Paulo Lemos, MD Clinical Chief of Anaesthesiology Centro Hospitalar do Porto - Portugal

1. BADS Annual Scientific Conference Portsmouth, 17 & 18 June, 2010 Outcome measures for Day Surgery Paulo Lemos, MD Clinical Chief of Anaesthesiology Centro Hospitalar do Porto - Portugal IAAS President

2. Hospital Geral de Santo António, Porto - Portugal

3. Summary • Introduction • The importance, classification & type of indicators • Examples of clinical indicators • How can outcome measures become helpful? • Conclusions

4. AMBULATORY SURGERY … Ambulatory Surgery Advantages • Has fewer complications, with reduced mental and physical disability • Allows earlier return to preoperative physiological state and early resumption of normal activities • Saves money and allows reducing surgical waiting list 1. SAFETY 2. EFFECTIVE 3. EFFICIENT … PROVIDES QUALITY CARE THAT IS COST-EFFECTIVE

5. However … Ambulatory Surgery Advantages • If patients are discharged home and readmitted to the Hospital a couple of hours later due to haemorrhage! 1. SAFETY ? • If patient fails to arrive at our DSU! 2. EFFICIENCY ? • If patients have severe pain (difficult to control with oral medication) or important post-operative nausea and vomiting that does not allow oral intake, needing overnight admission! 3. EFFECTIVE ? • If patients are not the focus of our attention, we loose quality and satisfaction among patients 4. SATISFACTION ?

6. International expression of DS UK – 60% Norway – 61% US – 75% Canada – 65% Sweden – 70% France – 45% Denmark – 65% Belgium – 43% The Netherlands – 58% Portugal – 46,4% 2009 National Survey Germany – 42% Italy – 49% Spain – 45% Australia – 47%

7. How can we achieve a high quality, safe and efficient day surgery programme ?

8. What is a clinical indicator ? • “A clinical indicator is a valid and reliable quantitative process or outcomes measure related to one or more dimension of performance” Performance Improvement in Ambulatory Care, Joint Commission on Accreditation of Healthcare Organizations, USA, 1997 They should: - occur with some frequency - reflect important aspect of quality - be easy to define - allow easy analysis

9. Type of indicators: Sentinel-event indicators • Identifies an individual event or occurrence that is significant (most sentinel events are highly undesirable and occur infrequently) Examples: - a patient complaint of negligent staff - medication error or allergic reaction to drug - patient requiring transfer to higher level of care Very useful in basic functions, like patient safety

10. Type of indicators: Aggregate-data indicators • Quantify a process or outcome that generally occurs frequently and may be related to many causes Data may be reported as: - a continuous variable (the value of each measurement can fall anywhere along a continuous scale) - a discrete or rate based variable (the value of each measurement is expressed as a proportion or as a ratio) Best indicators for measuring the overall level of performance in an organization

11. Classification of indicators Structure (the characteristics of the setting – material and human resources, organisation) - Proportion of specialists to other doctors - Clinical guidelines reviewed every 2nd year Process (what is actually done – activities in giving and receiving care) - Proportion of patients treated according to clinical guidelines - Proportion of patients waiting 1 month before surgery Outcome (the effect of care – physical or psychical changes) - Proportion of patients that had an overnight admission - Proportion of patients readmitted within 28 days - Patient Satisfaction

12. The importance of Clinical Indicators • Literature indicates: • A lack of documentation about how major illnesses are treated in most health care systems; • A lack of systematic outcome assessment; • A lack of resource evaluation related to quality for specific diseases; • Persisting variations among providers in care for similar patients; • That few formal monitoring systems are in place by health care providers or regulators. Mainz J. Int J Qual Health Care, 2003;15:523-30.

13. The importance of Clinical Indicators • Indicators have been defined in several different ways: • As measures that assess a particular health care process or outcome; • As quantitative measures that can be used to monitor and evaluate the quality of important governance, management, clinical, and support functions that affect patient outcomes; • As measurement tools, screens, or flags that are used as guides to monitor, evaluate, and improve the quality of patient care, clinical support services, and organizational function that affect patient outcomes. Mainz J. Int J Qual Health Care, 2003;15:523-30.

14. The importance of Clinical Indicators • Indicator measurement and monitoring make possible to: • Document the quality of care; • Do comparisons (benchmarking) over time between places (e.g. hospitals); • Establish judgments and set priorities (e.g. choosing a hospital or surgery, or organising medical care); • Support accountability, regulation and accreditation; • Support quality improvement; • Support patient choice of providers. Mainz J. Int J Qual Health Care, 2003;15:523-30.

15. The importance of Clinical Indicators • Outcomes indicators can be expressed as “The Five Ds”: • DEATH (bad outcome if untimely); • DISEASE (symptoms, physical signs); • DISCOMFORT (minor complications such as pain, ponv,…); • DISABILITY (impaired ability connected to usual activities at home, work, or in recreation); • DISATISFACTION (emotional reactions to disease and its care, such as sadness or anger). Mainz J. Int J Qual Health Care, 2003;15:523-30.

16. ACHS Clinical Indicators Source: http://www.achs.org.au

17. ACHS Clinical Indicators - for Day Surgery Programmes • Cancellation of booked procedures (1.91%*) • Failure to attend to the DSU (0.83%*) • Cancellation after arrival due to pre-existing medical conditions (0.17%*) • Cancellation after arrival due to an acute medical condition (0.28%*) • Cancellation after arrival due to administr / organisat reasons (0.63%*) • Unplanned return to the OR(0.047%*) • Unplannedovernight admission (1.45%*) • Unplanned delay in patient discharge(0.56%*) * Data from 2007

18. IAAS Clinical Indicators • Cancellation of booked procedures • Failure to attend to the DSU • Cancellation after arrival at the DSU • Unplanned return to the OR • Unplanned overnight admission • Unplanned return of the patient to a DSU / Hospital • < 24 hours • > 24 hours and < 28 days • Unplanned readmission of the patient to a DSU / Hospital • < 24 hours • > 24 hours and < 28 days • Patient satisfaction

19. Spanish Clinical Indicators (Ministerio de Sanidad Y Consumo, 2008) Efficient & Clinical Quality Measures: • Cancellation of booked procedures • Adverse events: • Unplanned return to the OR • Unplanned overnight admission • Urgent clinics • Unplanned return to the Day Surgery Unit / Hospital • Complications rate adjusted by patient risk Organisational Measures: • Substitution index (% DS proced / total proced – DS+IN) • Ambulatory Surgery index (% total DS proced / total surg proced) Quality Measures perceived by the patient: • Patient satisfaction rate

20. ASA Outcome Indicators Source: http://www.asahq.org

21. Agenzia Regionale Socio-Sanitaria del Veneto Venezia, Italia Financed by the European Commission Day Surgery Data Project Aims: 1 – Identify & validate a set of indicators and to develop the Information Systems on DS in Europe 2 – This project proposes to analyse DS data and health indicators both at international organization and MSs level. 3 – The project will also devise guidelines for the presentation, interpretation and utilization of indicators. 4 – Finally it will establish a strategy to continuously improve its quality, efficiency and equity.

22. Day Surgery Data Project - Process-based quality indicators McGory ML et al. Ann Surg, 2009;250:338-47. • Pre-operative evaluation performed prior to surgery • Readiness for discharge that includes: • Assessment of PDSS (Post-discharge score system) • Ability to tolerate fluids • Ability to void (obligatory in the case of neuroaxial blockades) • Assessment of mental status • Discharge instructions that should include a follow-up appointment with: • Surgeon • Primary care provider

23. Day Surgery Data Project - Process-based quality indicators McGory ML et al. Ann Surg, 2009;250:338-47. • The patient should have someone available to stay with him for the first 24 h after surgery • Follow-up phone call after surgery should be performed within 24 h of surgery, including assessment of: • Pain • Tolerance of food & liquids • Ability to ambulate • Mental status • Understanding of post-discharge instructions & medications

24. Day Surgery Data Project - Outcome-based quality indicators Lemos P et al. Oxford Specialist Handbook of Day & Short Stay Surgery. McWhinnie D, Smith I, Jackson I (eds). Oxford University Press, 2010 (in press) • Clinical • Peri-operative cardiovascular and respiratory adverse events • Minor post-operative morbidity (pain, ponv, …) • Unplanned return to the OR on the same day of surgery • Unplanned overnight admission • Unplanned return or readmission to the DSU or hospital • < 24 hours • > 24 hours and < 28 days

25. Day Surgery Data Project - Outcome-based quality indicators Lemos P et al. Oxford Specialist Handbook of Day & Short Stay Surgery. McWhinnie D, Smith I, Jackson I (eds). Oxford University Press, 2010 (in press) • Organisational • Proportion of elective surgery performed as day case • Accessibility to DS programmes – number of different procedures • Cancellation of booked procedures • Failure to arrive • Cancellation after arrival at the DSU • Social • Patient satisfaction • Functional health status / quality of life • Economic • Efficiency rate of operating room utilisation

26. Day Surgery Data Project - Outcome-based quality indicators Lemos P et al. Oxford Specialist Handbook of Day & Short Stay Surgery. McWhinnie D, Smith I, Jackson I (eds). Oxford University Press, 2010 (in press) • Dimensions of Performance: • Safety • Efficacy • Effectiveness • Efficiency • Respect & caring • Continuity • Timeliness • Availability

27. Continuous health quality care programme at CHP - Porto Minor post-operative morbidity – pain management * Haemorrhoidectomy Varicocelectomy Bilat ing hernia repair *Jan-May Lemos P. Data from DSU: 14,547 patients – Porto, Portugal (not published)

28. Continuous health quality care programme at CHP - Porto Minor post-operative morbidity – ponv control Droperidol, 0,625 mg, ev % + Dexamethasone, 5 mg, ev + Dexamethasone, 10 mg, ev *Jan-May Lemos P. Data from DSU: 14,547 patients – Porto, Portugal (not published)

29. Continuous health quality care programme at CHP - Porto Unplanned return OR & overnight admission % *Jan-May Lemos P. Data from DSU: 14,547 patients – Porto, Portugal (not published)

30. Continuous health quality care programme at CHP - Porto Cancellation of booked procedures % *Jan-May Lemos P. Data from DSU: 14,547 patients – Porto, Portugal (not published)

31. Continuous health quality care programme at CHP - Porto Patient satisfaction Lemos P et al. J Clin Anesth, 2009;21:200-5.

32. Continuous health quality care programme at CHP - Porto Patient satisfaction Lemos P et al. J Clin Anesth, 2009;21:200-5.

33. Continuous health quality care programme at CHP - Porto Patient satisfaction Lemos P et al. J Clin Anesth, 2009;21:200-5.

34. Continuous health quality care programme at CHP - Porto Efficiency rate in relation to effective operating room utilisation Lemos P. Data from DSU: 14,229 patients – Porto, Portugal (not published)

35. Take home messages Emphasis was pointed out on the importance for developing a safe, effective and efficient day surgery programme We showed that the evaluation of our day surgery practice should be done through the implementation of clinical indicators The implementation of clinical indicators are the best way to improve the quality of our healthcare services

36. Join us… 9th IAAS Meeting Copenhagen – Denmark, 8 – 11 May, 2011

37. Thank you so much for your attention! Trunk Bay Beach St John – US Virgin Islands paulo.f.lemos@netcabo.pt