quality assurance in ophthalmic service monitoring cataract surgery outcome
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Quality Assurance in Ophthalmic Service Monitoring Cataract Surgery Outcome. Dr. Goh Pik Pin Consultant Ophthalmologist Selayang Hospital. Introduction Why monitor treatment outcome?. Patient satisfaction -standard of treatment Self-audit – continuous professional development - PowerPoint PPT PresentationTRANSCRIPT
Health outcome conference July 2004
Quality Assurance in Quality Assurance in Ophthalmic Service Ophthalmic Service
Monitoring Cataract Surgery OutcomeMonitoring Cataract Surgery Outcome
Dr. Goh Pik Pin
Consultant Ophthalmologist
Selayang Hospital
Health outcome conference July 2004
Introduction Why monitor treatment outcome?
Patient satisfaction -standard of treatment
Self-audit – continuous professional development
Set standard or norm- monitor service performance
Practice of medicine - competent, accountable and ethical
Health outcome conference July 2004
How?
Current methods of quality assurance :
1. Legislation- hospital licensing law
2. Professional self-regulation - specialty board
3. Informal peer review- census, log book
4. Formal accreditation and credentialing
Health outcome conference July 2004
Limitations
1. Subjective- e.g. inspection by external reviewer
2. Arbitrary- e.g. must have performed minimum x number of procedures before credentialing, competence
3. No explicit reference to agreed standard
Health outcome conference July 2004
More Objective & Better Methods
1. Bench marking
2. Continuous quality monitoring• Statistical process control (SPC)
technique – trend of performance
e.g. Cumulative Sum (CUSUM)
Health outcome conference July 2004
Cataract Surgery OutcomeWhat do we measure?
1. Best Corrected Visual AcuitySnellen, LogMar
2. Visual FunctionGlare disability, contrast sensitivity
3. Quality of LifeVF 14, Vision Related Sickness Impact Profile, Catquest (Sweden), etc
Health outcome conference July 2004
Cataract Surgery OutcomeMethods
1. Population Based SurveyRapid assessment on cataract surgery service -WHO India, China, Nepal, Australia
2. Centre / Providers Based StudiesInternational Cat. Surgery Outcome Study- USA ,Canada, Denmark, SpainEuropean Cataract Outcome Group-1998USA- Medicare beneficiaries, NEON, PORTUK-National Cataract Surgery Survey-1997Sweden-National Swedish Cataract Register-1992Malaysia-MOH Census & National Cataract Surgery Registry
3. Individual surgeon Surgical log booksStatistical Processes Control – Cumulative Sum (CUSUM)
Health outcome conference July 2004
Ministry Of Health Hospitals Annual Census- Cataract service
1. Quantity 2. Practice pattern- day care, Phaco/ECCE, IOL3. Quality measurements
• Waiting time • Ratio of cataract surgeon to patients• Post-op infective endophthalmitis • Unplanned return to operating theatre
31 MOH HospitalsStandard census format Defined numerator and denominator
Health outcome conference July 2004
Rate of Post-Op Endophthalmitis
00.20.40.60.8
11.21.41.6
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31
Hospital
Rate
(%) Rate in 2002
Rate in 2003
Health outcome conference July 2004
National Cataract Surgery Registry(NCSR, www.crc.gov.my/ncsrwww.crc.gov.my/ncsr))
Establish –2002Prospective systematic data collection32 centers (MOH, army & universities hospitals, 1 private)Data collection- integrated into daily work Objectives:
to determine frequency of cataract surgery to monitor outcome and factors influencing outcomes to evaluate cataract surgery services
Health outcome conference July 2004
NCSRData collected1. Patient characteristics
Age, gender, 1st eye, ocular & systemic co-morbidity, presenting vision
2. Practice Pattern Day care, anaesthesia, operation, IOL, Viscoelastic
3. Outcome measurementsIntra-op & post-op complicationsPost-op BCVA by 12 weeks
Factors contributing to poor visual outcome 4. QA indicators
Post-op infective endophthalmitisUnplanned return to OT within 1 week
Health outcome conference July 2004
NSCRAnnual Report 2002 & 2003
2002
n-=12 ,798
(%)
2003
n=16,811
(%)
Day care surgery 38 37
Conventional -ECCE
Small Incision -Phacoemulsification
54
40
48
46
First eye 70 70
Health outcome conference July 2004
NCSRCataract Surgery Outcome
All ECCE PEA
2002
2003
86%
89%
83%
85%
91%
93%
Health outcome conference July 2004
NCSRBest corrected vision 6/12 at 12 weeks post operation
2002
%
2003
%
All 86 89
ECCE 83 85
Phacoemulsification 91 93
Health outcome conference July 2004
Best Corrected Vision ( 6/12) – phacoemulsification,year 2002
92
97
92929194
9187
94
8986
919290
88
97
85
97100
94
75
80
85
90
95
100
105
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Hospital
Pro
port
ion
(%)
Health outcome conference July 2004
Cataract Surgery OutcomeInternational comparison
* All patient (with & without ocular co-morbidity)
Survey UK
NCSS
1997N=18,000
USA
NEON
1997N=3342
Aust
VIP
2000N=249
Europe
ECOG
2000N=
M’sia
NCSR
2003N=16,811
BCVA 6/12 or better
92% 96% *85% *84% 89%93% Phaco
85% ECCE
Health outcome conference July 2004
Statistical Process Control –Cumulative Sum (CUSUM)
CUSUM chart Graph representation of the trend in outcomes of consecutive procedures performed over time by same surgeonEarly detection of unacceptable rate of adverse outcomeApplications
Monitoring of traineesContinuous surgical audit
Health outcome conference July 2004
What is CUSUM charting?..
CU
SU
M
Consecutive series of procedures5 10 15 20 25 30 35 40 45
0
1.13
2.26
3.39
4.52
Health outcome conference July 2004
CUSUM..
CU
SU
M
Consecutive series of procedures0 10 20 30 40 50
0
1.5
3
4.5
Consultant
Trainee
Health outcome conference July 2004
CUSUM Chart for ECCE (NCSR)
01.63.24.86.4
89.6
11.212.814.4
16
CU
SU
M
0 10 20 30 40 50 60 70 80 90 100 110 120Consecutive series of procedures
doctor 22 doctor 37
doctor 45 doctor 48doctor 54 doctor 57doctor 78 doctor 81doctor 85 doctor 92
doctor 93 doctor 97
Health outcome conference July 2004
Conclusion
Quality assurance in ophthalmic service
Mandatory
Continuous - trend
Sustainable - integrated into daily work process
Surgeons - appreciative self audit for continuous professional development
Providers - continuous quality monitoring
Confidentially and medico-legal implication - issues to be considered
Health outcome conference July 2004
Acknowledgement
Dr Mariam Ismail National Head of Ophthalmology Service, MOH
Head, Ophthalmology Department,Hospital Selayang
D.Lim Teck Onn Head, Clinical Research Centre, MOH
Dr.G.ArumugamPresident,Ophthalmological Soicety
Singapore Society of Ophthalmology