bluebookforpatients

UWTTIITTKHLLEEAHTEAPARTTIESNUTRSGECRAYN EXPECTFROM THEIR SURGEONSHEART OPERATIONS 1st APRIL 2001 - 31st MARCH 2011 SCTS Society for Cardiothoracic Surgery in Great Britain & Ireland HEARHTEAORPTEROAPTEIROANTSIO1NstSA1PsRt AILP2R0IL012-00381s-t3M1sAtRMCAHR2C0H1120//111 // 1

The Society for Cardiothoracic Surgery in Great Britain and Ireland (SCTS) is a charity that exists to promote the specialty of cardiothoracic surgery (surgery on the heart, lungs, chest wall and oesophagus). It has members who are doctors, nurses and other professionals allied to medicine. More recently it has been welcoming patients as associate members. Most consultant cardiac surgeons in the UK are members of the Society. It provides the clinical leadership for the National Adult Cardiac Surgery Audit. www.scts.org The National Institute for Cardiovascular Outcomes Research (NICOR) is part of the Centre for Cardiovascular Preventions and Outcomes at University College London. It is a partnership of medical professionals, IT experts, statisticians, academics and managers. It manages six cardiovascular clinical audits, including the National Adult Cardiac Surgery Audit. NICOR’s mission is to provide information that can be used to improve quality of care and outcomes for patients with heart disease. www.ucl.ac.uk/nicor The Northwest Institute for BioHealth Informatics (NIBHI) is an informatics research and e-Health innovation hub, centred at the Manchester Academic Health Science Centre (MAHSC) within the University of Manchester. Founded in 2004, NIBHI now has a portfolio of grants in excess of £25M and employs around 40 staff from a broad range of disciplines. Its environment is deliberately multi- and trans-disciplinary, harnessing computational thinking for public health. It carried out the analysis for this report. www.nibhi.org.uk The Healthcare Quality Improvement Partnership (HQIP) was established in April 2008 to promote quality in healthcare, and in particular to increase the impact that clinical audit has on healthcare quality in England and Wales. It is led by a consortium of the Academy of Medical Royal Colleges, the Royal College of Nursing and National Voices, and commissions NICOR’s management of the National Adult Cardiac Surgery Audit. www.hqip.org.ukAuthorsReport produced byRebecca Cosgriff (NICOR)Graeme Hickey (MAHSC and NICOR)Stuart Grant (MAHSC, NICOR and University Hospital of South Manchester)Ben Bridgewater (MAHSC, NICOR and University Hospital of South Manchester)AcknowledgmentsThe National Adult Cardiac Surgery Audit, on which many of the analyses in this report are based, is managedby the National Institute for Cardiovascular Outcomes Research (NICOR) and commissioned by the HealthcareQuality Improvement Partnership (HQIP). Analysis was carried out as part of a NIBHI-SCTS project, which isgenerously funded by Heart Research UK.We would especially like to thank both the surgeons and database managers who submit data to the NationalAdult Cardiac Surgery Audit. Without their input, we could not continue to produce the analyses required toeffectively monitor and improve the standard of adult cardiac surgery in the United Kingdom. 2 // UK HEART SURGERY WHAT PATIENTS CAN EXPECT FROM THEIR SURGEONS

CONTENTSFOREWORD 4INTRODUCTION 6What is the ‘Blue Book’? 6What is cardiac surgery? 6What is The National Adult Cardiac Surgery Audit? 7What does SCTS think that patients want? 8A patient’s view 10PART ONE: LOOKING AT OPERATION DATA TO ASSESS AND IMPROVE CARE 11Introduction 11How is cardiac surgery changing over time? 12Coronary artery bypass grafting (CABG) 16 First-time isolated CABG 18Valve surgery 22 Aortic valve surgery 22 First-time mitral valve surgery 26 First-time isolated mitral valve repair 28 First-time mitral valve repair plus CABG trends 29 First-time isolated mitral valve repair replacement (MVR) 30 Mitral replacement plus CABG trends 31How are hospital and surgeon mortality data communicated to the public? 32 Case mix plots 32 Mortality rates 33 How do these data improve the quality of patient care? 36PART 2: HOW ELSE DO SURGEONS MAKE SURE THEY ARE DOING A GOOD JOB? 37Introduction 37Measurement of patient experience 37Developing patient feedback on individual consultants: the Picker method 39REVALIDATION 47How do doctors make sure they are ‘fit to practise’? 47 Outcomes data and revalidation 47SCTS University 48AFTER MID STAFFS 51CONTACT INFORMATION 56 HEART OPERATIONS 1st APRIL 2001 - 31st MARCH 2011 // 3

FOREWORDJames Roxburgh, President of the Society In cardiac surgery there has been a tendencyfor Cardiothoracic Surgery (SCTS) for us to look back at the events that happened in children’s cardiac surgery in Bristol in the The Society for 1990s and argue that, whilst they occurred in our Cardiothoracic speciality, they could have happened and been Surgery in GB exposed in any branch of medicine at that time. and Ireland (SCTS) is a The recommendations following on from Bristol, charity that which involve the need to publish outcomes for exists to individual clinical teams, were generalised for promote the all medicine and not specific to cardiac surgery. specialties Indeed the recent events at Mid Staffordshire NHS of cardiac Foundation Trust, which are in many ways moresurgery, lung/oesophageal surgery and surgery profound, were not in any way related to cardiacon the chest wall. Our members are the surgeons surgery and have come some 10 years after Bristol.and other professionals who provide care for However, because Bristol was about cardiacpatients who are unlucky enough to suffer from the surgery, we as a professional group have been helddiseases we treat. to account by society (through politicians and the media) and have felt an important obligation toLike much of medicine, we have been respond and publish our results by named hospitalcoming to terms with improvements in the and consultant since 2005.medical profession’s ability to treat patientsalongside changing expectations of society in Whilst this was initially uncomfortable, we havea world driven by 24 hour news and instant come to understand an important principle;communications. The days of Dr Findlay and Sir patients come first. The only people who canLancelot Sprat are long gone! define the technical aspects of what quality of care the patients should get are the cardiacWithin the SCTS we embrace these changes and are surgeons, who must make those decisions inworking hard to ensure that we, as professionals, partnership with patients. We therefore have anare acting first and foremost in the interests of overwhelming obligation to work with patientour patients and their carers at all times. This representatives to define those standards clearly,has required a marked shift in our attitudes and and to monitor care to check those standards arepriorities, and to some extent we hope that this book always achieved. We know also that we must takeis evidence of those changes; until now we have action where they are not.directed all our publications and communicationsprimarily towards our professional colleagues; with There is accumulating evidence that thisthis report we are now trying hard to put the patients process gives clear benefits to patients, withfirst in all our activities.4 // UK HEART SURGERY WHAT PATIENTS CAN EXPECT FROM THEIR SURGEONS

MORTALITY is the in-hospital individual doctors, so we can all monitor our another word for mortality rates own performance from the patient’s view. Datadeath. When we talk about in the UK on outcomes, experience and other aspects ofmortality rates in this report (after making professionalism should be used to demonstratewe are talking about the appropriate that all surgeons are fit to practise through thepercentage of patients from a adjustments process of professional revalidation.specified group who die after for changingcardiac surgery. Mortality complexity of We have described these initiatives in the pagesrates are calculated for surgery), being of this report, and hope that you will find itspecific time periods after about 1/3rd of of interest. Key to us putting patients first issurgery; for example before what they were improving our understanding of what patientsdischarge or within a certain 10 years ago. want. We already have patient representativesnumber of days. who work with us. One of them, Mike Fisher, has written a contribution for this report (page 10). But Putting patients we would very much like to get further input aboutfirst is what we are now trying to do. We have what we are doing well, what we should do better,published our results of surgery by hospital and and what we should be doing but are not yet doingconsultant at www.scts.org/patients, which we at all. We would therefore seek feedback from thishope will drive further improvements in quality report, either through www.scts.org, where weand allow people to make informed choices about have a patient discussion forum, or by using thetheir care. We continue to collect information on contact details given at the end of this report.all operations undertaken in the UK, and have putthat data into the public domain atwww.bluebook.scts.org.We accept that clinical Screen shot of www.bluebook.scts.orgoutcomes of surgery are onlyone important facet of care, andbelieve that measuring patientexperience is also important.This should include not just avague question such as ‘wereyou satisfied’, but should featurequestions to allow specificaspects of care to be improvedwhere necessary. We alsobelieve that this informationshould be specific down to HEART OPERATIONS 1st APRIL 2001 - 31st MARCH 2011 // 5

INTRODUCTIONWhat is the ‘Blue Book’? Where you see words highlighted like this, a description of a term is given.The ‘Blue Books’ have been a series of largedocuments designed for people who work TIP: SCTS have made an onlinein healthcare. They contain lots of detailed version of the Blue Book,analyses of data collected about heart operations which you can visit by going tocarried out in the United Kingdom. They have www.bluebook.scts.org. Here you can seebeen produced by the SCTS in partnership up-to-date and patient friendly analysis ofwith Dendrite Clinical Systems Ltd, and can be National Adult Cardiac Surgery Audit data.downloaded from www.scts.org. What is Cardiac Surgery? This report is a The heart is a muscle in the body that is patient-friendly responsible for pumping blood containing nutrients and oxygen around the body. version of the Cardiac surgery is an operation related to the Blue Books, heart. There are lots of different types of cardiac surgery, designed to treat various problems with which has the way that the heart works. In this report we focus on the most common heart operations. been produced TIP: More information about specially for different types of heart surgery can be found at patients and www.scts.org/patients. members of the public withSixth Blue Book, 2008 an interest in cardiac surgery.It is written for people with little or no knowledgeof cardiac surgery, and aims to show only theinformation that is useful to patients.This report presents selected findings from theNational Adult Cardiac Surgery Audit for heartoperations that took place between 2001/2 and2010/11, alongside other information aboutcardiac surgery in the UK.6 // UK HEART SURGERY WHAT PATIENTS CAN EXPECT FROM THEIR SURGEONS

What is the National Adult Cardiac The audit has been running since 1977, with a moreSurgery Audit? complete set of data being collected since 1996. MAJOR Most of the tables It securely collects data on all major adult heart and graphs in this operations from the 35 NHS hospitals in the UK ADULT HEART report are based that carry them out. A number of Irish and UKOPERATIONS are where on data that is private surgical units also voluntarily submit data.the chest and the tough sac collected by thecontaining the heart (called National Adult All collection and use of data is in line with strictthe pericardium) is opened Cardiac Surgery government guidance and legislation about patientto perform a procedure on Audit. The audit is confidentiality and data protection. When we usethe heart. This is different managed by the data for analysis it is completely anonymised. Thisfrom what is called National Institute means that individual patients cannot be identified‘minimally invasive’ cardiac for Cardiovascular from the data.surgery, where instruments Outcomes Researchare passed into the body (NICOR), withthrough small incisions and professionalguided by cameras. Adults leadership providedare classed as patients who by the SCTS.are 18 years old and over. HEART OPERATIONS 1st APRIL 2001 - 31st MARCH 2011 // 7

The aims of the audit are to: What does SCTS think patients want?• Understand how cardiac surgery is changing We have been very fortunate as a professional over time, to enable better planning for society to benefit from excellent input from patient the future. representatives. Our first was David Geldard, MBE, who unfortunately passed away in 2011.• Analyse how different patient characteristics He has been succeeded by Mike Fisher, who has (age, sex, status of the heart and presence kindly written a section in this book entitled ‘A of certain diseases other than heart disease) patient’s view’ (page 10). affect the outcomes of surgery. Much of what we have learned about what• Support hospitals and surgeons to continually patients expect and want during cardiac surgery improve the quality of care that is given has come from our representatives. We have to patients. explored some of the issues in detail in our previous publication, ‘Maintaining patients’ trust’,• Detect hospitals or surgeons where patients which can be downloaded from www.scts.org. aren’t doing as well after cardiac surgery as we would expect. This allows for better understanding of the issues, and triggers appropriate action to be taken as necessary.• Track and publish the outcomes of cardiac surgery to provide information for patients that will help them to make informed choices.• Publish the outcomes of surgery for hospitals and consultant surgeons to drive the development of cardiac surgery services. Publishing the outcomes of surgery can also reassure the public that quality of care is being actively monitored and is of a high standard. TIP: Results of previous analysis of data can be found at www.ucl.ac.uk/ nicor and www.scts.org.8 // UK HEART SURGERY

We believe that: • It helps to know that your surgeon will take a personal interest throughout in the progress of• To help patients choose a hospital and surgeon your care and act as the point of contact should to carry out their heart operation, we must make any problems or queries come up. It is mainly available as much easy to access, accurate, and through this relationship that trust between clear information as possible. patients and doctors develops.• We recognise that patient’s experience of care • Some patients may not want to look in detail starts at the moment of referral and ends at the at analysis of clinical outcomes and patient final discharge. It is the whole of that experience experience, but will trust the SCTS to make sure that forms a lasting impression of quality. that all hospitals and surgeons are performing well. We must continue to deserve this trust.• High quality surgery and medical care is clearly important, but this must be combined with • Transparency is a given, not an option. great communication, empathy, and a clean and comfortable environment. Much of this is the It is for these reasons that we have put so much responsibility of the doctors to ensure, but other effort into establishing and running the National areas require nurses and hospital managers to Adult Cardiac Surgery Audit and educational fulfill their roles well. programmes like the SCTS University (page 48).• Patients expect that the doctor treating them will be up-to-date with their knowledge, and have the ability to apply that knowledge for the benefit of their patients. HEART OPERATIONS 1st APRIL 2001 - 31st MARCH 2011 // 9

A patient’s view significantly improving patient care. Pressure for even further improvement needs to beMike Fisher, SCTS Patient Representative maintained, which the recent announcement by NHS England that individual consultant mortality There is rates for ten specialties across surgery and a well- medicine must be published by summer 2013 established will help to facilitate, despite the opportunity for saying that “unforeseen consequences”. “if you do not measure it The environment in which the NHS now operates you cannot is changing significantly, and measurement manage it.”, practices need to reflect these changes. There has and since the to be an emphasis on the whole service provided, mid-1970’s not just the clinical outcomes. The ageing profile the Society of patients requires the balancing of personalof Cardiothoracic Surgery (SCTS) has been needs with clinical outcomes. Consultation withmeasuring the clinical outcomes of its cardiac patients on the options available to them requiressurgery patients. In the early 1990’s Sir thorough discussion.Bruce Keogh and Peter Walton developed acomprehensive database that enabled outcomes All this comes amongst demands to be moreto be compared, and in 2005 these data were cost effective, and rising patient expectations.published online at to the level of individual The Department of Health has recently publishedconsultant surgeons. its intention to follow a programme entitled “Putting Patients at the Heart of the InformationThis was a first for the SCTS and has acted Revolution”. This programme envisages theas the forerunner for many developments in introduction of a visible service culture in the NHSmeasurement across the NHS. The results have enabled by well-established technology.been very significant for patients. The mortalityfor all Coronary Artery Bypass Grafts (CABG) The amount of work required to achieve thesehas fallen from 2.2% in 2001 to 1.6% in 2011. For changes must not be underestimated, just as theisolated first-time aortic valve operations it has amount of work required to produce this reportfallen from 3.1% in 2001 to 1.7% in 2011 and for has been huge. My thanks are due to Professorcombined aortic valve and graft operations from Ben Bridgewater and his team for all of their6.6% in 2001 to 3.8% in 2011. efforts, which have made this report possible.  The focus on measuring mortality outcomes incardiac surgery has had the desired effect of10 // UK HEART SURGERY WHAT PATIENTS CAN EXPECT FROM THEIR SURGEONS

PART ONE: LOOKING AT OPERATION DATATO ASSESS AND IMPROVE CAREIntroduction It can also be used to monitor how good the outcomes of hospitals and specific surgeons are.Operation types and their outcomes can be The type of heart operation that a patient hasmeasured definitively. This sort of data is a good and their clinical outcome is understandably very important to patients. However, there are manyway of finding out which patients are having other things about coming to hospital to have cardiac surgery that affect patient’s experience. cardiac surgery, Other ways of measuring and improving the quality of care are discussed in part 2 of this book. CLINICAL what sort of surgery OUTCOME is the they are having, and What follows is a description of the analysis onchange in the health of what the outcomes National Adult Cardiac Surgery Audit data about operations carried out between 1st April 2001a patient as a result of a of surgery are. This and 31st March 2011.cardiac surgery. Examples information can beof good clinical outcomes used to examineare a reduction of chest trends in surgerypain, breathlessness, or a and assess thelonger life-expectancy. Bad effectiveness ofclinical outcomes include certain procedures.complications like stroke,and death. HEART OPERATIONS 1st APRIL 2001 - 31st MARCH 2011 // 11

How is cardiac surgery changing secondly there ‘OTHER’ CARDIACover time? has been an SURGERY: Patients increase in valve who have operations on the CORONARY ARTERY Cardiac surgery is and ‘other’ cardiac heart that are not coronary changing. Ten years surgery . There artery bypass graft, valve, or BYPASS GRAFT or so ago about has also been a major aortic surgery.SURGERY, often abbreviated 2/3 of all cardiac big increase into CABG, involves taking surgery activity was the proportion OTHER THANan artery or vein from isolated coronary of patients ISOLATED CABGelsewhere in the body artery bypass graft undergoing ‘other SURGERY: Isolated coronaryand attaching (grafting) it the isolated CABG artery bypass grafting (CABG) is surgery’ . when the surgeon performs onlyto the diseased coronary surgery (see page a CABG procedure during anartery below the point of 16). That has now These changes operation. If a surgeon performsnarrowing. This allows gone down to a half. have come about another procedure as well asthe blood to flow around There are two main because different a CABG, or any procedure(s)(bypass) the blockage and reasons for this; types of patients other than a CABG, this tendsreach the heart muscle firstly there has are now receiving to be more complex and canwithout restriction. been a decrease cardiac surgery. be described as ‘other than isolated CABG surgery’. in the number ofisolated coronary artery bypass operations andFigure 1: Number of cardiac operations (UK)Number of cardiac operations 40000 30000 20000 10000 0 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Financial year12 // UK HEART SURGERY WHAT PATIENTS CAN EXPECT FROM THEIR SURGEONS

Figure 2: Changes in types of surgery performed over time (UK) 30000Number of cardiac operations 20000 10000 0 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Financial year CABG All valve surgery Mitral valve surgery Aortic valve surgery UNDERSTANDING THIS GRAPH: over the last 10 years. This is probably because A patient who has combined people are becoming healthier and living longer. mitral valve and aortic valve But it is also because surgeons are getting better surgery has been counted once in the mitral results when operating on elderly patients with valve column and once in the aortic valve heart disease. column (twice overall). The same patient will only be counted once in the ‘all valve More patients are now female than ten years surgery’ column. ago. Women are higher risk when having cardiac surgery compared to men. The reasons for thisThe average age of patients who have cardiac are not completely understood. The proportion ofsurgery is rising, and has increased by 2 ½ years patients having more complex operations (‘other than isolated CABG’) has also increased. HEART OPERATIONS 1st APRIL 2001 - 31st MARCH 2011 // 13

Figure 3: Trends in risk factors for adult cardiac surgery (UK) 80 5040Percentage (%) Age (years)30 7020100 60 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Financial year Female % Other than isolated CABG % Average age RISK FACTORS Overall there has system called EuroSCORE (www.euroscore.org). are patient been an increase The EuroSCORE calculates a patient’s expectedcharacteristics that increase in the complexity of risk of dying by taking their risk factors intothe chance of complications patients coming to account. EuroSCORE expected risk is based onduring or after surgery. cardiac surgery over the state of cardiac surgery in 1995.They are things like old age, time, meaning that Because surgery has improved since then, thediabetes, and requiring more patient risk is higher EuroSCORE model expects the risk of death after surgery to be higher than it actually is now.complex surgery. than it was. More However, ‘expected mortality’ still allows us to examine relative trends over time. detailed information The observed mortality is the number of patients about risk factors who actually died in hospital after surgery.can be found at www.bluebook.scts.org.The following graph (Figure 4) shows howexpected and observed mortality has changedover time. Expected mortality is calculated using a14 // UK HEART SURGERY WHAT PATIENTS CAN EXPECT FROM THEIR SURGEONS

Despite the rise in expected mortality based on similar risk factors had surgery in 2011 rather thanrisk factors of patients having surgery, observed 2001 they would be 1/3 (33.3%) less likely to die.mortality has gone down a lot over the last ten This is a reflection of improvements in care thatyears (Figure 4). This means that if a patient with have been put in place over this time period.Figure 4: Trends in observed and expected mortality over time (UK) 8 7Mortality (%) 6 5 4 3 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Financial year Observed mortality Expected mortality HEART OPERATIONS 1st APRIL 2001 - 31st MARCH 2011 // 15

Coronary artery bypass grafting (CABG) frame called a stent. These procedures are called percutaneous coronary intervention (PCI). PCICoronary artery bypass grafting is the most procedures are undertaken by cardiologists throughcommon heart operation in the UK. The heart small incisions in the groin or arm. Far moremuscle is highly specialised and pumps blood patients used to be treated by CABG than PCI, nowaround the body. It has to work very hard and to more patients are treated by PCI than CABG.do so it receives its energy from oxygen rich bloodthrough blood vessels called coronary arteries. Recent internationally accepted guidelines1 have given clear recommendations about which MYOCARDIAL Heart disease can patients are best treated by CABG and which by INFARCTION is cause these vessels PCI. We expect that when these guidelines haveanother name for a heart to become narrowed been put into practice they will lead to an increaseattack. It is a condition where or blocked. This can in the overall number of patients who receivethe blood supply to the heart restrict the amount CABG surgery. This is because, for many patients,is restricted due to blockage of blood and the CABG has been shown to be a more effective way of treating the symptoms of angina and prolongingby a blood clot in the coronary oxygen that reaches life than PCI or treatment with medicines alone.artery, which damages to the the heart. When the It is good that patients with coronary arteryheart muscle. heart is deprived of disease have a number of possible treatment options. For example, patients in the process oxygen temporarily of having a heart attack are best treated by PCI. In this emergency situation a successfula person may feel shortness of breath, chest PCI procedure is associated with much better outcomes for patents, and CABG is not really antightness or pain (known as angina). If the heart option. In other groups, such as those with tight narrowing in all of the major coronary arteriesdoes not get the oxygen it needs for a longer and previous damage to the heart muscle, CABG is usually the best option. This is because it leadsperiod of time, the heart muscle may become to better life expectancy and relief of symptoms than either on-going medical management or PCI.permanently damaged by a heart attack (alsocalled a myocardial infarction).When there are serious or multiple narrowings/blockages of the coronary arteries, patients canoften benefit from coronary artery bypass grafting,which is undertaken by cardiac surgeons. In othercircumstances the blockages may be treated bystretching them open with a balloon or a wire 1. Kolh P, Wijns W, Danchin N, et al. “Guidelines on myocardial revascularization” Eur J Cardiothorac Surg 38 (Suppl 1): S1-S52.16 // UK HEART SURGERY WHAT PATIENTS CAN EXPECT FROM THEIR SURGEONS

For some patients, both PCI and CABG may be cardiologists who do PCI and surgeons who doviable options. CABG is generally associated CABG. Any recommendations from the meetingwith better long-term relief of symptoms and a should be discussed in detail with the patient andlonger life expectancy, but a slightly higher risk their carers to enable patient choice and sharedfrom the procedure and a longer recovery time. decision-making to take place.PCI will involve a smaller operation and fasterrecovery, but is associated with a higher chance As well as CABG and PCI there is alsoof symptoms returning, and no increase in life the option of continued management withexpectancy. We would recommend that patients medicines alone, which may offer relief orfor whom both CABG and PCI are options should control of symptoms without exposing patientsbe discussed at a multi-disciplinary team (MDT) to the risk or inconvenience of a hospitalmeeting. This MDT meeting should include both admission or an operation. HEART OPERATIONS 1st APRIL 2001 - 31st MARCH 2011 // 17

First-time isolated CABG have increased by Surgery is described 10% over the same as FIRST-TIME whenThe number of isolated first-time CABG period (and by 98% a patient has not had a majorprocedures being carried out peaked in 2007/08. over the past 10 heart operation before.Between then and March 2011 there has been years).a significant fall, of around 20%. PCI numbersFigure 5: PercuCtAaBnGeous CAolrl ovanlvaersyuIrngeteryrventioMnitrparlovaclevedusurregenruy mbersAo(rUtiKc )valve surgery 100000 80000Total PCI procedures 60000 40000 20000 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Financial yearData courtesy of the National Audit of Percutaneous Coronary Interventional Procedures.The following graph includes the number of patients according to the urgency of theirisolated first-time CABG procedures performed operation. When a procedure is more urgent, thebetween 2001 and 2011. We have split up the expected risk of death is higher.18 // UK HEART SURGERY WHAT PATIENTS CAN EXPECT FROM THEIR SURGEONS

Figure 6: Isolated first-time CABG procedure numbers (UK) 25000 20000 15000Procedures 10000 5000 0 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Financial year Elective Urgent Emergency Salvage Unknown Understanding this graph Elective: Routine admissions from the waiting list. Urgent: Patients in hospital who have not been scheduled for routine admission from the waiting list, but who require surgery before being discharged home. Emergency: Unscheduled patients with on-going unmanageable heart problems. Their surgery cannot be delayed regardless of the time of day. Salvage: Patients requiring cardiopulmonary resuscitation (CPR) on the way to the operating theatre or before anaesthesia is administered. Unknown: Patients for whom this information was not recorded. HEART OPERATIONS 1st APRIL 2001 - 31st MARCH 2011 // 19

The overall in-hospital mortality for isolated elective CABG surgery has fallen from 1.3% to 0.9%. The mortality for urgent surgery is slightly first-time CABG higher because these patients have usually just suffered a heart attack, or have on-going IN-HOSPITAL surgery has symptoms of chest pain. These mortality rates are MORTALITY refers fallen from 2.2% excellent compared to any international standard2.to patients who die after in 2001/02 tosurgery before being 1.6% in 2010/11.discharged from hospital. The mortality forFigure 7: Observed mortality rates for isolated first-time CABG surgery (UK) 4.0 3.5Observed mortality rates (%) 3.0 2.5 2.0 1.5 1.0 0.5 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Financial year Overall Elective surgery Urgent surgery 2. Bridgewater B, Gummert J, Kinsman R and Walton P. Fourth EACTS Adult Cardiac Surgical Database Report towards global benchmarking (Henley-on-Thames 2010).20 // UK HEART SURGERY WHAT PATIENTS CAN EXPECT FROM THEIR SURGEONS

The following graph shows that the expected patients have come to surgery. Despite this themortality (pink line) for CABG surgery has observed mortality (blue line) has decreased asincreased over time, as more elderly and high risk the quality of care has improved.Figure 8: Trends in observed and expected mortality for CABG surgery (UK) 5 4Mortality (%) 3 2 1 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Financial Year Observed mortality Expected mortality HEART OPERATIONS 1st APRIL 2001 - 31st MARCH 2011 // 21

Valve surgery like chest pain, shortness of breath, dizziness, collapse, and occasionally sudden death.The heart has four valves, which open and close toregulate the flow of blood through the heart and If surgery is required to restore the flow of bloodmake sure that it only travels in one direction. The through these valves a patient will either haveaortic and mitral valves are on the left side of the their valve(s) repaired or replaced. Valves tendheart and the pulmonary and tricuspid valves are to be repaired if they are leaky but not seriouslyon the right. damaged, whereas a narrowed or more severely diseased valve might be replaced. ReplacementHeart disease can cause these valves to either valves are either mechanical (man-made) orbecome narrowed or leaky. Narrowing of a valve tissue (animal).(stenosis) prevents blood flowing properly thoughit. This means that the heart has to work harder Aortic valve surgeryto pump enough blood through the smaller space, The aortic valve sits at the outlet of the heart atwhich can cause the heart muscle to become the base of the major blood vessel called thethicker and less effective. aorta. This valve opens when the heart pumps, to let the blood out. It then closes as the heart refills,A leaky valve allows blood to flow in the wrong to prevent the blood from flowing back from thedirection and means that the heart has to work aorta into the heart again.harder to pump the same amount of blood. If ithas to do this for a long time, the heart muscle The only effective treatment for narrowing of thewill become damaged. In both cases the result aortic valve is aortic valve replacement (AVR)is that the heart cannot pump enough blood to surgery. Leaky valves can sometimes be repaired.the areas that need it. This can cause symptoms22 // UK HEART SURGERY WHAT PATIENTS CAN EXPECT FROM THEIR SURGEONS

Total proceduresFigure 9: First-time Aortic valve replacement (AVR) procedure numbers (UK) 8000 7000 6000 5000 4000 3000 2000 1000 0 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Financial year AVR AVR with CABGThe mortality rate for isolated first-time AVR nature of the disease requires more complexsurgery has decreased significantly, from 3.1% surgery, but mortality rates have still fallento 1.7%. Mortality for combined AVR and CABG markedly over time from 6.6% in 2011/1 to 3.8%surgery is higher because the more extensive in 2010/11). HEART OPERATIONS 1st APRIL 2001 - 31st MARCH 2011 // 23

The following graph shows the observed and as more elderly and high risk patients come toexpected mortality rates over time for first- surgery. Despite this, the observed mortality hastime isolated Aortic Valve Replacement (AVR) gone down, reflecting better quality of care forsurgery. The expected mortality rate (pink line) these patients.for isolated first time AVR surgery has gone upFigure 10: Trends in observed and expected mortality for first-time isolated AVRsurgery (UK) 8 7 6Mortality rate (%) 5 4 3 2 1 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Financial year Observed mortality Expected mortality24 // UK HEART SURGERY WHAT PATIENTS CAN EXPECT FROM THEIR SURGEONS

For some patients, open heart AVR is considered incision either in the leg or chest. Since it wasto be too risky. For such patients, minimally introduced in the United Kingdom in 2007, 3879invasive Transcatheter Aortic Valve Implantation procedures have been recorded on the UK TAVI(TAVI) may be an alternative treatment. A thin registry (figures correct at 06/02/2013, for moretube, called a catheter, is used to insert a new information see www.ucl.ac.uk/nicor).valve across the diseased one through a small HEART OPERATIONS 1st APRIL 2001 - 31st MARCH 2011 // 25

First-time mitral valve surgery If the right side of the heart becomes faulty thisThe mitral valve (MV) sits between the major can affect the tricuspid valve, causing regurgitation.pumping chamber of the heart (the left ventricle)and the lungs. When blood flows back from the rest For this reason we have analysed all mitral valveof the body into the heart it is pumped through thelungs to pick up oxygen, then through the mitral operations that have been performed either onvalve before it is pumped back around the bodyagain. The mitral valve may either become narrowed their own, or along with tricuspid valve repair. In a(stenosis), leaky (regurgitation), or both (mixedmitral valve disease). tricuspid valve repair the valve is narrowed down toWhen the mitral valve leaks or becomes narrowed stop it from leaking.the heart compensates to start with, so there maybe few or no symptoms in the early stages. However, Atrial fibrillation ATRIALas things progress the most common symptom is (an irregularshortness of breath. A faulty mitral valve causes the heart rhythm) is FIBRILLATIONleft side of the heart to become stretched up due to common in patients ABLATION SURGERY isa build-up of pressure. However, as the condition with mitral valve designed to cure an irregularprogresses this can affect the right side of the heart. heart rhythm (arrhythmia), disease and we known as atrial fibrillation have therefore also (AF). AF can cause included mitral valve palpitations, and increases procedures where the risk of stroke. Ablation atrial fibrillation surgery uses energy to block ablation surgery has electrical signals that can been performed. cause AF.26 // UK HEART SURGERY WHAT PATIENTS CAN EXPECT FROM THEIR SURGEONS

Figure 11: Trends for first-time mitral valve surgery 1500Total procedures 1000 500 0 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Financial year Isolated 1st time MV repair Isolated 1st time MV repair + CABG Isolated 1st time MV replacement Isolated 1st time MV replacement + CABG HEART OPERATIONS 1st APRIL 2001 - 31st MARCH 2011 // 27

First-time isolated mitral valve repair and better long-term survival. The following graph shows the observed and expected mortality ratesThe most common cause of mitral valve disease over time for first-time isolated mitral valve repairthat leads to mitral valve surgery is called procedures. Observed mortality is consistentlydegenerative valve disease. It is generally accepted lower than the mortality rate that is expected forthat repairing the valve is a better treatment than first-time isolated mitral valve repairs.replacing it, as it gives lower in-hospital mortalityFigure 12: Trends in observed and expected mortality for first-time isolated MV repairsurgery (UK) 6 5Mortality rate (%) 4 3 2 1 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Financial year Observed mortality Expected mortality28 // UK HEART SURGERY WHAT PATIENTS CAN EXPECT FROM THEIR SURGEONS

First-time mitral valve repair plus CABG trends grafting (CABG) to treat both diseases is complex surgery. This means that the expected andDegenerative valve disease can occur together observed mortality rate for mitral valve repair pluswith coronary artery disease. Patients with both CABG is higher than for mitral valve repairs thatconditions are more unwell, and are at higher risk are carried out on their own.of dying after their surgery. Also, the combinationof mitral valve repair and coronary artery bypassFigure 13: Trends in observed and expected mortality for first-time MV repair plus CABGsurgery (UK) 12 10Mortality rate (%) 8 6 4 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Financial year Observed mortality Expected mortality HEART OPERATIONS 1st APRIL 2001 - 31st MARCH 2011 // 29

First-time isolated mitral valve cardiac surgery units have the expertise availablereplacement (MVR) to carry out complex mitral valve repairs. In these cases a mitral valve replacement may beAlthough mitral valve repair is generally carried out. The expected and observed mortalityconsidered to be a better treatment than mitral for isolated mitral valve replacement surgery isvalve replacement, it is not always an option due shown in the graph below.to the condition of the mitral valve. Also, not allFigure 14: Trends in observed and expected mortality for first-time Isolated MVRsurgery (UK) 10 8Mortality rate (%) 6 4 2 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Financial year Observed mortality Expected mortality30 // UK HEART SURGERY WHAT PATIENTS CAN EXPECT FROM THEIR SURGEONS

Mitral replacement plus CABG trends CABG surgery. The observed and expected mortality rates over time are shown in the graph below.As with mitral valve repair plus CABG, mitralreplacements are higher risk when carried out withFigure 15: Trends in observed and expected mortality for first-time MVR with CABGsurgery (UK) 20 15Mortality rate (%) 10 5 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Financial year Observed mortality Expected mortality HEART OPERATIONS 1st APRIL 2001 - 31st MARCH 2011 // 31

How are hospital and surgeon mortality resources, but these data are now available atdata communicated to the public? www.scts.org/patients. The data are presented as graphs, which show the types of surgeryIn 2005 the Guardian newspaper used the undertaken and mortality rates for hospitals andFreedom of Information Act to request the individual consultant surgeons. All graphs aremortality rates of all individual cardiac surgeons clearly explained in order to make the analysisin the UK. Members of the SCTS worked with as accessible as possible for patients and otherthe Guardian to make this information available interested members of the public.for publication. In response to this the SCTSpublished mortality rates by all hospitals and the Case mix plotsmajority of consultant surgeons in conjunction We have represented the proportion of differentwith the Care Quality Commission (CQC; operations performed in the format shown below.organisation responsible for regulating the qualityof care in English hospitals). These plots enable patients to see how much of the different types of surgery are performed byMore recently the CQC have decided they can each hospital or surgeon. We hope that they mayno longer publish these data, so the SCTS has be useful to help patients to make choices aboutstepped in to develop new web pages to present their care. There is some data to suggest thatthem to patients and the public. This has not higher volumes of surgery may be associated withbeen easy, as we are a small charity with limited better clinical outcomes.Example case mix plot The colour of each Procedures bar corresponds to Isolated CABG The number of procedures. a surgery type. AVR ± CABG Here, just over 150 The percentage of MV ± TV ± CABG procedures were done. total operations. All other surgery 150 100 500 26.2% 19.4% 11% 43.5%32 // UK HEART SURGERY WHAT PATIENTS CAN EXPECT FROM THEIR SURGEONS

Mortality rates are relatively rare, and it is very difficult to make appropriate adjustments for the risk associatedAfter consultation with our patient with these cases.representatives, we have chosen to display The funnel plots show how mortality rates of a particular hospital/surgeon compares to themortality data in the form of ‘funnel plots’, which national average, which is the standard that we have set for outcomes. The risk adjusted mortalityare thoroughly explained on the SCTS website. rates of hospitals/surgeons are plotted on the chart against the number of procedures undertaken.The operations included in these charts are adult Each hospital is represented by one dot on the funnel. The dot is the risk adjusted mortality. cardiac surgery RISK ADJUSTED operations on all patients over the MORTALITY: age of 18, excludingA hospital or surgeon’s heart transplants,mortality rate has been insertion of artificialadjusted using complex mechanical heartsmethods so that, effectively, and traumawe show what the mortality cases (these arerate would have been if all subjected toeach hospital or surgeonoperated on patients withthe ‘average’ case mix. This separate analyses).means that hospitals or We have also takensurgeons who operate on the decision toincreased numbers of high remove emergencyrisk patients don’t have an and salvageunfairly high mortality rate. operations fromMore information is provided the analyses, asat www.scts.org/patients. these operations HEART OPERATIONS 1st APRIL 2001 - 31st MARCH 2011 // 33

We would expect hospitals to cluster around the For this reason, the graphs also show control limits.average. As the number of procedures increasesthe variation between the points should decrease, Mortality rates that are higher than expected doas more procedures reduces the likelihood of the not necessarily mean that the individual hospitalmortality rate being high due to chance alone. or surgeon is doing a ‘bad job’. It may mean thatSimilarly, as the number of procedures decrease there are issues about the types of patients whothere will be an increased variation (wider spread) are coming to surgery, or the quality of the datadue to natural variability. The increased clustering submitted for analysis.around the ‘average’ line as procedure numbersgrow is what gives the chart its funnel shape. Also, when looking at the mortality rates for individual surgeons you should bear in mind that CONTROL LIMITS Using only an they work as part of a larger clinical team. This are lines on the ‘average’ line as team consists of anaesthetists, junior medicalfunnel plots that represent the standard makes staff, nurses, perfusionists, pharmacists, andthe expected range of values it difficult to tell physiotherapists. All of these team membersbased on the average. If whether units that may affect patient outcomes, along with aa hospital or surgeon’s are plotted away hospital’s facilities.mortality rate lies below the from it are withinred confidence limit, it should accepted limits Within the SCTS we believe it is important tobe understood to be an ‘as (there will always measure mortality rates and flag them up toexpected’ mortality rate. If be some variation hospitals and surgeons for appropriate actionthe mortality rate falls above between hospitals when they are higher than expected.the red line it means that it is and surgeons due tohigher than expected. natural variability).34 // UK HEART SURGERY WHAT PATIENTS CAN EXPECT FROM THEIR SURGEONS

Example consultant-level funnel plotRisk adjusted mortality rate 15% 5 3 n=378 1 Adj mort=2.33% 10% 250 500 2 750 5% Number of procedures 4 0% 0 Understanding the graph 1 The blue dot highlights the hospital or surgeon whose page you are currently looking at. ‘n =’ gives the number of procedures that hospital/surgeon has done during the await period. ‘Adj mort =’ shows the risk adjusted mortality rate for that hospital or surgeon during that same period. The grey dots show all of the other hospital/surgeons included in analysis. 2 The horizontal line along the bottom (called the x-axis) is the total number of cases done during the analysis period. 3 The vertical line running up the left hand side (called the y-axis) is the mortality rate adjusted for the expected risk of the patients undergoing surgery. 4 This line represents the ‘standard’, which is the average overall mortality rate in the UK for cardiac surgery over the period of time in question. 5 The highest expected risk adjusted mortality rate is represented by the pink dotted line called a ‘control limit’. HEART OPERATIONS 1st APRIL 2001 - 31st MARCH 2011 // 35

How do these data improve the quality of As with many successful teams, the Britishpatient care? Olympic cycling team being a recent example, we believe that large improvements can comeSince we first published mortality rates by from making small adjustments to manyhospital in the UK, there have been marked important things.reductions in the proportion of deaths aftersurgery. We have looked to see if this is because In our case that is about making sure thathigh risk patients are being denied surgery, but patients are as fit as possible prior to surgery,there is no evidence of this. Rather, as the graphs and improving anaesthetic, surgical, and post-in this report show, the opposite seems to be the operative care on both the intensive care unitcase; more and high risk patients are coming to and surgical wards. We have also focused onsurgery each year. provision of rehabilitation services. Because the overall improvements in cardiac surgical careWe cannot say for certain why the mortality have been so great, we are very pleased to hearrates have reduced so dramatically. But we the recent announcement by NHS England thatthink that it is due to hospitals and surgeons surgical outcomes will be published more widelymaking improvements in the care that is given in other specialties from summer 2013 as part ofto patients. This is driven by the availability of ‘Everyone Counts: Offer 2’. data to hospitals and surgeons about their ownperformance, and the fact that these data aremade available for examination by the public.36 // UK HEART SURGERY WHAT PATIENTS CAN EXPECT FROM THEIR SURGEONS

PART TWO: HOW ELSE DO SURGEONS MAKESURE THEY ARE DOING A GOOD JOB?Introduction health professionals and managers that patient experience is difficult to measure well, and is notWhether or not a patient’s experience of having as important as clinical outcomes.cardiac surgery is a positive one relies on morethan just the actual operation and the clinical Some recent CLINICALoutcome. For this reason the SCTS have explored failures of clinical GOVERNANCE isother ways that a patient’s experience can governance in the system through whichbe measured so that, along with data about NHS care have healthcare organisationsoperations, a more complete picture of care can highlighted that monitor and improve thebe assessed, and improvements made. poor experience for quality of care and services. patients, as well asThe SCTS think that it is also important for patientsto know that cardiac surgeons keep up to date being very importantwith their clinical knowledge through schemeslike ‘SCTS University’, which is described below. its own right, can be the beacon signallingIt is also reassuring to know that the SCTS havemechanisms for alerting individuals and hospitals significant underlying problems in the clinical care.when data from the National Adult Cardiac SurgeryAudit show that clinical outcomes are not as good This has now been recognised by the Governmentas we would expect. in several recent policies and pledges.As well as the SCTS governance procedures, in2013 a General Medical Council scheme was If levels of patient satisfaction are low you knowintroduced to ensure that all doctors are fit to there is a problem, but if you measure patientpractice. This is explained in more detail in the experience systematically you can see why‘Revalidation: how do doctors make sure they are satisfaction is low, and act efficiently to put it‘fit to practice’?’ section below. right. We have explored these issues in more detail in our previous publication ‘MaintainingMeasurement of patient experience patient’s trust’, which is available for download from www.scts.org.The three pillars of patient care are now generallyaccepted to be; clinical outcomes, patient safety We believe that, to a large extent, patients trustand patient experience. For patients and their their doctors and nurses to be professional anddoctors, this means the results of diagnosis and to conduct the technical aspects of hospital caretreatment, the safety of care given, and the quality to a high standard. In cardiac surgery patientsof the patient-doctor relationship. In the past the have no recollection of the key element offirst and second aspects have been given more care. This is because the operation itself takesattention by the medical profession than the third. place when patients are deeply asleep under aThis has been due in part to the idea amongst general anaesthetic. However, other aspects of care are very important, particularly the clinical consultation where the decision to have the operation is taken, and the follow up care after discharge from hospital. HEART OPERATIONS 1st APRIL 2001 - 31st MARCH 2011 // 37

Because of this These data we have embarked THORACIC surgery upon a programme are fed back to PROFESSIONAL treats diseases of to measure patients’ the individualthe chest and lungs such as experience of consultants, to REVALIDATIONtumours and infections. enable them to is the process whereby reflect on their all doctors are required the care given by practice and learn to regularly prove to the General Medical Council surgeons in more that they are currently up to detail. We are doing CARDIOLOGISTS this in partnership lessons where date and fully fit to practise. are doctors with with Picker Institute necessary. The See the chapter entitledspecial training in finding, Europe (www. data will also be ‘Revalidation’ (page 47).preventing, and treating pickereurope.org).heart and blood vessel used locally bydiseases. They treat doctors for thepatients using medicines So far we have annual evaluation of their work (known as anand minimally invasive undertaken aprocedures. Where these pilot project at appraisal) by their manager, and will feed intotreatments are not suitable, their professional revalidation.a cardiologist may refer a one hospital; Further details about the pilot are given on the following pages. We expect that these methodspatient to a cardiac surgeon. the University will be used more widely by the profession in the future, and would hope that this will contribute Hospital of South further to ensuring that all patients get high quality care. Manchester. Herewe have identified all patients coming throughthe outpatient clinics that have been seen by eachconsultant. We have included surgeons (cardiacand thoracic) and cardiologists in the study. Wehave sent out a specially developed questionnaireto these patients to ask them what they thoughtabout the consultation, with an explanatory letterabout the patient experience measurementpilot study. Patients are asked to complete thequestionnaire and return it by pre-paid post.38 // UK HEART SURGERY WHAT PATIENTS CAN EXPECT FROM THEIR SURGEONS

Developing patient feedback on individual How were the questions developed?consultants: the Picker method If questionnaires are to provide useful feedbackPicker Institute Europe from patients, they must generate informationPicker Institute Europe is developing a patient that can be used to assess the skills and qualitiesfeedback questionnaire capable of gathering of doctors that are important to patients, orinformation that is relevant in all specialties, which have been demonstrated to have an impactand reliable enough for use in continuous quality on the quality of patient care. It is vital that anyimprovement and assurance through professional questionnaire reflects the professional standardsrevalidation. The standards it describes flow from expected of doctors. Such standards are set out15 years of development, informed by professional in Good Medical Practice, which is guidancevalues and research into patients’ expectations. published by the General Medical Council (GMC). This guidance is primarily for doctors, but also letsIn cardiac surgery Picker has partnered with the public know what they can expect from doctors.individual SCTS members at the University The questionnaire has been designed to gatherHospital of South Manchester to assess the evidence on the performance of an individualperformance of consultants on important aspects doctor that can only be obtained from patients.of their patient care. To find out the best questions to ask, theThe objectives of the pilot study summarisedhere were to: following work was completed:• Develop a way of collecting patient feedback • Interviews with patients to understand what on individual consultants that is reliable and makes a good consultation. fit for purpose. • A review of Good Medical Practice to identify• Trial the questionnaire and the feedback the specific aspects of care that patients are collection process to understand how it best placed to give feedback about. worked, and make improvements if necessary. • A review of the reasons why patients complain• Conduct statistical analysis to understand about doctors. By asking questions that relate how the feedback may be interpreted and to these aspects of care regularly, we hope to used; what kinds of factors influence patients’ identify underperformance as soon as possible. ratings, and how the data may be used in making judgements about the performance • A review of best practice in the ways of consultations? communication skills are taught. By asking questions that reinforce good practice, we can• Use the feedback to identify strong and poor help to show doctors why it is so important that performance and drive quality improvement. their communication skills are effective. HEART OPERATIONS 1st APRIL 2001 - 31st MARCH 2011 // 39

Good Medical Practice Who gave feedback?Good Medical Practice describes the essential Feedback was gathered from 658 patients of 13duties of a doctor registered with the General cardiologists and 10 cardio-thoracic surgeonsMedical Council (GMC). working at the University Hospital of South Manchester. Feedback questionnaires were sentThe GMC tells doctors that they must: to all patients aged 16 and over who attended outpatient appointments with consultants• Make the care of their patients their first concern. between August 2012 and January 2013.• Treat patients as individuals.• Respect their dignity by treating patients A response rate of 54% was achieved (56% for cardiology consultants’ patients and 49% for politely and considerately. cardio-thoracic surgeons’ patients). Judging from• Respect each patient’s right to confidentiality. similar studies in the past, this is about the level• Work in partnership with patients. of feedback to be expected.• Listen to patients and respond to their How was feedback collected? concerns and preferences. Patients were sent the questionnaire through the• Give patients the information they want or need post and asked to complete and return it using a pre-paid envelope. A postal method was chosen in a way they can understand. because it meant that the consultants themselves• Respect a patient’s right to reach decisions with did not select patients to give the questionnaires to. The process was invisible to the consultants their doctors about their treatment and care. and was managed without taking up valuable• Support patients in caring for themselves to clinic time. Patients could answer at their leisure without feeling inhibited or pressured. improve and maintain their health. Did it work?Questions designed to examine whether doctors Statistical analysis showed that the feedback doesare fulfilling these obligations are included in provide a stable way of measuring consultants’the questionnaire. attitudes and communication skills. Testing indicated that although ideally over 50 responses per consultant are required, 30 or more responses still provide reasonable accuracy.40 // UK HEART SURGERY WHAT PATIENTS CAN EXPECT FROM THEIR SURGEONS

Because many of the questions are framed What did patients say?around the obligations described in Good MedicalPractice, we would expect patients to give their An example of an interim feedback report fromconsultants a high score on the questionnaire. In the pilot study for one SCTS member - Professorfact, a high score should be regarded as ‘normal’ Ben Bridgewater, Consultant Cardiac Surgeonfor obligatory standards. Whilst feedback was at University Hospital of South Manchester – isgenerally very positive, it appears that there is shown below.some poor performance. However, other issuessuch as the patient’s opinion of their health status Consultants who participated receive their ownand the success of surgery may affect their view individual feedback report to reflect on andof the doctor’s consultation skills. Ensuring discuss with their manager. University Hospitalsa big enough sample size should iron out any of South Manchester NHS Foundation Trust haspotentially biased views so that judgements can committed to publishing the feedback on itsbe made based on the results. website so that patients have access to more information, and to reinforce the values of the HEART OPERATIONS 1st APRIL 2001 - 31st MARCH 2011 // 41

‘South Manchester Way’ - a set of principles that indicate that patients are very happy with hisdefine how the Trust operates, with patient care at approach, but some suggest a need for longerits heart. This information can be found at consultation times or that, on occasion, he couldwww.uhsm.nhs.uk. be more open and friendly in his consultations.The feedback given below suggests that Professor SummaryBridgewater is performing at a level which is This pilot study has shown that it is possible tocomparable with other doctors in his hospital. produce a questionnaire to gain feedback onHis overall Picker score was 9.5 /10, which doctors’ consultation skills in a way that will:suggests that there is no need for improvement.More detailed examination, however, shows that • Generate evidence to reassure patients thathis score “for giving emotional support” was they are getting a good standard of care.lower than average. Whilst this difference wasnot substantial, this reflects an aspect of care • Help the hospital and individual doctorswhere he may want to change the nature of his continually improve the care given toconsultation. For example, he could improve by their patients.asking questions of his patients such as, “howdid that make you feel?” to allow more useful and • Provide evidence for doctors that will feed intosupportive conversations to take place. professional revalidation, the GMC process by which doctors now have to demonstrate thatThe detailed ‘additional commentary’ made by his they have the knowledge, skills and attitudespatients is also useful. Many of these comments needed to maintain their license to practise.42 // UK HEART SURGERY WHAT PATIENTS CAN EXPECT FROM THEIR SURGEONS

We believe that the regular feedback of patient Current advice from the GMC is that feedbackexperience should become a routine part of from patients for revalidation should be ahealthcare delivery and measurement, and “one off” event drawing on the experiencethat the methodology that has been described of thirty patients every five years. We do notwill become widespread throughout medicine. believe that this tiny sample will give theIn particular we hope that in the future the best opportunities for continuous qualitySCTS will make these data available to the improvement, or that it will be sufficient topatients of all their consultants. identify deficiencies when they are present.We believe that this will improve quality and Excerpts from an individual Consultant’sprevent failures of care. We are confident that communication skills report are given below.this methodology will support patient choice These reports are issued to consultants soand help to gain and retain public faith in that they can act on feedback to improve theirdoctors and the NHS against the backdrop of communication skills if required.failures that have been reported recently inthe media. HEART OPERATIONS 1st APRIL 2001 - 31st MARCH 2011 // 43

Chart 1: Your Picker Consultation Score Does not meet Partially meets Fully meetspatients’ expectations patients’ expectations patients’ expectationsConfidence intervalsThe confidence interval shows the range within which your (overall) score would fall in 95 out of 100 equivalent samplesof patients. This shows how reliably your level of communication skill has been estimated.Chart 2: Your Communication Skills in Detail Speaking clearly 10.0 Explaining any risks and/or benefits of treatment options* 9.8 9.8 Explaining what would happen next 9.5 Listening carefully 9.5 9.5 Treating you with respect and dignity 9.4 Explaining things 9.4 Letting you talk 9.4 9.3 Involving your companion in the consultation in the way you wanted* 9.3 Making you feel at ease 9.2 Being prepared 9.2 8.6Involving you as much as you wanted in decisions about your care and treatment Treating you as an individual Fully understanding your worries or concerns Giving you emotional support Examining you sensitively* Explaining the reasons for advice* 0 1 2 3 4 5 6 7 8 9 10*Lower sample size (question only applied to some patients).44 // UK HEART SURGERY WHAT PATIENTS CAN EXPECT FROM THEIR SURGEONS

Chart 3: How you compare to othersQuestion Your score Average score Significant differenceSpeaking clearly 10 9.6 NoneExplaining any risks and/or benefits of 9.8 9.5 Nonetreatment options* 9.8 9.4 NoneExplaining what would happen next 9.5 9.4 NoneListening carefully 9.5 9.6 NoneTreating you with respect and dignity 9.5 9.5 NoneExplaining things 9.4 9.3 NoneLetting you talk 9.4 9.4 NoneInvolving your companion in the consultation in 9.4 9.4 Nonethe way you wanted* 9.3 9.3 NoneMaking you feel at ease 9.3 9.1 NoneBeing prepared 9.2 9.3 NoneInvolving you as much as you wanted in 9.2 9.2 Nonedecisions about your care and treatment 8.6 9 NoneTreating you as an individual - 9.6 -Fully understanding your worries and concerns - 9.5 -Giving you emotional supportExamining you sensitively*Explaining the reasons for advice** Lower sample size (questions only apply to some patients). HEART OPERATIONS 1st APRIL 2001 - 31st MARCH 2011 // 45

Patient CommentsComments are only edited if any patient-identifiable information needs to be anonymised. Where thisis the case, the edit will be shown between square brackets [...]. In all other cases, comments arereported verbatim. Q36: Was there anything that your consultant did particularly well in your most recent appointment? Mr. Bridgewater has my heartfelt thanks for saving my life and for his care towards me. He advised me to visit an NHS Dentist which I have managed to get a slot on [ DATE ] Made me feel at ease. Mr. Bridgewater came to the consultation very well prepared. He explained what was the matter and possible treatments concisely and clearly. With respect, treat one like an individual. Quite happy to be in Mr. Bridgewater’s care, he has outlined the possibilities, at my age, reassured me as well as can be. Pleased to see Mr. Bridgewater who gave me advice on my condition and possible future surgery. Came straight to the point. Transferred back to the medical cardiology on the medical regime prescribed while in hospital. Said only problems would be referred back. Mr. Bridgewater immediately made me feel at ease and reassured about my future treatment. He has a very friendly and yet professional manner. Told me that I didn’t think operation necessary but [ HOSPITAL NAME ] would keep a check on me. Very brief and to the point. Inspired confidence. Q37: Was there anything that your consultant could have improved on? No - excellent care. He had not been supplied with info. about previous tests and therefore the consultation was a waste of time and I don’t know what will happen for another month. More time to ask questions but felt time was limited due to the number of patients to be seen. He could have been warmer and smiled more. He was a bit stiff and cold, although efficient. 46 // UK HEART SURGERY WHAT PATIENTS CAN EXPECT FROM THEIR SURGEONS

REVALIDATIONHow do doctors make sure they are Outcomes data and revalidation‘fit to practise’? For the purposes of developing informationIn December 2012 the General Medical Council on clinical outcomes data for revalidation weintroduced professional revalidation for doctors. have analysed mortality data for all hospitalsThis is the process by which all doctors will have and surgeons in the NHS. We have looked forto prove that they are suitable to continue to mortality rates that are higher than expected,practise by presenting evidence to an appointed after making adjustments for different case mixsenior member of staff in their hospital/practice and patient profiles, and have fed that data backon a five-yearly basis. Before this was introduced, to the hospitals and surgeons. The vast majorityall that had been necessary to remain on the of hospitals and surgeons have mortality ratesmedical register was an absence of concerns that are ‘as expected’, as we have publishedabout that individual, rather than any positive on our website, and the overall mortality ratesdemonstration of competence. This major change are very low. A small number of hospitals andhas come about in response to the events in surgeons have mortality rates that are higherpaediatric cardiac surgery in Bristol and a series than expected, and whilst this may be due toof high profile cases involving doctors who had chance alone, we have fed this data back to theunsatisfactory practice that had gone undetected surgeons and their hospitals to allow further(including the serial killer, Dr Harold Shipman). investigation and actions to take place. WhenIn the SCTS we embrace the introduction of surgeons undergo revalidation they will use theserevalidation for all doctors. data to demonstrate that their results of surgery are good. When the mortality rates are higherFor cardiac surgeons, we feel that we are than expected we anticipate that there will bealready well on the way to developing a robust a discussion exploring these issues further. Asystem of monitoring the quality of care given complete understanding of any problems and ato patients. This involves the measurement of satisfactory plan of action must be put in placeclinical outcomes, the assessment of knowledge, to ensure that patients are receiving high qualityand we are also working on developing better care, and to allow for that individual totools for the measurement of patient experience continue practicing throughdata. It will also be necessary for surgeons to revalidation.provide information on what their colleaguesthink about them from multi-source feedback,which may help to improve team working andpick up behavioural or other problems. We haveexplored the use of multisource feedback in moredetail in ‘Maintaining Patients Trust’, which can bedownloaded from www.scts.org. HEART OPERATIONS 1st APRIL 2001 - 31st MARCH 2011 // 47

To support our members we have developed show the public that the quality of cardiac care ina project that we call the SCTS eLab. This is a the UK is high. It should also reassure the publicseries of up to date, internet based ‘windows’ that the SCTS actively and effectively monitors theinto National Adult Cardiac Surgery Audit data outcomes of cardiac surgery for all hospitals andto allow people to better understand cardiac surgeons to ensure that no one has results thatsurgery in the UK. are unacceptable for patients.On one level this allows free access to national SCTS Universitydata about the number of operations, themortality associated with those operations and Ben Bridgewater,the incidence of the various patient risk factors. consultant cardiacData are updated regularly and the graphs can surgeon at thebe filtered to show particular hospitals and/or University Hospital of South Manchester, Nationalprocedures. This part of the elab is called the Adult Cardiac Surgery Audit Lead.‘Blue Book online’ and is available for free toeveryone at www.bluebook.scts.org. Ian Wilson, consultant cardiac surgeon, and SCTS meeting secretary.The second section of the SCTS eLab is a seriesof tools to help hospitals and surgeons to All cardiac surgeons must successfully passimprove the quality of their care by monitoring through medical school and then, after spendingtheir activity and outcomes in detail. As these several years rotating through different sorts ofdata are updated on a quarterly basis, before medicine, undergo a competitive process to entersurgeons have had the opportunity to correct specific training in cardiac surgery. This ‘higherany data errors, we have restricted the access surgical training’ in cardiac surgery programmesto them for the time being. Instead, mortality is extensive and takes around six years.data for hospitals and surgeons that has beenthoroughly checked for accuracy is available in A good cardiac surgeon must have technicalthe public domain at www.scts.org/patients. expertise coupled with up to date knowledge and the ability to apply it. It is important to acquire thisWe hope that both the Blue Book online and knowledge during training as a young surgeon,the data available on the SCTS website will help and it is equality vital that this know-how ispatients to choose where to go for surgery, and refreshed and updated throughout a surgeon’s career. We call this ‘lifelong learning’.48 // UK HEART SURGERY WHAT PATIENTS CAN EXPECT FROM THEIR SURGEONS

Professional Societies, like the SCTS, have long the meeting they can still benefit from its content,taken ongoing education of surgeons seriously, and they can use the internet to go back and viewbut the advent of professional revalidation makes the educational material as often as they wouldthese initiatives even more important, and will like to reinforce messages.drive all surgeons to engage in the process. This SCTS University Library ( www.scts.org/Since 2010 the SCTS has organised a ‘University’ university ) affords the opportunity for the mostfor its members, to help educate them and keep contemporary educational material to be madethem up to date. The SCTS University has to date available to SCTS members, and Allied Healthbeen largely a single day as part of our annual Professionals who work within the clinical area ofmeeting, but more recently we have been looking cardiothoracic surgery. This educational resourceto use modern internet-based approaches to can facilitate continued professional developmentmake all the education available more widely. This within the field.means that even if a surgeon is unable to attend HEART OPERATIONS 1st APRIL 2001 - 31st MARCH 2011 // 49

Since 2010 more than 1,800 SCTS University to SCTS University delegates. This will enableattendees have participated in the SCTS University SCTS members to demonstrate contemporaryeducational days, and since the launch of the understanding of the most up-to-date nationalSCTS Library in January 2013, more than 4,870 and international educational materialvisitors to the library have been recorded. available to them.The next phase of this initiative is the development The SCTS envisage all members developingof an on-line Personalised Evaluation of their own portfolio of PEAK reinforced continuingKnowledge (PEAK) programme, to underpin professional development to demonstrate goodthe educational material delivered in the SCTS levels of knowledge within their own areas ofUniversity educational programme and Library. clinical practice.This PEAK programme will be a series ofinteractive web-based scenarios, developed toreinforce the educational material delivered50 // UK HEART SURGERY WHAT PATIENTS CAN EXPECT FROM THEIR SURGEONS