Making the case for personal professional monitoring in health care.

The use of databases to identify both good and bad (acceptable to identify good and failing performance’ [19]. The article in this issue demonstrates the applicability of such mechanisms and unacceptable) trends in the performance of simple and complex procedures in medicine has a long history and was to detect poor performance and the relative ease of their introduction [13]. advocated by such important medical and nursing practitioners as Florence Nightingale, Ernest Codman, Lord MoyThe issue of professional or specialist group acceptance of this type of performance monitoring is addressed by nihan and others [1–7]. Unfortunately, not all of these committed clinicians have gained the respect of their local adjustment of the ‘acceptable’ and ‘unacceptable’ adverse event rates and the allowable type 1 error ( ) and allowable medical colleagues [2,8,9]. Thus the need for objectively endorsed systems to monitor the occurrence of adverse type 2 error ( ) rates. Thus it would be reasonable to have a higher ‘acceptable’ adverse event rate for trainees than for clinical outcomes in day-to-day practice is paramount [10–12]. In pursuit of this goal the article by Spiegelhalter et al. in this specialists [20]. Exactly what these rates are will depend on clinical impressions, data from pilot studies, and early data issue is a welcome contribution [13]. The demonstration by the authors that the adverse events collections [20]. The adverse event rates are likely to decline with monitoring as techniques, training and equipment imoccurring in the practice of both the paediatric cardiac surgeons in Bristol and the general practitioner Harold Shipprove [21]. However it should also be borne in mind that rates may increase as procedures become more difficult man could have been detected by routine data monitoring confirms earlier work arising from the Kennedy Inquiry and due to changing conditions such as age, obesity and illness severity [22]. the Dame Janet Smith Inquiry [14–16]. Unfortunately, in the Bristol case, similar information had already been presented Changing the ‘acceptable’ and ‘unacceptable’ adverse event rates has the effect of changing the distance between the to the surgeons, anaesthetists and managers involved in the care of these patients with little impact on the service [17, horizontal lines on a Cusum plot. Similarly, changing the and values—that is, where is the risk of incorrectly 18]. In fact a Cusum graph based on the same criteria employed by the Great Ormond Street paediatric cardiac assigning the practitioner to an ‘unacceptable’ and to an ‘acceptable’ performance level—will also change the vertical surgery group had been presented to paediatric cardiac anaesthetists and surgeons well before the lethal series of distance between the horizontal Cusum lines on the Cusum plot. Decreasing the value will increase the distance between operations was suspended [5]. The problem of professional performance monitoring remains one of objective review the lines of the Cusum plot. This will make it more difficult for a clinician’s Cusum plot to span a boundary interval and coupled with acceptance of performance data. This issue was clearly identified by Professor Ian Kennedy when he therefore more difficult for that clinician’s performance to be declared acceptable. concluded in his inquiry: ‘Bristol was awash with data. There was enough information from the late 1980s onwards to In medical models the and limits have traditionally been set at 0.1 for ease of presentation of the data. If the cause questions about mortality rates to be raised both in Bristol and elsewhere had the mindset to do so existed’ [19]. and levels are the same, the horizontal Cusum lines are superimposed making interpretation of the graphs much Unfortunately the service was not suspended until 1995, by which time as many as 40 children may have died unnecessarily simpler [5,20,23]. Why has such a mechanism not been introduced uniformly [14–16]. Kennedy goes on to identify the need for objective external criteria by which clinical services can be assessed. in clinical practice? Why are patients and their relatives still waiting for the widespread introduction of this type of ‘The clinicians in Bristol had no one to satisfy but themselves that the service which they provided was of appropriate monitoring process even though advocates of this process have made life-saving claims for its application [21]? One of quality. There was no systematic mechanism for monitoring the clinical performance of healthcare professionals or of the answers is clinician resistance, probably best enunciated in the early debate [22]. However, a degree of criticism must hospitals. For the future there must be effective systems within hospitals to ensure that clinical performance is monalso be levelled at those health care administrators who have failed to ensure that such monitoring processes have been itored. There must also be a system of independent external surveillance to review patterns of performance over time and implemented. The necessary change in culture has sadly not