Time for hard decisions on patient-centred professionalism

To the Editor: Two recent articles in the Journal highlight the need to re-evaluate the collection of performance data in Australian healthcare, as well as the uses and analysis of these data.1,2 Individual report cards are an extremely good and ethically mandated means of monitoring performance, especially when the information is given to patients as part of an informed-consent process.2 However, it is possible to provide more valuable analyses than simple crude complication or mortality rates.

Cusum (cumulative summation) analysis was developed for industrial quality assurance to monitor production processes and detect subtle deviations from a preset, defined level of achievement. It can be applied to clinical practice to identify statistically significant improvements (or decrements) in performance, using agreed definitions of “acceptable” and “unacceptable” performance levels.3,4 It can be risk-adjusted if necessary. Cusum analyses are routinely undertaken by the Geelong Hospital Department of Anaesthesia for monitoring performance of College-accredited trainee anaesthetists, and have been suggested by surgeons as a method for monitoring performance of a series of procedures.5

Although cusum analysis may seem highly threatening to many senior professionals, the support it provides and the cultural change it achieves in trainee anaesthetists have already been well documented in a unique Australian initiative.4

Modern regulatory theory describes three levels of regulation: the individual (micro), organisational (meso), and state or national (macro) levels. The personal professional monitoring program based on personal digital assistants (PDAs) and cusum analysis that was introduced for accredited trainee anaesthetists by Geelong Hospital operates at all these levels. It encourages reflection on individual performance by accredited trainees in a supported environment; organisational review by the supervisor of training within a clinical governance framework; and College supervision, collation and endorsement as part of a national training program.

The fact that the reporting structures inherent in this PDA-based model conform to these highest standards of regulatory theory and clinical governance confirms that the required professional change recommended by Irvine1 can be easily achieved through mechanisms already operating in Australian hospitals. The model also achieves cultural change in the trainees and the highest incident reporting rate in modern healthcare (96.7%–100% voluntary reporting of critical incidents occurring in their practice). 6

These two factors should mandate the wider introduction of the PDA-based program in Australian hospitals if the profession and the industry are to be taken seriously on this issue.