Background
The Society of Cardiothoracic Surgeons of Great Britain and Ireland was the first professional body to co-ordinate national data collection in the United Kingdom with the introduction of the United Kingdom Thoracic Surgical Register in 1976 and the Cardiac Surgical Register in 1977. These voluntary registers collect simple activity and mortality data from all NHS cardiothoracic and thoracic surgical units in the UK in an anonymous fashion. The evolution of cardiothoracic surgical practice has been attended by an understanding of the influence of cardiac and non-cardiac factors on survival from cardiac and thoracic surgery. Mortality is mainly influenced by severity of illness and associated co-morbidities, but appropriateness of treatment and in-hospital quality of care also play a significant role. It has become clear that greater complexity of surgery in an increasingly diverse population severely undermines the value of simple surgical mortality as a measure of quality of care. Over the last few years various statistical algorithms have become available that relate operative mortality and morbidity to casemix.
A combination of marketplace competition together with public and political awareness has raised vigorous debate on issues relating to quality of care and both institutional and individual surgical performance. The Society of Cardiothoracic has chosen to take the initiative and recommend that all cardiothoracic surgical units throughout the UK should undertake regular review of their practice in a risk-stratified fashion. We believe that this approach represents good risk management policy for Trusts, hospitals, individual units and their surgeons, and will raise the overall quality of clinical care.
The implementation of such an approach and the responsible interpretation of the resultant data requires national and local agreement, and co-ordination of responsibilities.
Individual and Institutional Responsibilities
The Hospital Trust should provide the hardware, software and personnel to allow patient orientated data collection for risk stratification, and to facilitate the downloading of data into the Societys National Cardiac and Thoracic Surgical Databases.
The Cardiothoracic Surgical Unit should define the strategy for data collection, collation and presentation, and should dedicate time each month for presentation and discussion of surgical activity and results. The unit should identify one consultant with overall responsibility for co-ordinating and developing the audit programme.
Each Consultant Surgeon must assume full responsibility for collection of complete, accurate and honest data on all cases under his/her care, provided that the Trust has met the obligations outlined above.
The Society of Cardiothoracic Surgeons of Great Britain and Ireland will provide individual clinicians and Trusts with guidance on contemporary standards of care. To this end the Society will:
www.scts.org
- define the minimum dataset for each surgical patient
- develop and provide statistical models enabling individual- and group-risk predictions, and outcome comparison
- define contemporary levels of performance based on these statistical models
- circulate an annual audit report to members
- publish summarised and aggregated data on the internet at
The Royal College of Surgeons Specialist Advisory Committee for Higher Surgical Training will seek evidence during inspections that effective audit meetings have taken place, all surgical staff have attended regularly, appropriate records have been kept and that adequate audit assistance and computer systems are available.
The Audit Process
Data collection:
Data collection remains the joint responsibility of the Trust and the Surgeon. To facilitate effective risk- stratification, data should be collected in line with the appended Minimum Dataset (MDS) defined by the Society of Cardiothoracic Surgeons. The current MDS, and its associated definitions, is compatible with all existing initiatives in the UK such as the UK Heart Valve Registry, the Central Cardiac Audit Database (CCAD) and the British Cardiac Intervention Society database (BCIS). The definitions and data fields are also compatible with evolving European initiatives and the Society of Thoracic Surgeons (USA), American College of Cardiology and the Healthcare Financing Administration (HCFA) in the United States.
The Society strongly encourages collection of the "Minimum Dataset" which allows robust risk-stratification together with tracking of several aspects of surgical practice including surgical training and measurement of outcomes other than mortality alone.
Data collection strategies must be determined locally. However, algorithms for risk-stratification are becoming more complex and numbers of patients will grow. A networked, computerised system with good statistical capabilities is recommended.
Data validation:
Local validation should be performed by a random selection of case notes to reduce gaming / fraud.
External validation of data will be performed by the Society on 3-yearly to 5-yearly cycle. Details of the validation process will be forwarded to individual units.
Audit meetings should be held monthly in allocated and dedicated time. All consultants should attend meetings and should take it in turn to chair the meetings, and they should foster an air of constructive analysis and criticism. Specialist registrars should be involved as part of their training, and attendance of nursing, technical and other staff should be encouraged. A register of attendance should be kept. The form of presentation and discussion should be agreed and developed locally, but meetings should address:
- Total surgical activity
- Risk stratified activity
- Mortality and morbidity
- Intermittent, detailed review of specific issues and outcomes in order to improve practice.
Surgeon specific review
By unanimous agreement within the speciality, surgeon-specific outcome data for marker operations has been returned to the Society of Cardiothoracic Surgeons from 1st April 1997. This will be collected annually in a format defined by the Society and will be collated and analysed as part of the established UK Cardiac and Thoracic Surgical Registers. The President of the Society will seek clarification from any surgeon whose performance lies outside predefined limits. Clearly this clarification will be greatly simplified for all parties if facilities for comprehensive data collection and risk-adjustment are in place. If concern persists then the Medical Director of the Trust will be contacted and the Society will provide, in conjunction with the Royal College of Surgeons, a discrete and supportive external review by senior cardiothoracic surgeons. The aim of such a visit would be to determine the nature and severity of the perceived problem and to develop a collaborative strategy for resolution of the problem.
In addition to the mandatory return of surgeon-specific data to the Society, individuals should continuously review their own progress using risk-stratified data. Surgeon-specific data should be reviewed jointly by the consultant surgeons on at least an annual basis. The Society will respond supportively to an approach from a concerned member, his colleagues or the Trust, recognising that in some instances this may simply be an issue of rebuilding personal or institutional confidence and credibility.
The Society of Cardiothoracic Surgeons of Great Britain & Ireland accords the highest priority to surgical audit and requests that all concerned give due consideration to the value and importance of the professional responsibilities outlined above.
