Quality of surgery

How would you define ‘quality of surgery’? How do you measure it? Do you know if you are doing a decent job for your patients? To measure quality we need some reliable tools and measurement strategies. A number of clinical indicators are widely used as surrogates in an attempt to quantify certain elements of quality that were thought to be immeasurable in the past. However, some frontline clinicians may feel that these clinical indicators are simply figures that healthcare administrators played around in their armchairs. Worst still is that when they displayed resistance to these measurements, the implementation of clinical indicators in a constructive manner would end up as complete failure. Some colleagues may think the use of clinical indicators or measurement of quality is repackaging of the term ‘surgical audit of surgical outcomes’. Obviously, it would be too narrow or restricted if we just put our focus on post-operative complications and mortality. The whole surgical experience of our patients should be taken into account and quality should be referred to such wider concept. If good clinical indicators are being used effectively in organizations such as the Hospital Authority, apart from providing evidence for quality improvement, they would generate information useful for decision makers on resource allocation and re-deployment at the organizational level. If similar set of clinical indicators are being measured in different hospitals or departments, they can facilitate international or local bench marking and performance comparison. One of the many problems with measurement of clinical indicators is that while clinicians may improve their results on specific measures of performance, other issue may get neglected. This problem was demonstrated by a study on ‘pay-for-performance’ [colleagues working in the Hospital Authority may have goosebumps once they heard about P4P] in the United Kingdom. Primary care physicians only performed in areas tied to incentives and quality of care declined in areas not being tied to monetary incentives. Although one may argue that particular study on primary care cannot be extrapolated to surgical practice, it does not discount the challenges of making data collected meaningful and results measurable to achieve better surgical outcomes. Talking about surgical outcomes, the findings of inter-hospital variation by the Hospital Authority’s Surgical Outcome Monitoring and Improvement Program (SOMIP) was reported recently in the local news. Though the report said the variation was worrying, I think it is even more worrying in not knowing the variation of performance. Firstly, it is not scientific to assume every surgeon or every surgical unit would have the same level of performance. Secondly, without identifying areas of inadequacy, we cannot improve. The beauty of SOMIP is that data are collected by nurse reviewers and automatic catchment of computerized information of the IT system and the chance of underestimating the complication rate is much reduced. Knowing that not all harms are preventable, we can identify those correctable factors in our system and in longer term lead to improvement in surgical care. Furthermore, since the analysis of data is risk-adjusted, we can interpret the data scientifically and fair comparison of performance is allowed. Having said that, we must be mindful about the problem of “named and shamed” to individual hospital if we adopt a total transparency approach for the release of data to the public. Although a recent study showed there was not much progress in patient safety over a period of 6 years in the 10 hospitals in North Carolina, it should not be seen as a discouragement to our endeavor to improve the quality of surgical care. While we can have healthcare professionals educated about how to identify and fix safety hazards, or how to communicate better with team work through some CME activities, the most important task for us is to get ourselves engaged in the safety efforts. Although penetration of evidencedbased safety practices and cultivation of a culture of surgical safety take a little while, now would be the best time to buy-in. At the time when we can say ‘sit back, relax, and enjoy the surgery’ to our patients before they are put asleep by our anaesthetist friends – that’s high quality surgery reflecting our simple (sometimes naïve) intention to serve the best interests of our patients.