surgeon specific outcomes in the nhs - amazon s3€¦ · hawthorne experiments •conducted under...
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Yasir Abu-Omar MB ChB DPhil FRCS(CTh)
Consultant Cardiothoracic and Transplant Surgeon
Papworth Hospital
Cambridge, UK
Epworth Cardiac Sciences SymposiumMalbourne 2017
Papworth 1918 - …………
2018
Epworth Cardiac Sciences SymposiumMalbourne 2017
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…
Epworth Cardiac Sciences SymposiumMalbourne 2017
Where did it all start?
Epworth Cardiac Sciences SymposiumMalbourne 2017
UK Heart Valve Register
Ken TaylorHammersmith Hospital
London
Epworth Cardiac Sciences SymposiumMalbourne 2017
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
Epworth Cardiac Sciences SymposiumMalbourne 2017
• 1992 News of Bristol Heart Scandal broke in Private eye
• Contact directly with the whistle-blower
• Evidence that management and DoHwere aware of problems!
Epworth Cardiac Sciences SymposiumMalbourne 2017
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
Epworth Cardiac Sciences SymposiumMalbourne 2017
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."
Epworth Cardiac Sciences SymposiumMalbourne 2017
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
see
– Public confidence
• Early warning system
Epworth Cardiac Sciences SymposiumMalbourne 2017
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
Epworth Cardiac Sciences SymposiumMalbourne 2017
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
MHRA
Performance of doctors
GMC
Setting the “Standards”
NICE
National Performance Management
Epworth Cardiac Sciences SymposiumMalbourne 2017
Risk scores
• Mortality depends on • operation performed• underlying state of the heart • presence of other illnesses
• Parsonnet
• STS
• Logistic EuroSCORE
• EuroSCORE II
Epworth Cardiac Sciences SymposiumMalbourne 2017
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%
Epworth Cardiac Sciences SymposiumMalbourne 2017
Service level performance
Epworth Cardiac Sciences SymposiumMalbourne 2017
Papworth data
Papworth
Epworth Cardiac Sciences SymposiumMalbourne 2017
Individual performance
Epworth Cardiac Sciences SymposiumMalbourne 2017
My data
Epworth Cardiac Sciences SymposiumMalbourne 2017
SCTS
Epworth Cardiac Sciences SymposiumMalbourne 2017
Epworth Cardiac Sciences SymposiumMalbourne 2017
What’s good about it?
• Transparency
• Public trust
• Setting and maintaining standards
• Improving quality of care
• Ensuring public safety
• Patient choice
• Promotes healthy competition
Epworth Cardiac Sciences SymposiumMalbourne 2017
Hawthorne Effect
• Hawthorne electrical works – Chicago
• Experiments conducted – assessing productivity 1924-1932
Epworth Cardiac Sciences SymposiumMalbourne 2017
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
Epworth Cardiac Sciences SymposiumMalbourne 2017
Hawthorne Experiments
Light increased
Light increased
Productivity measured
Productivity measured
improvedimproved
Conclusion: When light is increased in the workplace, productivity
improves
Epworth Cardiac Sciences SymposiumMalbourne 2017
Hawthorne Experiments
Light reduced
Light reduced
Productivity measured
Productivity measured
improvedimproved
Epworth Cardiac Sciences SymposiumMalbourne 2017
Hawthorne Experiments
Change in working
conditions hours /
breaks etc.
Change in working
conditions hours /
breaks etc.
Productivity measured
Productivity measured
improvedimproved
Epworth Cardiac Sciences SymposiumMalbourne 2017
Hawthorne effect
Conclusion:
performance tends to improve
when it is measured
Epworth Cardiac Sciences SymposiumMalbourne 2017
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?
Epworth Cardiac Sciences SymposiumMalbourne 2017
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
Epworth Cardiac Sciences SymposiumMalbourne 2017
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
Epworth Cardiac Sciences SymposiumMalbourne 2017
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
Epworth Cardiac Sciences SymposiumMalbourne 2017
Naming and shaming
Epworth Cardiac Sciences SymposiumMalbourne 2017
Patient choice
• Patients are reassured that they will receive treatment safely and to a good standard
• Not necessarily the best!
Epworth Cardiac Sciences SymposiumMalbourne 2017
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.
Epworth Cardiac Sciences SymposiumMalbourne 2017
A tale of two cities…
Hospital A Hospital B
3.50%
0.70%
30 day mortality
Hospital A Hospital B
4.93%
0.70%
6 months mortality
Same surgeonSame risk profile
But…
Epworth Cardiac Sciences SymposiumMalbourne 2017
• General opposition amongst surgeons towards SSMD
• Consider shift towards team-based results
Epworth Cardiac Sciences SymposiumMalbourne 2017
What can we do about it?
• Solution 1:
– Stop reporting outcomes?
• Difficult as already started
• Look suspicious!
• Solution 2:
– Go round the difficulties….
Epworth Cardiac Sciences SymposiumMalbourne 2017
Birth of the ‘STAR CHAMBER’
Surgical council
Aim:
To mitigate the damaging effects of transparency on
our patients and us
Westmininster 1500s
Papworth 2017
Epworth Cardiac Sciences SymposiumMalbourne 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
Epworth Cardiac Sciences SymposiumMalbourne 2017
Discussion to determine:
• Should an operation be offered
• Nature of the operation and strategy
• Who to perform it on behalf of the chamber
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Advantages
• Avoids overloading individual surgeons with exceptionally high risk cases
• Team-approach
• Most importantly:
Ensures the best outcome for the patient
Epworth Cardiac Sciences SymposiumMalbourne 2017
In summary
• Cardiac surgeons should be applauded for leading the way in performance monitoring
• Clear benefit demonstrated
• But note the potential – important -limitations
Epworth Cardiac Sciences SymposiumMalbourne 2017
• Why not?
"This above all: to thine
own self be true”…
Hamlet (Act I, Scene III)
Thank you