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B. Collopy, L. Rogers, J. Williams, N. Jenner, L. Roberts, J.Warden
1999
As the number, variety and complexity of day procedures increase it is clearly important to ensure maintenance (and improvement) in the quality of the care given. To do so the Australian Day Surgery council, assisted by the Australian Council on Healthcare Standards Care Evaluation Program, introduced five generic performance indicators. They were addressed by 240 healthcare organisations in 1997 reflecting the management of over 380 000 patients in day procedure facilities. Aggregate rates for the five indicators in 1997 were: failure to arrive, 1.5%; cancellation of procedure after arrivzl, 0.9%; unplanned return to operating room, 0.08% and unplanned delayed discharge, 0.56%. The unplanned overnight admission rate was significantly lower in freestanding than in attached facilities and significantly lower rates were noted for private compared with public facilities for all the indicators. Numerous actions were reported by 64% of organisations (as a result of indicating monitoring) including increased patient education, the production of information leaflets, establishment of pre-anaesthetic clinics, alteration of surgical techniques, introduction of drug trials and numerous policy changes. (C) 1999 Elsevier Science B.V. All rights reserved.
In 1995 Ira Rutkow wrote that 'ambulatory surgery is one of those rare socio-economic poitical movements in which all the participants have benefited as demonstrated by public interest and demand, surgeon satisfaction, patient participation and most importantly, prayer encouragement and mandate'[1]. However, there is no mention of quality in this statement and as the number, variety and complexities of day procedures it is clearly important to ensure the maintenance (and improvement) of the quality of care given. This issue has been addressed by the Australian Day Surgery Council (ADSC) and the Australian Council on Healthcare Standards (ACHS) Care Evaluation Program (CEP) in the development and implementation of a set of performance measures or clinical indicators [2]. They now form part of the larger program of the ACHS CEP and the medical colleges which has seen the inroduction of 15 sets of clinical indicators into the Evaluation and Quality Improvement Program (EQuIP), the new accreditation process of the ACHS [3]. This has enabled the establishment of a 'national' database reflecting the quality of medical care. It is unique in its provider (medical college) involvment and the wide range of conditions and procedures addressed [4].
Clinical indicators are defined as measures of the management and/or outcome of care whose purpose is to act as flags of possible problems in patient care.
Five generic indicators have been developed reflecting access anf efficiency of booking, appropriateness of patient selection, safety of anaethesia and surgery and discharge planning. They are:
Table 1
Aggregate results for all indicators
| Indicator | No. Of Orgs | Num. | Denom. | Rate(%) |
| Failure to arrive (FTA) | 191 | 4876 | 317 416 | 1.5 |
| Cancellation of procedure after arrival (CAA) | 190 | 2850 | 314 365 | 0.9 |
| Unplanned return to O.R. (UpROR) | 193 | 268 | 333 569 | 0.08 |
| Unplanned overnight admission (UpO/NA) | 226 | 8520 | 384 401 | 2.2 |
| Unplanned delay in patient discharge (DD) | 170 | 1469 | 268 446 | 0.56 |
The indicators were introduced in 1996 for health care organisations undergoing an accreditation survey in that year and were addressed by 101 organisations. From January 1997 all health care organisations in the EQuIP program were requested to forward data 6 monthly to the CEP. In that year 240 organisations forwarded data and 54 of these were free standing facilities using prospective data collection methods utilising computerised programs and special facilities. The data received reflected the management of over 380,000 patients in day procedure facilities.
Compared with other indicator sets there was less reliance on the medical record, with more than 60% of facilities using prospective data for the 'failure to arrive' indicator, but little difficulty collecting data for the other indicators was experienced.
Table 3
Freestanding versus attached units
| Indicator | Free standing rate(%) | Attached unit rate(%) | P-value |
| FTA | 1.4 | 1.6 | 0.05 |
| CAA | 0.3 | 1.1 | 0.0001 |
| Up ROR | 0.05 | 0.09 | 0.1 |
| Up O/NA | 0.4 | 2.7 | 0.0001 |
| Unplanned DD | 0.18 | 0.66 | 0.0002 |
room were 0.05% in 1996 and 0.08% in 1997. The rates for unplanned delay in patient discharge were 0.46% in 1996 and 0.56% in 1997. As organisation move more to propective data collection, using special registers, fewer errors are likely and whilst the whole program remains an educational one (without funding implications), to stimulate 'internal' review, there is little incentive for 'gaming' of data.
Kazandjian and co workers in the Maryland program of indicators have commented that the repsonsiveness' of an indicator, that is its ability to induce action in facilities monitoiring the indicator, is the best index of its value [14]. It was pleasing to note that 64% of the facilities monitoring these indicators took some action after reviewing their results.
The types of action taken related to: patient education, e.g. advice about fasting and cessation of certain drugs; information leaflets, e.g. explanations of procedures and follow up requirements; the establishment of pre-admission clinics; alteration to surgical techniques; a review of the type of procedures, e.g. ERCP was dropped by one facility as a day procedure; alteration to the order of procesdures and follow up requirements; the establishment of pre-addmission clinics; alteration to surgical techniques; a review of the type of [rpcedures, e.g. procedures requiring a long recovery period were listed in the morning, alteration to drug policies-numerous policy changes were reported and a number of drug trials were initiated.
As with the other indicator sets the ACHS CEP and ADSC working party for these indicators will review the qualitative and quantitative information on a yearly basis and make appropriate changes to the indicators on a biennial basis. Consideration will be given to the introduction of specific procedure indicators in the future, for example laproscopic procedures. Specificity will better enable "peer" comparisons but it will be desirable
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