Issue 7 / 4 March 2013

PLANS to publish performance data on UK surgeons are causing some angst in the UK. But they do raise the question of how we, in Australia, measure surgical competence and performance.

The Royal Australasian College of Surgeons (RACS) provides surgical education and training focused on developing fitness for surgical practice across nine competencies — professionalism and ethics; medical expertise; technical expertise; clinical decision making and judgement; communication; collaboration and teamwork; health advocacy; management and leadership; and scholarship and teaching.

An RACS guide to these technical and non-technical competencies highlights the importance of defining, observing and assessing surgical performance, and recommends that individual surgical performance be assessed across this whole range of competencies.

Assessing the performance of individual surgeons is different from monitoring surgical outcomes in hospitals. Although surgical outcome is inherently linked to the surgeon and procedure, there are many other aspects of care that outcome measures, including the contributions of different cadres of health worker in the treating team, and the quality of the facilities and resources available. Surgical outcomes are also determined by the pathophysiology of the patient (their comorbidities) and stage of disease.

Combined team skills such as are required for hospital practice are much harder to assess though this has been achieved in the UK’s NHS fractured neck of femur quality improvement program.

Fractured neck of femur requires a multidisciplinary team approach for success, as patients are usually elderly and comorbid, requiring orthogeriatrician assessment and surgery within 24 hours to produce the best outcomes. Postoperative outcome will be determined by the varied skills of nurses, physiotherapists and those involved in aged care and rehabilitation.

Performance data comparing institutions, services or surgeons are usually based on audits of clearly defined surgical outcomes such as mortality or a particular morbidity. Some morbidities can be easy to define such as amputation rates, reoperation rates, or discharge to usual place of residence. However, other outcomes such as lack of pain, better mobility and improved life status require scales of assessment that are often applied inconsistently.

A number of registries record surgical outcome data for specific conditions, such as the ANZ hip fracture registry.

Data from registries or craft group/specialty audits are valued and meaningful, because they are usually accurate and reliable, and the conclusions drawn are informed by the relevant specialist input and interpretation.

There already are a number of reliable surgical audits championed by surgeons and the RACS. Most audits produce summary reports that include a small number of key performance indicators.

Specialty audits such as those available for breast, colorectal, vascular, cardiothoracic or rural surgery do report key outcomes or complications as a percentage or rate, to enable benchmarking of performance.

The audits of surgical mortality approach performance from a different angle, prompting in-depth peer review of cases involving mortality and an examination of what can be learned to drive improvement. The audits do not include the overall number of procedures performed for which there is a death under the care of a particular surgeon.

Publication of surgical outcome is to be welcomed, and every effort must be made to ensure that what is published is reliable, and is in a format that facilitates interpretation by those for whom it is intended.

The best way to achieve this is to fund audits and registries, use agreed definitions for disease, procedures and outcomes, and ensure that everyone is able to understand, interpret and value the reports.

Patients, health service providers and the surgical profession are motivated by the hope of ever-improving surgical outcomes.

Professor David Watters is chair of the Professional Development and Standards Board, Royal Australasian College of Surgeons, and Professor of Surgery at Deakin University and Barwon Health, Geelong.

Posted 4 March 2013

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5 thoughts on “David Watters: Judging performance

  1. Amanda Willemyns says:

    Well said, David.

  2. ex doctor says:

    Information on corporations, credit status, criminal background, auction prices, etc, is very useful to investors, employers and those who need to know. Such information is available from multiple providers but at a price.
    If published data on individual or institutional surgical performance has value other than to those contributing such information, then it too will have a market price. This should be tested in the information market place. This way the outside user of the information meets some of the very substantial cost of collecting and analysing information and not the surgeons, colleges or the long suffering taxpayer.

  3. TIM BAILEY says:

    However, I suppose that if the ‘taxpayer’ is calling for it, the ‘taxpayer’ can pay. Is the taxpayer calling for it? The MJA poll would suggest that the answer is ‘yes’.

  4. ex doctor says:

    The MJA poll demonstrates a demand. Next step, test the price.

  5. Dr. John B. Myers says:

    Audits are fine, especially by bureaucrats who fail to take into account the human factor, for instance co-morbidities, time to presentation, mortality risk etc. The point I wish to make is that the surgeon and the surgery are not the only operative outcome factors, not to mention the patient’s attitude and involvement of the patient in decision-making throughout the episode.

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