**1. Introduction**

74 Perioperative Considerations in Cardiac Surgery

[24] Ramamoorthy C, Haberkern CM, Bhananker SM, Domino KB, Posner KL, Campos JS, et

al. Anesthesia-related cardiac arrest in children with heart disease: data from the Pediatric Perioperative Cardiac Arrest (POCA) registry. *Anesth Analg*;110(5):1376-82.

> In the UK there are a small number of highly specialised areas of cardiac surgery that are centrally planned, funded and monitored these include Heart Transplantation in children and adults, Extra Corporeal Membrane Oxygenation (ECMO) in children and adults, Pulmonary Endarterectomy, and Ventricular Assist Devices (VAD) as a bridge to cardiac transplantation in children and adults.

> In England, the National Specialised Commissioning Team (NSCT) is responsible for planning, funding and monitoring these highly specialised services within the English National Health Service (NHS) (Kenny et al., 2008). In total the NSCT commissions approximately 70 services, each of these service involves is commissioned centrally due to one or more of the following reasons:-


This chapter will discuss our approach, experience and the impact closely monitoring clinical outcomes has in this area of highly specialised surgery. While much that is written on monitoring outcomes focuses solely on formal data collection, analysis and interpretation we believe this is only a small, although important, part of the process of monitoring clinical outcomes when your aim is improvement of clinical services. Not only does formal data alone not give clear answers, but also they require detailed understanding of the service and interpretation. This is particularly true when the data refer to small volumes of clinical activity.

The small numbers of cases within these highly specialised areas are an issue for both the development of expert performance and for monitoring that performance. There is a significant sensitivity of any aggregate outcomes to the case-mix of the cases operated on and understanding how to interpret the results in a fair, measured, proportionate and transparent manner is essential.

If formal data alone are used for 'performance management' then even if the aim of the appraisal is performance improvement there are two more likely effects. The first is distortion of data and the second is distortion of the service, these occur because they appear to produce the same results, but it is much harder to produce real improvements in any system. Therefore, we strive to ensure that these data are never examined in isolation so that inadvertent or deliberate distortion of either the service or the data are identified and prevented.

### **1.1 Our philosophy and approach**

The basis of our approach is close personal working relationships, collaboration and mutual trust between those providing the service and those monitoring it. Each of these is equally important.

Close personal working relationships because although each of these service has detailed service specifications, exacting standards and a full and complex contract, we have found that when you have to resort to the use of these formal documents then you are unlikely to get the quality of service and the ongoing improvement that these highly complex service need.

Collaboration because there are synergies that arise from the joining of multiple perspectives. In the case of these highly specialised service when the perspectives of the provider, the purchaser and the patient are brought together to develop a service, solve a problem or resolve an issue the solutions are often far stronger and more long-sighted than the solution if only one perspective were considered.

Mutual trust because there are so many opportunities for the development of perverse incentives, short-term gain with long-term losses and gaming of any performance indicators that it is, in our opinion, very challenging to contract with people and organisations where such trust is undermined or becomes compromised.

Into each of these relationships, we believe we bring sensitivity and a thorough understanding of each service that allows us to use appropriately the 'dark art' of interpreting outcomes bases on small numbers.

We also insist on the development of clinical and managerial systems that wrap around these services and provide prompt, timely and appropriate feedback so that expert performance can develop (Klein, 1998). Encourage reflection so that each opportunity for learning from these scarce experiences if optimised for both individual learning and vicariously by the wider team and service. In addition, focus on performance improvement because however far a service has come however good it is, we find that either services improve or they deteriorate. Keeping a service's performance static requires as much if not more effort than improving it and our preference is, by far, for services that improve.

#### **1.2 How the national specialised commissioning team uses the outcome data**

Every service commissioned by the National Specialised Commissioning Team is allocated to a Triumvirate of a commissioning manager, a finance manager and a medical advisor. This Triumvirate oversees all elements of the commissioning process on an ongoing basis and through a number of simultaneously delivered processes.

The first process that underpins each service we commission is the development of clinical and service standards. These standards are developed collaboratively, with both our team and the service contributing fully to their development. In spite of this collaborative development, or maybe because of it, the standards are invariably high and most commonly represent, wherever possible, best practice, based on evidence rather than a lowest common denominator consensus.

The second process is formal twice-yearly face-to-face review meetings between each service provider and the Triumvirate. These twice-yearly review meetings cover all elements of the service and include a formal review of clinical audits, feedback on service in the form of complaints, compliments, patients surveys, satisfaction questionnaires and the key clinical

inadvertent or deliberate distortion of either the service or the data are identified and

The basis of our approach is close personal working relationships, collaboration and mutual trust between those providing the service and those monitoring it. Each of these is equally

Close personal working relationships because although each of these service has detailed service specifications, exacting standards and a full and complex contract, we have found that when you have to resort to the use of these formal documents then you are unlikely to get the quality of service and the ongoing improvement that these highly complex service need. Collaboration because there are synergies that arise from the joining of multiple perspectives. In the case of these highly specialised service when the perspectives of the provider, the purchaser and the patient are brought together to develop a service, solve a problem or resolve an issue the solutions are often far stronger and more long-sighted than

Mutual trust because there are so many opportunities for the development of perverse incentives, short-term gain with long-term losses and gaming of any performance indicators that it is, in our opinion, very challenging to contract with people and organisations where

Into each of these relationships, we believe we bring sensitivity and a thorough understanding of each service that allows us to use appropriately the 'dark art' of

We also insist on the development of clinical and managerial systems that wrap around these services and provide prompt, timely and appropriate feedback so that expert performance can develop (Klein, 1998). Encourage reflection so that each opportunity for learning from these scarce experiences if optimised for both individual learning and vicariously by the wider team and service. In addition, focus on performance improvement because however far a service has come however good it is, we find that either services improve or they deteriorate. Keeping a service's performance static requires as much if not

more effort than improving it and our preference is, by far, for services that improve.

**1.2 How the national specialised commissioning team uses the outcome data** 

and through a number of simultaneously delivered processes.

denominator consensus.

Every service commissioned by the National Specialised Commissioning Team is allocated to a Triumvirate of a commissioning manager, a finance manager and a medical advisor. This Triumvirate oversees all elements of the commissioning process on an ongoing basis

The first process that underpins each service we commission is the development of clinical and service standards. These standards are developed collaboratively, with both our team and the service contributing fully to their development. In spite of this collaborative development, or maybe because of it, the standards are invariably high and most commonly represent, wherever possible, best practice, based on evidence rather than a lowest common

The second process is formal twice-yearly face-to-face review meetings between each service provider and the Triumvirate. These twice-yearly review meetings cover all elements of the service and include a formal review of clinical audits, feedback on service in the form of complaints, compliments, patients surveys, satisfaction questionnaires and the key clinical

prevented.

important.

**1.1 Our philosophy and approach** 

the solution if only one perspective were considered.

such trust is undermined or becomes compromised.

interpreting outcomes bases on small numbers.

outcomes agreed for the service. The focus of the reviews is on how the service is developing and changing because of the information it is receiving from each of the preceding data sources.

The third process is an annual clinical audit day where all the providers of a service meet to go through the clinical outcomes of the service. These outcomes are based on 100% consecutive case-series of outcome reporting i.e. outcomes from every single patient cared for by a service in a given year.

The fourth process specific to the highly specialised cardiac services and the other transplant services takes the form of monthly monitoring of outcomes using the O-E (observed expected) monitoring and tabular CUSUM (cumulative sum control chart). This monitoring allows each of the service providers and the National Specialised Commissioning Team to track any changes in outcomes in real-time, which allows early identification of any change from that which might be expected and allows the timely questioning of why such variation may have occurred. Details of such investigations are presented in the published UK Cardiothoracic Transplant Audit annual reports, leading to shared learning and shared service development and improvement based on centre level clinical outcome data and timely reporting and analysis.

Throughout each of these processes, our emphasis is on the use of data, from all sources, to provide feedback on the performance of the service and guide them to where the time would be most valuably spent improving.

We apply all of the above principles to all of the services we commission whether they are secure mental health services, diagnostic services, surgical services or those for cardiac transplantation (see www.specialisedservices.nhs.uk for the full list of services commissioned by the National Specialised Commissioning Team). To demonstrate this application we will use heart and lung transplantation as a case study, which includes a detailed reflection on an external review carried out at one of the heart and lung centres that involved a detailed statistical analysis of mortality data that informed the review findings.

We then conclude with summaries of the other nationally commissioned cardiac services and the use of outcome data within them.
