OPINION - Can safer surgery be legislated?
BY DR PETER SUBRAMANIAM
In June, a Royal Australasian College of Surgeons Queensland Audit of Surgical Mortality report sparked Queensland government action that may trigger new federal and state laws for public reporting of patient safety data across public and private hospitals. By August, Queensland had released a discussion paper and its push for such standards nationally was supported by federal and state health ministers at COAG Health Council. The Council tasked the Australian Commission on Safety and Quality in Health Care to work with ‘interested jurisdictions’ on such standards and to incorporate the work into national performance and reporting frameworks.
Compliance with audits of surgical mortality like the Queensland report is a mandated professional practice requirement for all surgeons while all public hospitals and almost all private hospitals already participate in the audits. So, the question doesn’t appear to be hospitals’ compliance with public reporting of performance data on patients admitted to hospital under a surgeon. The relevant questions seem to be what constitutes metrics of patient safety-oriented surgical performance and whether legislation can protect patients’ safety.
What are the metrics of patient safety-oriented surgical performance?
Patients admitted under a surgeon in a hospital are treated by a surgical team regulated by the hospital’s organisational framework that is part of a public or private hospital network. So, correctly, the metrics of patient safety-oriented surgical performance are metrics of the effectiveness of both surgical team performance and organisational performance of the hospital and its parent organisation. Only if both sets of metrics are reported will the public be fully informed about whether the hospital, public or private, is effective at protecting their safety.
This concept of patient safety-oriented surgical performance is backed by evidence. Patient safety depends on effective surgical team communication and adverse events by individual surgical team members are typically rooted in faulty systems and inadequate organisational structures. This evidence is reflected in local experience of more than 33,000 cases over eight years reported in the Australian and New Zealand Audit of Surgical Mortality National Report 2016. Its key points include that surgical team communication is a key element of good patient care and delayed inter-hospital transfers of patients with limited reserves can significantly affect surgical outcomes.
So, metrics of patient safety-oriented surgical performance must show effective surgical team communication as being timely decisions and actions to prevent, diagnose and treat surgical complications and deteriorating patients e.g. prompt resuscitation and surgery for postoperative bleeding. Likewise, such metrics must also show effective hospital and parent organisational systems enabling surgical teams’ decisions in a way that protects patient safety e.g. prompt inter-hospital transfers, timely ICU bed and OR access, safe working hours and staff levels.
Can legislation protect surgical patient safety?
The results of the Australian and New Zealand Audit of Surgical Mortality suggest surgical patient mortality represents a segment of Australia’s aging population who are at the extreme of life with co-morbidities that are a stronger predictor of death than the type of surgery. When an acute surgical condition supervenes, they have a rapidly shrinking window of opportunity with almost a quarter being irretrievable. They are prone to surgical complications which often leads to cardiac or respiratory failure with rapid deterioration and death. Nonetheless, surgical mortality in Queensland and nationally has been improving over the last eight years so it is difficult to envisage how new legislation will add much to improving surgical patient safety.
Is legislation necessary?
In 2016, a number of NSW private hospitals did not participate in the audit of surgical mortality despite compliance by all public and private hospitals in all other jurisdictions through the system funded by all State and Territory Governments. If legislation is to bring private hospitals in line with this public reporting system, it should be directed specifically for this reason. If it is to improve surgical patient safety or to inform patient choice, it is not clear how it will improve on the current public reporting system supported by governments. If a national performance and reporting framework is being developed, it should be directed at metrics of surgical team and organisational performance.
It remains to be seen if Government will be surgical in its approach to patient safety.
Dr Peter Subramaniam MBBS MSurgEd FRACS is a cardiothoracic surgeon in Canberra who is currently pursuing a Juris Doctor law degree at the Australian National University. He established the Australian and New Zealand Cardiac and Thoracic Surgeons national cardiac surgery database in the ACT as well as the multidisciplinary ACT Cardiac Surgery Planning Group. He also has extensive experience in undergraduate and postgraduate surgical education.
Views expressed in the opinion article reflect those of the author and do not represent official policy of the AMA.
Published: 08 Dec 2017