Surgeon specific outcomes in the NHS - Amazon S3€¦ · Hawthorne experiments •Conducted under...

transcript

Yasir Abu-Omar MB ChB DPhil FRCS(CTh)

Consultant Cardiothoracic and Transplant Surgeon

Papworth Hospital

Cambridge, UK

Epworth Cardiac Sciences SymposiumMalbourne 2017

Papworth 1918 - …………

Surgeon specific outcomes

• How did it start

• Why and when

• Has it made a difference

• What’s been good about it?

• What’s been bad?

• The future…

Where did it all start?

UK Heart Valve Register

Ken TaylorHammersmith Hospital

London

But… important limitations

• Unit based results• Individual outliers may be camouflaged

• Poor individual performance dismissed as case mix issue

• Infrastructure for accurate data collection was insufficient

• Public understanding of the data

• 1992 News of Bristol Heart Scandal broke in Private eye

• Contact directly with the whistle-blower

• Evidence that management and DoHwere aware of problems!

Whistle blowing

Whistle blower on the Bristol Scandal

• Went to press

• High death rates (double) amongst babies undergoing cardiac surgery

• Result of audit

• DoH and RCS informed

• Sir Terence recommended re-designating the service

• Operating did not stop until 1995

Stephen Bolsin

The Kennedy Report

• Huge document (529 pages)

• Provided blueprint for wider reform within NHS

• Joining up and prioritising services for children

• Openness• Independent external

monitor• Publishing results to

drive quality

"Bristol was a turning point in the history of the NHS. We are determined that some good can come from the tragedy that took place there."

What happened next…

• Evaluation and monitoring of clinical services

• Cardiac surgery led the way– Easy to monitor

– Largely limited operations

• More transparency– Outcomes are there for all to

– Public confidence

• Early warning system

The current state

• SCTS has been reporting outcomes for named surgeons since 2005

• Using this example, NHS England published outcome data from 10 other specialties in 2013

Monitoring Performance

A hospital monitors its performance at a number of different levels:

• National Performance Monitoring

• Hospital Wide Performance Monitoring

• Service Level Performance Monitoring

• Individual Performance Monitoring

Financial

NHS Improvement

Quality, outcomes and feedback from

patients and staff

Care Quality Commission

NHS Digital

Safety of medicines,

products and devices

Performance of doctors

Setting the “Standards”

National Performance Management

Risk scores

• Mortality depends on • operation performed• underlying state of the heart • presence of other illnesses

• Parsonnet

• STS

• Logistic EuroSCORE

• EuroSCORE II

EuroSCORE

European System for Cardiac Operative Risk Evaluation

www.euroscore .org

For example:

76 year old male, needs CABG, moderately impaired LV, asthma

Risk: 1.44%

Service level performance

Papworth data

Papworth

Individual performance

My data

What’s good about it?

• Transparency

• Public trust

• Setting and maintaining standards

• Improving quality of care

• Ensuring public safety

• Patient choice

• Promotes healthy competition

Hawthorne Effect

• Hawthorne electrical works – Chicago

• Experiments conducted – assessing productivity 1924-1932

Hawthorne experiments

• Conducted under the supervision of Elton Mayo, an Australian-born sociologist, then professor of industrial research at Harvard

• Study the effect of physical conditions on productivity

Hawthorne Experiments

Light increased

Productivity measured

improvedimproved

Conclusion: When light is increased in the workplace, productivity

improves

Light reduced

improvedimproved

Change in working

conditions hours /

breaks etc.

Change in working

conditions hours /

breaks etc.

improvedimproved

Hawthorne effect

Conclusion:

performance tends to improve

when it is measured

The Hawthorne effect at Papworth? three targets

65% Parsonnet65% Parsonnet

EuroSCOREEuroSCORE

50% log EuroSCORE50% log EuroSCORE

Abu-OmarNashef

O/E mortality for first-time cardiac surgery

IS THERE A DOWNSIDE?

Outcome measures

• Focus on mortality

• What about morbidity (stroke, renal failure, infection etc…)

• Survival (mid- and long-term)

• QoL

• Disruption of innovation

• Teaching and training

Risk aversion and gaming?

Do the public understand risk adjusted data?

I can’t tell you how sorry I am… your husband’s death is really going to bugger up our performance figures

Risk aversion

• Survey:• >1/3 surgeons admitted turning down high

risk patients• Admitted reason: fear of impact on

published outcomes• Despite the belief that it is the patient’s

best interest

Naming and shaming

Patient choice

• Patients are reassured that they will receive treatment safely and to a good standard

• Not necessarily the best!

Teamwork

• Elton Mayo and Hawthorne• An important finding was the effect working in groups

had on the individual

The desire to stand well with one's fellows, the so-called human instinct of association, easily

outweighs the merely individual interest and the logic of reasoning upon which so many spurious

principles of management are based.

A tale of two cities…

Hospital A Hospital B

30 day mortality

Hospital A Hospital B

6 months mortality

Same surgeonSame risk profile

But…

• General opposition amongst surgeons towards SSMD

• Consider shift towards team-based results

What can we do about it?

• Solution 1:

– Stop reporting outcomes?

• Difficult as already started

• Look suspicious!

• Solution 2:

– Go round the difficulties….

Birth of the ‘STAR CHAMBER’

Surgical council

To mitigate the damaging effects of transparency on

our patients and us

Westmininster 1500s

Papworth 2017

Patient criteria

• Inclusion• Turned down for surgery by another centre

• Referred for transplant when conventional surgery is contemplated

• Logistic EuroSCORE >25 – EuroSCORE II >12

• Surgeon feels an exceptional risk or grave doubt about risk / benefit

• Attended by four consultant surgeons

Discussion to determine:

• Should an operation be offered

• Nature of the operation and strategy

• Who to perform it on behalf of the chamber

Advantages

• Avoids overloading individual surgeons with exceptionally high risk cases

• Team-approach

• Most importantly:

Ensures the best outcome for the patient

In summary

• Cardiac surgeons should be applauded for leading the way in performance monitoring

• Clear benefit demonstrated

• But note the potential – important -limitations

• Why not?

"This above all: to thine

own self be true”…

Hamlet (Act I, Scene III)

Thank you

Surgeon specific outcomes in the NHS - Amazon S3€¦ · Hawthorne experiments •Conducted under...

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