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EDITORIAL |
China
The goal of comprehensive quality assurance in cardiac surgery is quite simply to provide a mechanism whereby the patient is subjected to the least threatening journey through the hospital and is assured of an outcome that conforms to internationally accepted norms. For this to be achieved, there must be a robust framework in place, providing ongoing assessment, multidisciplinary input, and monitoring of all variables that affect the patient’s journey. Important areas of assessment within this framework include patient outcomes (surgical results), appropriateness of care, institutional performance, resource management, and patient and healthcare provider satisfaction.
The assessment of surgical outcome following cardiac surgery is routine and public in many countries. In the United Kingdom, for the first time last year, individual surgical results were published in the national press.1 There is an annual report from the Society of Cardiothoracic Surgeons of England and Ireland in the public domain, which gives institutional results and aims to educate both the public and profession alike on the difficulties and pitfalls of preoperative risk assessment and the complexities of analyzing and reporting surgical performance.2 There is a national quality accreditation program ongoing, organized by the Society, which will ensure that there is data validation in individual units, with the aim of providing the most robust and accurate data on which to base analyses regarding surgical risk and performance.3 Local quality improvement programs have also been developed in an attempt to ensure data validation and the adherence to best clinical practice in individual units operating in geographically defined areas. This brings a uniqueness to inter-professional and interdepartmental cooperation, and further publication of outcomes into the public domain.4
Appropriateness of care relates not necessarily to meeting outcomes in terms of surgical results or delivery of care, but to the appropriateness of the care decided upon for each individual patient presenting to that department. In times of increasing public scrutiny regarding individual results in some countries, and an increased risk profile of patients presenting for surgical intervention, there has been discussion regarding surgeons adopting risk-adverse practices and avoiding perceived high-risk cases by turning them down for operation, despite the fact that these patients may benefit from surgery. By introducing the concept of appropriateness of care, this can be avoided and dissipated by multidisciplinary discussion and input into the decision-making process by the various professional groups responsible for the individual patient. One way of introducing a measurement of this variable is a random review of selected cases (identified by predetermined criteria) from one institution, by a professional group from another. This very concept would depend upon and demand inter-institutional as well as inter-professional cooperation. This concept (still in its infancy) is used in other countries to assess institutional performance in terms of appropriateness of care in cases of mortality following coronary artery bypass grafting.5
Institutional performance relates not only to the provision of cardiac surgery to internationally recognized standards in terms of overall results, but to the provisional of effective care throughout the overall patient journey. This is multidisciplinary by definition, and is monitored by implementation of multidisciplinary mortality and morbidity meetings with an ongoing complimentary audit process that again includes all professional groups involved in patient care and tackles perceived problems in effective care with scientific rigor, openness, and a desire to improve.
Resource management is an increasingly important factor in any modern healthcare economy. It must be used as a tool to ensure that the cardiac surgical service is making best use of its resources in order to achieve its goals, i.e., ensuring the safest journey for the patient through the hospital, with the most appropriate outcome. It must include measures of efficiency, such as intensive care stay and total hospital stay, but analyses must also take into account additional variables including the provision of adequate aftercare facilities for patients, provision of adequate primary healthcare, and implementation of appropriate rehabilitation programs. Without adequate external supporting facilities, resource implications might be far more significant to the institution providing the acute service, but with analysis, these data can be used to provide health purchasers with this information and either gain additional resources or distribute resources in a more effective manner.
The provision of patient and healthcare provider satisfaction is self-evident. A happy patient is one who has progressed through the hospital journey in the safest possible manner with an acceptable outcome, and a happy healthcare provider is one who knows (and is given evidence) that this has been achieved with effective resource management.
Cardiac surgery in Asia is changing, people’s expectation of healthcare in Asia is changing, and resource implications for healthcare providers in Asia are changing. Cardiac surgery in Asia is in a unique position to learn lessons from countries that have struggled with similar dilemmas but embraced the concept of quality assurance, introduced it, and continued to develop it. There is an urgent need for data collection, these data must be validated and risk-assessed to ensure that future analyses of risk and surgical results are accurate and valid. Patients undergoing cardiac surgery in Asia are unique, and the assessment and scoring systems should reflect this. These data need to be independently collated, analyzed with appropriate professional input, and presented into the public domain. It needs resources, but at the same time, clinicians need to be able to use the final data to present the healthcare providers with evidence of efficient, high-standard, and effective delivery of cardiac surgical care. There will be demand for quality assurance in cardiac surgery in Asia; it will come from the changing perception and demands of patients, it will come from healthcare providers, and it will come from within the profession itself. The time has come to anticipate these changes, embrace them, learn lessons from abroad, and with a degree of urgency, introduce the framework and infrastructure to provide the highest level of quality assurance in cardiac surgery worldwide.
REFERENCES
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