Quality care is Job One

As a junior surgical resident, one of my most compelling and inspirational experiences was to be shown the report of a surgical practice self-audit completed by the late Louis-Philippe Mousseau, a distinguished, pioneering surgeon at Edmonton's General Hospital. His audit, entitled “100 cases of gastric malignancy,” identified outcomes of Dr. Mousseau's surgical intervention for this devastating illness, beginning in 1934! The report was replete with a striking level of detail on surgical assessment, resection and reconstruction, pathology (including adequacy of nodal harvest) and 3- and 5-year patient survival outcomes. This audit clearly reflected Dr. Mousseau's reputation as a surgeon of choice for a difficult problem during difficult times. The report has continued to inspire me to engage in regular thoughtful reflection of outcomes in my own surgical practice.

Now Birch and colleagues¹ have outlined a superb approach to self-audit and practice appraisal in the current issue of the Canadian Journal of Surgery (CJS). As the authors indicate, practice audits or self-audit have been described as the most educationally sound method for continuous professional development. This framework should resonate well among surgeons-as-providers, patients and government paymasters alike, who are interested in the benefits that audit provides for improved quality of care. The report is most timely, with the recent increased public scrutiny of quality of medical care. This scrutiny was ushered in by the Institute of Medicine's report in 2001.² Recent data³ suggests that in the year 2000, around 7.5% of Canada's 2.5 million hospital patients experienced at least 1 adverse event. In the surgical domain, the existence of clear documentation of variations in the quality of surgical care has sparked enthusiasm for quality improvement programs.⁴

What is the evidence that audits of surgical practice improve quality of care? Recent data from the National Surgical Quality Improvement Project (NSQIP) compared outcomes in different institutions within the Veterans Affairs (VA) health system. Coincident with this program, the reduction of morbidity and mortality across large groups of providers in VA hospitals was very convincing.⁵ Whereas this program focuses upon feedback and sharing of larger group practices, the role of surgeon-specific tracking of outcomes by individual surgeons will become an increasingly important audit for the improvement of quality of care.

In Canada, the introduction of programs like NSQIP will meet with challenges due to confidentiality issues with patient data. However, the program's template can serve as a useful guide for surgeon and specialty societies to develop their own practice audits, and the report by Birch and coauthors¹ adds an advantageous new approach. Furthermore, several recent initiatives have heightened a commitment toward improving safety and quality in Canada's health system. After the 2003 First Minister's Accord on Health Care Renewal and further follow-up work by the National Steering Committee on Patient Safety, a Canadian Patient Safety Initiative (CPSI) was formally announced in December 2003. The strategic business plan for CPSI involves the development of foundations for ongoing safety of the health system. One of the principles of this plan is to champion leading practices and effective interventions. Surgeons should position themselves at the forefront of this initiative by participating in their own data collection and audits of practice.

Who will provide the resources to support these initiatives? Programs like NSQIP have educated nurse–clinicians to perform expert audits of clinical records. According to recent data,⁶ institutional funding to support practice audits proves to be funding that is well invested. Considering the substantial costs associated with postoperative complications, reduced morbidity resulting from quality improvement audits generates sufficient savings to offset the resources needed to participate in the program.⁶ In Canada there is renewed enthusiasm for creating patient safety and quality committees that work at the level of regional health authorities. In our health region, the Regional Surgical Executive Council has engaged this process to review leading practices that can improve quality of care.

The benefits of practice self-audit will also be apparent in surgical education at all levels. In centres that support teaching programs, clinical audit and improvement could be a regularly scheduled part of surgical instruction to residents. A template such as the one described by Birch and associates¹ could provide a very effective improvement for the often rambling and ineffective “morbidity and mortality” rounds. Previous audits of surgical practices have found their way into earlier publications of CJS as powerful tools for our greater surgical community to continuously improve standards of care with best available evidence.⁷ Thus the practice audit can form an integral part of scholarship in both teaching and publication.

In summary, the template provided by Birch and colleagues for the Evidence-Based Surgery Working Group sets new standards for effective audits of clinical practice. The challenge is to continuously improve individual clinical performance. This will come at a cost of increased investment of time and resources but the result of this effort will be more than repaid in better-quality care at reduced costs.

Garth L. Warnock Coeditor