Quality Assurance in Ophthalmic Service Monitoring Cataract Surgery Outcome

transcript

Health outcome conference July 2004

Quality Assurance in Quality Assurance in Ophthalmic Service Ophthalmic Service

Monitoring Cataract Surgery OutcomeMonitoring Cataract Surgery Outcome

Dr. Goh Pik Pin

Consultant Ophthalmologist

Selayang Hospital

Introduction Why monitor treatment outcome?

Patient satisfaction -standard of treatment

Self-audit – continuous professional development

Set standard or norm- monitor service performance

Practice of medicine - competent, accountable and ethical

Current methods of quality assurance :

1. Legislation- hospital licensing law

2. Professional self-regulation - specialty board

3. Informal peer review- census, log book

4. Formal accreditation and credentialing

Limitations

1. Subjective- e.g. inspection by external reviewer

2. Arbitrary- e.g. must have performed minimum x number of procedures before credentialing, competence

3. No explicit reference to agreed standard

More Objective & Better Methods

1. Bench marking

2. Continuous quality monitoring• Statistical process control (SPC)

technique – trend of performance

e.g. Cumulative Sum (CUSUM)

Cataract Surgery OutcomeWhat do we measure?

1. Best Corrected Visual AcuitySnellen, LogMar

2. Visual FunctionGlare disability, contrast sensitivity

3. Quality of LifeVF 14, Vision Related Sickness Impact Profile, Catquest (Sweden), etc

Cataract Surgery OutcomeMethods

1. Population Based SurveyRapid assessment on cataract surgery service -WHO India, China, Nepal, Australia

2. Centre / Providers Based StudiesInternational Cat. Surgery Outcome Study- USA ,Canada, Denmark, SpainEuropean Cataract Outcome Group-1998USA- Medicare beneficiaries, NEON, PORTUK-National Cataract Surgery Survey-1997Sweden-National Swedish Cataract Register-1992Malaysia-MOH Census & National Cataract Surgery Registry

3. Individual surgeon Surgical log booksStatistical Processes Control – Cumulative Sum (CUSUM)

Ministry Of Health Hospitals Annual Census- Cataract service

1. Quantity 2. Practice pattern- day care, Phaco/ECCE, IOL3. Quality measurements

• Waiting time • Ratio of cataract surgeon to patients• Post-op infective endophthalmitis • Unplanned return to operating theatre

31 MOH HospitalsStandard census format Defined numerator and denominator

Rate of Post-Op Endophthalmitis

00.20.40.60.8

11.21.41.6

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31

Hospital

(%) Rate in 2002

Rate in 2003

National Cataract Surgery Registry(NCSR, www.crc.gov.my/ncsrwww.crc.gov.my/ncsr))

Establish –2002Prospective systematic data collection32 centers (MOH, army & universities hospitals, 1 private)Data collection- integrated into daily work Objectives:

to determine frequency of cataract surgery to monitor outcome and factors influencing outcomes to evaluate cataract surgery services

NCSRData collected1. Patient characteristics

Age, gender, 1st eye, ocular & systemic co-morbidity, presenting vision

2. Practice Pattern Day care, anaesthesia, operation, IOL, Viscoelastic

3. Outcome measurementsIntra-op & post-op complicationsPost-op BCVA by 12 weeks

Factors contributing to poor visual outcome 4. QA indicators

Post-op infective endophthalmitisUnplanned return to OT within 1 week

NSCRAnnual Report 2002 & 2003

n-=12 ,798

n=16,811

Day care surgery 38 37

Conventional -ECCE

Small Incision -Phacoemulsification

First eye 70 70

NCSRCataract Surgery Outcome

All ECCE PEA

NCSRBest corrected vision 6/12 at 12 weeks post operation

All 86 89

ECCE 83 85

Phacoemulsification 91 93

Best Corrected Vision ( 6/12) – phacoemulsification,year 2002

92929194

919290

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Hospital

Cataract Surgery OutcomeInternational comparison

* All patient (with & without ocular co-morbidity)

Survey UK

1997N=18,000

1997N=3342

2000N=249

Europe

2000N=

M’sia

2003N=16,811

BCVA 6/12 or better

92% 96% *85% *84% 89%93% Phaco

85% ECCE

Statistical Process Control –Cumulative Sum (CUSUM)

CUSUM chart Graph representation of the trend in outcomes of consecutive procedures performed over time by same surgeonEarly detection of unacceptable rate of adverse outcomeApplications

Monitoring of traineesContinuous surgical audit

What is CUSUM charting?..

Consecutive series of procedures5 10 15 20 25 30 35 40 45

CUSUM..

Consecutive series of procedures0 10 20 30 40 50

Consultant

Trainee

CUSUM Chart for ECCE (NCSR)

01.63.24.86.4

11.212.814.4

0 10 20 30 40 50 60 70 80 90 100 110 120Consecutive series of procedures

doctor 22 doctor 37

doctor 45 doctor 48doctor 54 doctor 57doctor 78 doctor 81doctor 85 doctor 92

doctor 93 doctor 97

Conclusion

Quality assurance in ophthalmic service

Mandatory

Continuous - trend

Sustainable - integrated into daily work process

Surgeons - appreciative self audit for continuous professional development

Providers - continuous quality monitoring

Confidentially and medico-legal implication - issues to be considered

Acknowledgement

Dr Mariam Ismail National Head of Ophthalmology Service, MOH

Head, Ophthalmology Department,Hospital Selayang

D.Lim Teck Onn Head, Clinical Research Centre, MOH

Dr.G.ArumugamPresident,Ophthalmological Soicety

Singapore Society of Ophthalmology

Quality Assurance in Ophthalmic Service Monitoring Cataract Surgery Outcome

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