MANAGING MEDICAL PERFORMANCE

1
MANAGING MEDICAL PERFORMANCE

• Mark Exworthy
• 21 May 2008

2
Outline

• Professional performance
• Clinical performance
• Disclosure of clinical performance data
• Current ESRC project
• St Georges Hospital
• Theoretical perspectives
• Micro, meso and macro levels

3
Professional performance

• Professional resistance
• External accountability
• Systemising work
• Managerial control
• Minimalist strategy
• Notion of equality of competence
• Only peer review permissible
• New frontiers of control?
• From internal to external, implicit to explicit
• Performance test of professional power

4
Professional performance is about power
5
Clinical performance issues
Attribution Cause /effect relationship Unit of
analysis Anonymity
Audience Multiple audiences
Choice of performance measure Input / output /
outcome
Purpose QI / managerial / regulatory
Incentives rewards and penalties Voluntary /
compulsory? Case-mix / severity / risk?
6
Factors prompting disclosure of clinical
performance

• Patient revolt
• Consumerism in health-care expert patient
• Media reporting of scandals
• Bristol RI, Shipman, Neale, Ledward, Alder Hey
  etc
• Freedom of information
• 2000 Act applicable in UK since 2005
• Modernisation of welfare
• Challenge to established professions
• Changing professionalism
• Evidence-based medicine
• Professional re-stratification
• Re-professionalisation
• International policy networks
• Policy transfer

7
History of attempts to publish surgical outcome
data in England

• Health Secretary promises to publish hospital
  death rates for individual cardiac surgeons by
  2004. Deadline missed.
• Guardian newspaper uses Freedom of Information
  Act to gain and publish results data variable
  and sometimes raw
• Healthcare Commission requires all hospitals
  doing heart surgery to publish risk adjusted data
  on death rates for individual surgeons.
• 17 units provide data on individual surgeons 13
  units only provide aggregate data 3 fail to
  provide any data by deadline.
• Healthcare Commission website publishes results
  for units
• Rate of survival said to be well above expected
  range overall survival 96.6 - expected range
  93.7 to 94.5

2002 2006 2007
8
NHS surgery success rates to be made publicJohn
Carvel, GuardianTuesday 28 August 2007

• A radical overhaul of NHS strategy which will
  give patients a right to know the success rates
  of every specialist unit in every hospital is
  being planned by leading surgeons and government
  officials.
• For the first time, patients will be allowed to
  compare the quality of the clinical care provided
  in each NHS department. People with a particular
  medical condition will be able to assess the
  quality of the relevant specialist teams at rival
  NHS hospitals before choosing where to go for
  treatment. In some specialties, results for
  individual surgeons may be available.

9
(No Transcript)
10
Mortality at St George'shttp//www.stgeorges.nhs.
uk/mortalityindex.asp

• At the time of writing we are the first
  hospital in the UK to publish inpatient death
  rates by clinical specialty. This means that if
  you are a patient, relative, or member of the
  public, you can see how we have been performing
  in different clinical areas. Included is a
  careful explanation of how the graphs are worked
  out, how we adjust for risk-factors, and
  important caveats about what this information
  should not be used for.As a leading centre in
  cardiac surgery, we also collect and analyse very
  detailed information about our performance in
  this area.This section of the site contains
  'raw' and risk adjusted mortality rates for
  individual surgeons, as well as information about
  post-operative quality.

11
Risk adjusted mortality for Coronary Bypass Graft
(CABG)- Individual Surgeons - (01.04.2002 -
31.03.2005)
12
Risk adjusted mortality data for Thoracic
Surgery(October 2002 - March 2007)
13
Complications following all operations and
coronary artery bypass graft (CABG)

14
International experience

• Sweden
• National quality registries, mainly since 2000
• Australia
• Public hospital report, announced 2008
• Germany
• Hospital reports, since 2005
• USA
• Report scorecards. Eg. New York from 89

15
(No Transcript)
16
Pennsylvania cardiac surgery, 2005
http//www.phc4.org/reports/cabg/05/docs/cabg2005r
eport.pdf
17
Pennsylvania cardiac surgery, 2005
http//www.phc4.org/reports/cabg/05/docs/cabg2005r
eport.pdf
18
Disclosure of clinical performance dataExtant
evidence suggests...

• Limited use of published performance data
• Data are often crude, ambiguous, difficult to
  interpret
• Published data are available to managers /
  external agents previously
• Reasons for disclosure are complex and overlap
• Perception of transparency
• Avoids potential intrusive surveillance later
• Reputation (Patient Choice policy)

19
Project Managing Medical Performance a pilot
study to investigate the impact of surgical
performance upon clinicians and managers

• Team
• Dr. Mark Exworthy (PI RHUL)
• Prof. Jon Gabe (RHUL)
• Prof. Ian Rees Jones (Bangor University)
• Dr. Glenn Smith (RHUL, from 1 July 2008)
• Time
• 1 year, 2008-2009
• Funding
• ESRC Public Services Programme (3rd call)
• www.publicservices.ac.uk

20
(No Transcript)
21
Managing medical performanceResearch questions

• To investigate the inter-connections between
  theoretical perspectives in terms of the motives,
  meanings and impacts of competing notions of
  performance upon cardiac surgeons, other
  clinicians, hospital managers, regulators and
  policy-makers.
• To conduct an empirical investigation of the
  motives, meanings and impacts of (published)
  performance data upon cardiac surgeons, other
  clinicians, institutional managers and external
  regulators and policy-makers, so as to inform a
  wider study of medical performance and
  governance.

22
Managing medical performance multi-level
analysis

• Micro-level
• Inter-professional relations
• Socialisation of surgeons
• Meso-level
• Use of data by managers
• Impact on organisational culture
• Macro-level
• Impact of / on regulatory regime of performance
  disclosure

23
Theoretical perspectivesMicro-level

• Soft governance
• Complete control impossible
• Rigid exterior with loosely coupled practices
• Senior professionals
• Key organisational role but possess weak external
  powers
• Senior professionals play role in legitimation
• Re-stratification
• Not de-professionalisation but re-professionalisat
  ion
• Disclosure promotes admin elite interest
  vis-a-vis rank-and-file professional

24
Theoretical perspectivesMeso-level

• Panoptic surveillance
• External gaze at internal practices
• Calculating selves
• Control at a distance
• Structural interests
• Do managers challenge or collude with
  professionals?
• Is there a challenge to medical power (eg.
  questioning merits of surgery)?

25
Theoretical perspectivesMacro-level

• Regulation
• Self-regulation under threat?
• Role of the GMC and Healthcare Commission
• State-profession contract
• Re-alignment between state and profession
  relationship
• How far is the profession itself changing?
• Role of Royal Colleges professional bodies