Clinicians should remain in charge of governance parameters
BY DR OMAR KHORSHID, CHAIR, AMA HEALTH FINANCING AND ECONOMICS COMMITTEE
As I wrote in my Australian Medicine column in May, Australia enjoys what is internationally recognised as close to the best health care in the world. In terms of outcomes, it is the best. Our overall life expectancy is 4th in the world, a remarkable feat considering our diverse population. Notwithstanding our world renown performance on patient outcomes, it appears Government Ministers want more. More system-wide efficiencies and even better patient outcomes.
The Department of Health is currently leading a consultation on behalf of COAG Health Ministers, to introduce a Clinical Quality Registry (CQR) National Framework to achieve four priorities:
- Improve [healthcare] efficiency and ensure financial sustainability;
- Deliver safe, high quality care in the right place at the right time;
- Prioritise prevention and help people manage their health across their lifetime;
- Drive best practice and performance using data and research
The idea of implementing a CQR National Framework has been around since 2010, and much of the ground work was done at this time but it was never implemented. There are at least 60 different CQR in Australia and it could be beneficial if there was a system to broaden the range of clinical quality registries and participation in them. Certainly, CQRs are widely recognised as a powerful tool to improve the quality and effectiveness of patient care within a clinical domain.
There could also be substantial benefits if all CQR in Australia were of a consistent high standard, with similar architecture, operating systems, data structure and governance to permit comprehensive national reporting. But there are some details in the draft consultation paper that clinicians should be aware of.
The role of clinicians is uncertain. In one part of the consultation paper there is recognition that clinician leadership is critical to CQR success. However, responsibility for determining important CQR parameters, such as the design of the clinical indicator instruments that determine which patient outcomes are measured, and the management of outliers and the granularity of benchmarked data reporting, is allocated to the government agencies. It is critical that clinicians, though their Colleges, Associations and Societies, remain in charge of designing the accreditation standards and governance parameters relevant to measuring quality of patient care. They have the specialty and sub-specialty expertise, know best practice standards and best placed to nominate the most relevant clinical indicators.
Another design feature of the CQR Framework is ‘consistent outlier management’ and reporting. This needs to be well managed to encourage, rather than deter, clinician engagement. The interpretation of benchmarked outlier data points is not straight-forward. The measurement is a point in time and the cause will be relevant to the particular clinical indicator, the clinical domain and patient characteristics. Possible reasons for clinical variation might be inaccurate data, insufficient case-mix adjustment or some underlying problem with administrative practices, resource constraints (i.e. delayed access to diagnostic equipment/treatment), clinical knowledge or technique.
The Australian Orthopaedic Association’s National Joint Replacement Registry (AOA NJRR) has been highlighted as a world-leading registry that has changed the practice of orthopaedics in Australia and around the world and saved government and the public hundreds of millions of dollars as a result. The AOA NJRR has recently commenced providing feedback to individual surgeons on their joint replacement revision rates compared with their peers as a professional way to reduce consistent outliers. This is an instructive example of a profession and clinician led CQR that is improving patient outcomes without naming and shaming alleged outliers and while maintaining the profession’s control of the sensitive data.
Rushing to publish and ‘expose’ individual clinicians on the basis of benchmarked data will not improve patient care in a complex, team-based healthcare system. Instead, it will engender a culture of blame, fear, and reluctance to openly report or treat high risk/high complexity patients for fear of reputational damage. Furthermore, it will deter clinicians and public hospitals for taking on difficult patient cases because this will diminish their performance in league tables.
It would be a poor outcome indeed, if the approach to reporting identified outcome data perpetuates a reduced supply of clinicians with the skill and experience of treating complex patients. This outcome does not make any sense with a population that continues to get older and sicker.
All clinicians should be sceptical about the meaning of ‘low value care’ and how this term is used in the draft CQR National Strategy. I have no objection to moving away from health care procedures that are no longer endorsed by clinical colleges, associations or societies as current best practice. Clinical evidence is constantly evolving. However, the last thing we need in this country is the erosion of clinician led healthcare, replaced by recipe book medicine – where the ‘recipe’ is written by governments, or government agencies.
As a head of department in a public hospital, I have spent years implementing our own patient reported outcome measurement project. In my experience, doctors are interested in the best outcomes for patients and in a system that delivers high quality care in an efficient manner. However, clinicians will and should resist change for change sake or government-led change that erodes clinician decision making.
 Department of Health, Maximising the Potential of Australian Clinical Quality Registries, A National Strategy 2019 p10
 Department of Health, Maximising the Potential of Australian Clinical Quality Registries, A National Strategy 2019 p25
Published: 12 Jul 2019