title: Performance monitoring in cardiac surgery: application of statistical process control to a single-site database.
abstract: BACKGROUND
  Graphical Statistical Process Control (SPC) tools have been shown to promptly identify significant variations in clinical outcomes in a range of health care settings. We explored the application of these techniques to quantitatively inform the routine cardiac surgical (CAS) morbidity and mortality (M&M) review processes at a single site.
  
  
  METHODS
  Baseline clinical and procedural data relating to 5265 consecutive cardiac surgical procedures, performed at St Andrew's War Memorial Hospital (SAWMH) between the 1st January 2003 and the 30th April 2012, were retrospectively evaluated. A range of appropriate clinical outcome indicators (COIs) were developed and evaluated using a combination of Cumulative Sum charts, Exponentially Weighted Moving Average charts and Funnel Plots. Charts were updated regularly and discussed at the cardiac surgery unit's bi-monthly M&M meetings. Risk adjustment (RA) for the COIs was developed and validated for incorporation into the charts to improve monitoring performance.
  
  
  RESULTS
  Discrete and aggregated measures, including blood product/reoperation, major acute post-procedural complications, cardiopulmonary bypass duration and Length of Stay/Readmission < 28 days have proved to be valuable measures for monitoring outcomes. Instances of variation in performance identified using the charts were examined thoroughly and could be related to changes in clinical practice (e.g. antifibrinolytic use) as well as differences in individual operator performance (in some instances, driven by case mix).
  
  
  CONCLUSIONS
  SPC tools can promptly detect meaningful changes in clinical outcome thereby allowing early intervention to address altered performance. Careful interpretation of charts for group and individual operators has proven helpful in detecting and differentiating systemic versus individual variation.
authors: St Andrew's Medical Institute, 457 Wickham Terrace, Spring Hill, Queensland 4001, Australia.
authors: Ian R
authors: IR
authors: Smith
authors: Michael A
authors: MA
authors: Gardner
authors: Bruce
authors: B
authors: Garlick
authors: Russell D
authors: RD
authors: Brighouse
authors: James
authors: J
authors: Cameron
authors: Peter S
authors: PS
authors: Lavercombe
authors: Kerrie
authors: K
authors: Mengersen
authors: Kelley A
authors: KA
authors: Foster
authors: John T
authors: JT
authors: Rivers
mesh_terms: D006348:Cardiac Surgical Procedures; D016208:Databases, Factual; D005260:Female; D006801:Humans; D008297:Male; D008954:Models, Biological; D008991:Monitoring, Physiologic; D012189:Retrospective Studies
keywords: Cardiac surgical procedures; Outcome measures; Quality improvement; Statistical data interpretation