Quality Accreditation Scheme for Adult Cardiac Surgery

The Society can be justly proud of its track record in quality monitoring when compared to that of other medical and surgical specialities. The national registers for adult and thoracic surgery procedural mortality has been one of the earliest examples of self-regulation and quality monitoring in any medical field. More recently, the introduction of index procedure mortality data gathering for individual surgeons' performance has expanded the remit of the Society's monitoring system. The development of the Society database for adult cardiac surgery has further enlarged the scope of data gathering and looks set to be the first project to succeed in developing a national, risk-stratified database with 85% of all units currently submitting at least partial data to the project.

Nevertheless, the current medicopolitical climate allows no room for complacency in this important field. The existing systems are valuable, but their value is limited by the absence of data validation and comprehensive data collection and, in the case of the register and index procedural results, also from a lack of a suitable measure of casemix. This is particularly important if surgeons are expected to continue to offer potentially life-saving surgery to high-risk patients. This scheme aims to address these issues by offering public recognition of those units in which quality is monitored by a robust system of measurement of risk-stratified outcomes with clear performance targets and mechanisms for dealing with underperformance as measured against such targets.

The scheme has two further, important aims. The first is to promote a culture in which quality monitoring as outlined above becomes the norm in surgical practice, thus providing the incentive for hospital management and purchasers to supply the resources necessary for surgical units to qualify for accreditation. The second is to act as a model for extending quality monitoring to other aspects of our own speciality (thoracic surgery, paediatric cardiac surgery and transplantation) and to other surgical and medical specialities.

The Society Executive wishes to encourage members of the Society to read this document carefully and to give serious consideration to the participation of their hospital or unit in the scheme.

Participation
Any unit or hospital performing adult cardiac surgery in Britain and Ireland is eligible to apply for accreditation. Participation is wholly voluntary and the process is only initiated at the request of an individual unit. Members of the Society are encouraged to examine the criteria for accreditation to ensure that their unit has the necessary mechanisms in place before applying and, if not, to take steps to install these mechanisms.

Principles of accreditation
The Society will grant quality accreditation to participating units provided they satisfy the Society that there are in place

• robust mechanisms for quality monitoring
• satisfactory clinical quality
• sound mechanisms for dealing with instances where there are quality concerns.

Accreditation criteria
The Society must be satisfied that the unit fulfils all of the ten criteria listed below:

1. There are reliable data on the number of adult heart operations performed in the unit.
2. There are reliable data on the number of adult heart operations performed under the care of every consultant surgeon in the unit.
3. There are reliable data on the breakdown of these operations by broad category types, such as coronary surgery, valve surgery, combined coronary and valve surgery and others.
4. There is a valid system of assessing casemix. This can be a simple system, such as one based on age and sex, an additive risk stratification system, such as Parsonnet or EuroSCORE, or a more complex system such a regression analysis system or a Bayesian model. (The collection of the Society minimum dataset is encouraged but this is not a prerequisite to accreditation).
5. There are reliable data on clinical outcome measures. At the very least, these must include hospital or 30-day mortality.
6. There is a preset level of minimum acceptable performance in relation to the casemix measure. This level must be acceptable to the visitors. Examples are mortality within 70% of Parsonnet predicted mortality, or within 2 standard deviations of EuroSCORE predicted mortality.
7. The pre-set minimum acceptable performance must be applied to the unit's performance as a whole as well as to that of individual consultant surgeons.
8. The data on numbers (1, 2, 3, and 5 above) are reliable and can be validated by review of an appropriate sample of case notes or by the presence of a robust local system of data validation.
9. The casemix data (4 above) are reliable and can be validated by review of an appropriate sample of case notes or by the presence of a robust local system of data validation.
10. There is in place a clear and effective mechanism to investigate and appropriately to deal with any performance that falls outside the minimum acceptable performance level (6 above). The mechanism must include identification of the nature of the problem, measures to correct the problem, reassessment after a predetermined period and an action plan to be followed should initial measures fail.

Mechanism
A unit which volunteers to participate will inform the Standards of Care Subcommittee (SoCS) of its application for accreditation. The SoCS will nominate two cardiac surgeons, neither of whom will be employed at that unit, to carry out an inspection visit.

The visitors will arrange a mutually convenient time for an inspection visit to the unit. They will invite a member of the NHS regional office to be present at the visit as an observer who is external to the speciality. The visitors will assess the unit by a combination of interview, data review, data validation and any other mechanism necessary to satisfy themselves that the unit in question fulfils the criteria for quality accreditation as detailed above. They will then submit a confidential report to the SoCS of the Society.

Accreditation
The visitors may make three recommendations to the SoCS: to grant accreditation, to grant accreditation with specific suggestions for improvement or to withhold accreditation, giving reasons and suggestions for achieving accreditation at a later date. The SoCS will consider the visitors' report and recommendations and, if satisfied, will then grant accreditation to the recommended units on behalf of the Society.

Accredited units may make public their accreditation to purchasers, patients and health authorities and may use the Society's quality accreditation logo on notepaper, in correspondence and elsewhere if appropriate.

Accreditation will be valid for a period of five years. Continuance will require a further visit along the same lines.

Cost of the scheme
The Society's limited resources do not allow it to fund the scheme entirely from its own budget. The cost of the visits will therefore have to be borne by the participating units. The visitors will give their time without charge, and it is expected that the cost to the unit will only extend to covering the modest travel and subsistence expenses associated with the inspection visits.

Scheme development
The scheme was approved by both the SoCS and the Society Executive at their regular meetings in February 2000 and is being launched at the Society annual general meeting in March 2000. The Society expects the first participating units to be visited in the summer of 2000. Subject to the success of the scheme, the Society will seek endorsement of the scheme by the Royal Surgical Colleges, the General Medical Council and the Department of Health.

Further information    E-mail  S.A.M. Nashef with your comments and suggestions