialities will have their own particular never events. It is impossible that every event in every corner of the hospital could be included in an infinitely long list of never events. There is however, merit in the publication of a hospital's performance as regards the occurrence of generic never events. The number of never events occurring in a hospital reflects its general approach to patient safety. They have featured in the recent Keogh report on underperforming hopsitals. Publication of these lists is in my opinion a positive and important development. I just hope that access to the performance of all hospitals in England hospital will be easy and straightforward for patients and that eventually occurrence of never events will become vanishingly rare.

 

 

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Off Pump Coronary Surgery (OPCAB) and the Evolution of My Pragmatism!

I have been observing and then performing coronary artery surgery since 1988. It was in 1992 when I first heard of Subramanian's first published accounts of LIMA to LAD coronary bypass done off pump i.e. without the aid of a heart lung machine.

Is this A Dangerous Precedent ?

I really cannot tell whether suspending paediatric cardiac operations at Leeds General Infirmary was the right or wrong thing to do - I just do not have the facts to make a judgement .
What I can tell for sure is that Sirs Bruce Keogh and Roger Boyle, both of whom I know and greatly respect, have set a precedent on how to deal with adverse surgical outcomes.
From April 1st,  Bruce Keogh promised that outcomes of a number of surgical procedures performed in England will be published. There will be surgeons and units with mortality rates that are double the national average.
Are we therefore going to see a whole host of closures and investigations started before the month of April is up?

Surgical Outcomes Reporting - why we are Missing the Point.

JAMA Network | JAMA Surgery | Failure to Rescue Patients After Reintervention in Gastroesophageal Cancer Surgery in EnglandFailure to Rescue in Gastroesophageal Cancer

Although cardiac surgery is very different from other surgical specialties (and cardiac surgeons seem alien to many!) there is a lot I, as a cardiac surgeon can learn from more conventional surgical specialties. I often browse through thoracic and general surgical journals. I even enjoy reading the Annals of my College - the Royal College of Surgeons of England. I stop short however of reading orthopaedic rags - I have never had ANY professional affinity with that lot - no offence boys/odd female!!
I digress. This paper in JAMA surgery (the journal formerly known as Archives of Surgery!) is fascinating. It confirms what has been previously publicized in yet another excellent piece by surgeon racconteur, Atul Gawande in this piece in the New Yorker. Gawande describes the findings of a research study from University of Michigan that demonstrated that a major reason for variation in mortality rates after surgical procedures between different hospitals was not the incidence of things going wrong or morbid events but the ability of the institution to rescue patients once things went pear shaped. This study from England looking at events occurring after (o)esophagectomy replicates these findings. If one thinks about the incidence of morbid events or death after surgery, these findings are perhaps not so surprising. We know from many studies in different surgical specialties that a major contributor to the spread of incidences of complications are the patients themselves - advanced age, co-morbid conditions etc.   But how much does the surgeon's ability contribute to variation in mortality between centres after surgery? In any one developed country, the vast majority of surgeons are trained to the same standards -standards which  do not vary greatly between schools of surgery. In addition graduates from each school end up working all over the country. Both these factors contribute to the uniformity and narrow standard deviations of surgical ability in any one country.  This  paper is therefore significant on a number of levels - it confirms the fact on both sides of the Atlantic that variation between surgical outcomes are due predominantly to systemic institutional factors. It is also important because Bruce Keogh, medical director of the National health service in England and ex cardiac surgeon has decided that many surgical specialties should follow the Cardiac Surgeons and publicly report individual surgeons' outcomes. There is a moral case for this - patients are entitled to know what the clinical outcomes of the surgeon who is about to operate on them, are. This paper above, other studies and common sense suggest however that Bruce Keogh and many of the colleges and professional societies who support this stance, are missing the point.

What is Quality in Surgery - Sir Bruce Speaks.

The European Association of Cardiothoracic Surgeons has released a number of videoed discussions that took place at their annual meeting in Barcelona in October 2012.

Surgical Self Flagellation

Sir Bruce Keogh is  in the news today because of his appearance on tonight's edition of ' The Report'  - a topical programme on Radio 4 which today deals with Surgeons under Scrutiny. 

How the Great British Public Can help to train Surgeons.

I recently blogged about the amazing memorial to all those who have donated their bodies to medical science found at Cardiff Medical School.  I am not sure whether dissection of human cadavers is really necessary for the teaching of undergraduate anatomy.

Public Reporting of Outcomes - History, Ethics, Keogh and the NHS Reforms

I recently posted why I felt that reporting of the outcomes of an individual clinician was wrong. I believe very strongly however in the principle of outcomes reporting.