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Quality and Clinical Indicators

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Paulo Lemos, MD, with collaboration of DSDP partners

Introduction
There is growing recognition that a capacity to evaluate and report on quality is a critical building block for system wide improvement of health care delivery and patient outcomes.
Health care organisations are frequently being requested to provide data on many aspects of their activity. Clinical indicators results provide valuable information in assessing the performance of health services. This focus on performance management has emerged through increased competition, a more recent focus on quality improvement and safety and an increase demand for evidence of performance.
Except for the work developed by the Australian Council on Healthcare Standards (ACHS) since 1989, clinical indicators are not yet worldwide routine tools for the evaluation of quality performance. The popularity of day surgery is continuously increasing because of the associated clinical, economic and social advantages. The low rates of adverse events or complications during the perioperative or immediate post-operative period further justifies the rapid growth of day surgery.
Nevertheless, these surgical programmes should be continuously monitored in order to guarantee that high quality services are provided for the population. Clinical indicators, and especially outcome measures, should therefore be implemented to ensure a safe, effective and efficient environment in day surgery.
The identification of universally acceptable clinical indicators for quality assurance in day surgery is one of the most important goals of the International Association for Ambulatory Surgery (IAAS) and its materialization is one of the major achievements in ensuring those high standards of care that we persuade for day surgery. Recently, IAAS developed a European project, named Day Surgery Data Project (DSDP), financed by the European Commission aimed to identify and validate a set of indicators and to develop the information systems on day surgery in Europe. This project proposes also to analyse day surgery data and health indicators both at international organization and member states level.
Clinical Indicators
Clinical indicators are norms, criteria, standards and other direct qualitative and quantitative measures used in determining the quality of healthcare. They attempt to describe the effects of care on the health status of patients and populations. They should be easy to define and analyse, be valid and reliable, and the indicator measured should occur with some frequency and reflect an important aspect of quality.
To have an overall overview of quality issues, DSDP identified different dimensions of performance on day surgery, such as, Input, Patients Characteristics, Access, Process, Output, Outcome, Safety, Satisfaction / Responsiveness and Cost / Productivity. The related indicators trying to evaluate day surgery services in a unit level, where divided in a list of essential (Table 1) and ideal indicators (Table 2). These indicators were based on the definitions proposed by IAAS for Ambulatory Surgery / Day Surgery, Office Based Surgery and Short Stay Surgery and the list of basket procedures that should be considered when reporting at international level (Table 3).

Table 1: Essential set of day surgery indicators at a Day Surgery Unit Level
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Table 2: Ideal set of day surgery indicators at a Day Surgery Unit Level
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Table 3: DSDP list of basket procedures based on the OECD Surgical Procedures
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Finally, DSDP has developed Essential (Table 4) and Ideal (Table 5) sets of Indicators for National / Regional Level, as well, with the special purpose to allow comparisons of performance across countries.

Table 4: Essential set of day surgery indicators at National / Regional Level
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Table 5: Ideal set of day surgery indicators at National / Regional Level
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Rationale for using different dimensions’ Indicators of performance in day surgery

Input Indicators
Availability of resources is a precondition of services provision. For the national level, simple measures of resources allocation to day surgery are figures concerning the number and proportion of DSUs, differentiating between integrated and freestanding, and number of theatres fully dedicated to day surgery. Such measures clearly indicate if an effective policy of day surgery promotion was successfully designed and implemented or, on the contrary, surgery remains business as usual ignoring day surgery’s substantial advantages in terms of safety, patients’ satisfaction and efficiency.
Access Indicators
Access concerns the availability of DSUs in a specific geographical area and population; more significantly, access involves the waiting time between a diagnosis and the relevant procedure. The access indicator “Median waiting time for overall and each basket procedure” measures how long, on average, it takes between a request for a procedure and its actual provision. In a context of expanding needs for surgical services due to a growing elderly population and shrinking public finances, waiting times is an inescapable issue. Its relevance derives also from its politically sensitiveness; some national health services grant the right to access services within maximum waiting times. Degree of respect for such right must be monitored.
Process Indicators
Processes are health care activities carried out by providers to patients and for patients, e.g. a diagnostic tests or a surgical procedure. Measures of clinical processes are recorded and analysed where services are provided and information about them have limited relevance to top managerial levels. “Percentage of patients who have received a pre-anaesthesia assessment before day surgery” is an indicator which signals if services are well organised and aware of the ever present potential of harming patients. Pre-anaesthesia assessment prevents both cancellations and complications in patients whose medical contraindications are discovered only just before or even during or after a procedure. Percentage of patients with standardised preoperative evaluation and tests has similar meaning.
Output Indicators
Output indicators reveal the absolute volume of activities performed by a system or a unit. They also measure the proportion of procedures carried out in a day surgery setting out of those which should be complete through this approach. Thus “Percentage of elective surgery performed as day surgery for the overall list of elective basket procedures and each basket procedure” is also an indicator of appropriateness of care. This means that it determines the extent to which day surgery performance achieves the goal to provide services for about 80% of surgical needs.
Outcome indicators
Outcomes have to do with the degree of improvement or, on the opposite, deterioration of patients’ health status as a consequence of encounters with healthcare. In other words, an outcome is a result in terms of positive or negative, short or long term changes in health status of patients, e.g. death within one week of procedure or health problem, e.g. inguinal hernia, still cured five years after the procedure.
Both national and individual units should collate the indicator “Case fatality ratio within 30 days for patients undergoing any of elective basket procedure”. It should be stratified by specialty and also by procedure because the risk of death for cataract removal is very different from that inherent in knee replacement procedures.
The other outcome measures in the lists are proxy indicators. This means they use indirect measures, which are easier to collect and interpret, for example proportion of unplanned admissions or proportion of patients returned to the operating room (OR) within one week, but still reflect the dimension of outcome (and safety). Unplanned hospitalizations, admissions to a hospital or a return to an OR within 24 hours or a week after a day surgery procedure are clear signs that clinical or administrative processes are problematic. Proxy indicators’ usefulness derives also from the fact that the events measured by them are much more common than patients’ deaths. Unplanned admissions or returns to hospital should be thought and managed as warning sign of dysfunctional processes not to be ignored. Similar episodes should prompt managers and providers to study day surgery services delivery in depth and consider the necessity to redesign structures, processes and procedures and possibly retrain staff.
Patients’ Safety Indicators
Safety involves the delivery of services in absence of preventable adverse events; it has been recognised a key element of healthcare since the Hippocratic oath. Starting with the publication in 1999 of the Institute of Medicine study “To err is human”, patients’ safety has become a topic that cannot be ignored by modern systems of healthcare. Numerous studies have brought to light the reality that medical errors and adverse events in healthcare delivery are much more common than previously thought and many of them, around half, are avoidable. Beyond the damage to patients, these potentially avoidable outcomes frequently increase the length and cost of stay adding significantly to the economic difficulties of health organizations and whole systems including day surgery. Errors also compromise credibility of individual professionals as well as teams, nits and whole institutions. A vicious cycle of errors, re-work and financial restraint, followed by further financial difficulty due to the costs of dealing with errors and their consequences, such as repeated procedures and prolonged hospitalizations, become the norm in hospitals and ambulatories which are unable or unwilling to systematically confront patients’ safety. This is not so especially within organizations able to design reliable services where preoccupation with possible failures represents a constant presence. In summary, medical errors and adverse events must be monitored.
Falls and wrong sites/side/patients are well documented and dangerous safety problems in hospital care; the tight schedule with high volume of procedures that characterize day surgery, presumably make these adverse events potential threats to be monitored. Hence “Percentage of day surgery admissions who experienced a wrong site, a wrong side, wrong patient, wrong procedure or wrong implant” should be included in each of the four lists and “Percentage of DSU admissions experiencing a fall within confines of the DSU” in the ideal set for DSUs. With the exception of the essential list for the national level, indicators measuring frequency of wound infections should be computed.
Cost / Productivity Indicators
Cost indicators concern actual expenditure for day surgery, as absolute amount or relative to total healthcare outlay. A productive and efficient service does not suffer from chronic and substantial waste. Examples of measures of waste are “Percentage of cancellations of surgical procedures without notification by the patient (“fail to arrive” or “did not attend”) and “Percentage of cancellations of the booked procedure after arrival at DSU”. “Recurring delays of surgical procedures” and “Percentage of utilised theatre sessions over weekly planned theatre sessions” are other cases in point. A key goal for managers is to use resources in such a way to maximize their yield. This is the economists’ perspective, i.e. always trying to do better given specified available resources.
Patients’ Satisfaction Indicators
Healthcare systems and the individual organization delivering services exist to solve citizens’ health problems. The core of Continuous Quality Improvement is orientation of the organization to satisfying its customers’ needs and expectations. Some citizens and professionals do not like the use of the word “customers”, but the use of a name is less significant that the tenet about users the central focus of services delivery.
Essential to the creation and maintenance of quality care is the thorough understanding of customers and their needs. Establishing a customer-oriented organization entails a genuine ongoing commitment to measuring, understanding and meeting customer expectation. As with any re-orientation of an organization, adapting to a customer-oriented focus implies changes to its culture, the shared understanding of its reason of being and the processes used to carry out the work. A paternalistic and bureaucratic organization remains insensitive to customers and still might adopt instruments to measure patients’ satisfaction in order to pay lip service to a politically correct issue.
DSDP set of essential indicators at national level does not include any patient’s satisfaction indicator and this makes sense because variability among units and areas is wide and an average measure would hide this discrepancy. The essential list for a DSU includes a generic measure of overall satisfaction with services. The same indicator is recommended for the ideal set at national level, whereas relative frequency of discharges with written complaints by clinical, providers’ manners and organizational cause is deemed useful for the units.
Obviously a survey of patients’ satisfaction should be standardised across systems and units and also include more specific measures to be analysed within a particular situation. For example, another useful indicator might be the percentage of patients who would recommend the same services to friends.
Conclusion
With the continuous growth of day surgery, evaluation of the different dimensions of the day surgery programme as a whole becomes more and more important in order to achieve a safe, effective and efficient high quality patient-centred day surgery programmes, for a very satisfied population. The introduction of clinical indicators in day surgery practice can have a determinant role in reaching these goals. Outcomes research into new developments in day surgery must continue in the future with the aim of ever improving the quality of patient care.

Further Reading
Day Surgery Data Project. Final Report, 2012. (http://www.dsdp.eu)
Lemos P, Barros F (2011). Outcome measures. In: Day Case Surgery, Smith I, McWhinnie D, Jackson I (eds), Oxford University Press (OUP), United Kingdom. Chap 16.
Lemos P, Regalado AM (2006). Patient Outcomes and clinical indicators for ambulatory surgery. In: Lemos P, Jarrett P, Philip B, eds. Day Surgery, Development and Practice, International Association for Ambulatory Surgery, Porto. Chap 12.
Australian Council on Healthcare Standards (2008). Australasian Clinical Indicator Report 2001-2007: determining the potential to improve quality of care, 9th edn. (http://www.achs.org.au/pdf/AustralasianClinicalIndicatorReport_9thEdition_FullReport.pdf)
British Association of Day Surgery (2009). BADS Directory of Procedures, 3rd edn.
Healthcare Commission (2005). Acute hospital portfolio review, Day Surgery. (http ://www.healthcarecommission.org.uk)
Ministerio de Sanidad Y Consumo. España (2008). Manual de Unidad de Cirugía Mayor Ambulatoria. Estándares y recomendaciones. Informes, Estudios e Investigación.
Shnaider I, Chung F. Outcomes in day surgery. Curr Opin Anaesthesiol 2006 ; 19 : 622-9.
Wu CL, Berenholtz SM. Systematic review and analysis of postdischarge symptoms after outpatient surgery. Anesthesiology 2002; 96: 994-1003.
Deutsch N, Wu CL. Patient outcomes following ambulatory anesthesia. Anesthesiology Clin N Am 2003; 21: 403-15.
Smith I, Cooke T, Jackson I, Fitzpatrick R. Rising to the challenges of achieving day surgery targets. Anaesthesia 2006; 61: 1191-9.