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Monitoring Quality

Audit and subsequent action is of fundamental importance to the successful practice of ambulatory surgery. Furthermore, failure to establish standards and implement satisfactory monitoring, audit and quality measures will lead to problems for patients, their General Practitioners and ultimately the day unit concerned. As we move clinical activity from the inpatient setting to ambulatory surgery it is important that this clinical activity is monitored and audited to ensure that problems experienced by patients or primary health care colleagues are quickly identified and rectified. The move to ambulatory surgery is probably the biggest change in practice in any health service and requires effective management. If quality is compromised in any way then patients are affected and it is important that we pick this up and deal with it quickly.

Monitoring

This can be defined as maintaining regular surveillance and can even include the concept of regulation. The combination of surveillance and regulation is useful for our discussion. Monitoring allows a Day Unit to judge its performance against explicit standards. Standards in this context can be defined as agreed measures by which performance or achievement can be judged. They can be set locally (by a unit), nationally (by the government) or internationally (IAAS Standards) and provide a yardstick against which to measure performance.
Examples of factors suitable for monitoring include
  • number of cancellations as a result of the patient being found to be unsuitable on the day of surgery
  • proportion of patients admitted overnight
  • proportion of patients readmitted within one week
  • did not attend rate
  • utilisation of theatre time by each surgeon
  • proportion of ambulatory surgery to elective inpatient surgery
  • number of patients contacting the unit post discharge with problems
  • number of patients requiring intervention of GP post discharge
  • number of patients cancelled on day of operation
The number of cancellations on the day of surgery provides a clear indication of the effectiveness of the preoperative assessment service. The proportion of patients admitted overnight provides early warning of problem areas that need attention. The reasons for all admissions should be carefully examined, are patients being assessed appropriately or are inappropriate operations being performed on the unit. Similarly the number of patients readmitted due to complications of their surgery is important - is the surgeon operating on inappropriate patients? Every time a patient does not attend the opportunity is lost to use a valuable resource i.e. the nursing and clinical time that has been set aside for the management of that patient. The number of patients contacting the unit with problems or requiring intervention of their general practitioner post discharge provides an indication of problems with patient selection, anaesthetic technique, surgical technique or discharge arrangements.
These are some of the reasons that you may consider monitoring some of these areas, you may well have thought of others that are more important for your unit.

Telephone follow up service

Telephone follow up after day case surgery has been found to be very useful when developing ambulatory surgery. The purposes of such a service are twofold;
  1. to provide post-discharge support for patients,
  2. to gather specific data for audit purposes in this early post-operative period
This sounds really supportive and it seems difficult to perceive how an individual would not wish to be contacted to discuss how they are feeling. However, like any other aspect of treatment or care ,patients have the right to refuse and so permission to contact them at home must be sought prior to discharge. Although an unstructured phone call may seem the best approach to maintain informality, the use of a structured questionnaire will provide much better feedback for the ambulatory surgery unit. Areas to be covered should be to ask about the severity of post operative side effects such as drowsiness, sore throat, headache, muscular aches, nausea and vomiting. This should be supplemented with questions to assess the degree of pain experienced and how well it has been controlled.