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Using data to develop and improve day surgery performance

Dr Mark Skues Past President British Association of Day Surgery and Consultant Anaesthetist, Countess of Chester NHS Foundation Trust spoke at today’s Innovation and Quality in Day Surgery conference on:

•Currently available data on day surgery
•Using data to improve services
•Using data to drive innovation

Dr Skue's opened his presentation by saying; "incremental improvements do matter in prder to improve your overall day surgery pathway."  

Abstract of Dr Skues’ presentation

This abstract is an overview of the availability of day surgery outcomes in the United Kingdom on the Internet, with advice on where and how to find it.

There is no doubt of the value of outcome data related to Day Surgery, so that organisations have comparative insight into operative procedures that are suitable for ambulatory care, with timely evidence of their own activity. However, it should be recognized that day surgery is a pathway of care that embraces environment, processes, managerial and staff motivation, and leadership. Facets of these components that enhance day surgery outcomes will be discussed over the course of the day. So here’s an overview of the data currently available. I have concentrated on the NHS in England as the significant provider of health funding, but have also included Wales, Scotland and Northern Ireland  as searchable resources.

England
15 years ago, outcome reporting was based upon the use of the “Basket of 25” day surgery procedures promoted by the Audit Commission. Trusts originally provided data that were replicated in Healthcare Commission and DoH documentation (1,2), but contemporary access to the information was limited. There was also evidence that a limited cohort of procedures adversely affected development of new operations made possible by advances in minimally invasive surgical and new anaesthetic techniques designed to facilitate more prompt discharge. 

To address this shortfall, the British Association of Day Surgery developed and published a series of guides called “the Directory of Procedures” (3) that is now in its 4th Edition, and first published in 2007. These were unique publications, as they provided expert insight into the likely duration of stay for over 160 surgical procedures deemed feasible for day surgery, as well as other short stay operations. Coding mechanisms were developed to specify individual operations by OPCS 4.6 coding mapped to HRG 4, and provided guidelines for length of stay by a variety of collaborative experts.  BADS has also developed biennial updates showing the performance of the top 5%, 25% and 50% of English Trusts for each operation cited in the Directory of Procedures (4).

Developments in data reporting were augmented in 2011 with the establishment of the ‘Better Care Better Value” (BCBV) Indicator website at www.productivity.nhs.uk by the Institute for Innovation and Improvement, where a specific section deals with day case productivity and the ability to drill down to the percentage of patients managed as daycase for 123 operations, largely based upon the Directory of Procedures. This has been something of a “game changer” with the national reporting of Day Surgery activity, and the ability to explore the site with (free) registration to further explore the site. However, given that BCBV transferred to the aegis of NHS Elect in 2013, and then, in April 2015 to NHS Improvement, with a prospect of potential closure within the next 6 months, the future of the website may be in some debate, given ongoing financial constraints.

The final component of development that has influenced the rate of day surgery uptake has been the adoption of Best Practice Tariffs by NHS Payment by Results. Originally configured to financially enhance successful daycase outcomes for laparoscopic cholecystectomy with financial incentivisation of an additional £250 compared with an inpatient stay, the ethos has been extended to a further 14 procedures since then, with a suggestion that for the 2016/17 tariff round, an extra 22 operations are incentivized. It remains to be seen how successful the ongoing drive to develop Day Surgery outcomes will be.

Wales     
The situation is a little less clear cut with Wales. BADS has access to day surgery outcome information based upon the Procedure Directory on an irregular basis, with the last request made in March 2015, but such information is obtainable via other ‘net resources. First search is to http://www.infoandstats.wales.nhs.uk with a drill down to ‘PEDW data online’ (Patient Episode Database for Wales).

From here, a search for “Principal procedures (4 character detail by LHB [Local Health Board] Provider” for 2014-2015 will download an Excel file stratified by OPCS codes from which comparison by BADS Procedure Directory will identify the appropriate day case data. So for example, for laparoscopic cholecystectomy, which have OPCS codes of J181 and J183, summation of the daycase data across all of the Local Health Boards will reveal the daycase percentage. I believe the correct search page to download this is:
http://www.infoandstats.wales.nhs.uk/page.cfm?orgid=869&pid=41010&subjectlist=Principal+Procedure+%284+character+detail%29+by+LHB+Provider&patientcoverlist=0&period=2014&keyword=&action=Search

Northern Ireland
Preliminary search for Northern Ireland information was fraught with difficulty, as the province is fixated on reporting Day surgery information using the ‘Basket of 24’ (terminations of pregnancy are excepted) rather than a wider search mechanism. An initial check at: www.dhsspsni.gov.uk/index/statistics will reveal some data, but the information is not stratified by operative procedure, but by departmental activity only. It is therefore possible to learn the number of daycase procedures performed by (for example) gynaecology departments, but not the individual procedures. 

Scotland
Scotland produces information on Day Surgery where the percentages of day surgery by speciality are recorded, but like Northern Ireland, there is no drill down to individual procedures. The relevant webpage can be found at http://www.isdscotland.org/Health-Topics/Hospital-Care/Operations-and-Procedures/ with a download in Excel format under “British Association of Day Surgery (BADS) Procedures”. One can therefore search for the number of procedures performed, for example, by “Breast surgery” in Ayrshire and Arran for 2013/4 (30.06%), but not the number of simple mastectomies. Work is ongoing to try to refine this sheet!

And finally…
The Association is ever sensitive to relevant information on performance in the day surgery arena. In June 2014 (5), I presented information on the potential development of the ‘BADS Top 10” that are a collection of procedures that are high volume, show wide variation, and from 2016, will all be incentivised by ‘Best Practice Tariff’ under “Payment by Results”. A spreadsheet is available on the BADS website allowing comparison between every hospital in England over the last two years, that I will bring to this meeting, for delegates to upload to their ‘ memory sticks’ over the course of the day.

References
1) Day Surgery: Operational Guide. Department of Health, August 2002.
2) Acute Hospital Portfolio Review- Day Surgery. Healthcare Commission. July 2005
3) Skues M, McWhinnie D, Jackson I. The BADS Directory of Procedures 4th Edition. British Association of Day Surgery (available from www.bads.co.uk)
4) Skues M. Directory of Procedures: National Dataset for Calendar Year 2013. British Association of Day Surgery (available from www.bads.co.uk)
5. Skues M. “How are we performing? Day Surgery across the UK. 1) England.” British Association of Day Surgery Annual Scientific Meeting; Torquay, June 2015. 
Available at https://bads.talkingslideshd.com/view?presentation=519 (Log in and registration required)

Dr Skues' full presentation is available for download at the end of this page.

Mark is a Consultant Anaesthetist in Chester, having been originally appointed in 1992. Graduating from Nottingham University Medical School in 1980, with postgraduate training in Nottingham, Bristol, Sheffield, and New Zealand, he underwent a subsequent formal consultant appointment process to take on the role of Director of Day Surgery in Chester in 2000. An enthusiastic proponent of evidence based practice in Short Stay surgery, he has developed the BADS reference database for Day Surgery, the BADS Procedure Directory that is now widely regarded as the benchmarking index for Day and Short Stay care in the NHS, and has been the recipient of the Association's Fellowship award and President's Prize. Appointed to Council of the British Association of Day Surgery in 2008, Editor of the Journal of One Day Surgery from 2009 to 2011, and President of the Association from 2012 to 2014, he is also a member of the Scientific Committee of the European Society of Anesthesiology for ambulatory surgery, Editor-in-Chief of ‘Ambulatory Surgery’, the Clinical Lead for NHS Payment by Results since 2010, and author of over fifty peer reviewed publications, booklets and book chapters on Day and short stay Surgery in the last five years. In his spare time, he is the ongoing benefactor to three children (now grown up) and a dysfunctional dog called Dylan (sadly, still not grown up, yet!).

Future events of interest:

Effective Consent Practice: Implementing the new duty to explain risks to patients
Tuesday 9 February 2016 
Hallam Conference Centre, London


Download: Dr Mark Skues full presentation

26 November 2015

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