The Scottish Arthroplasty Project

Clinical Governance

Clinical Governance: “A framework through which NHS organisations are accountable for continually improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish.”  (Scally & Donaldson, 1998)

Measures for Improvement

The Scottish Arthroplasty Project (SAP) monitors the clinical outcomes of hip and knee replacement patients following surgery. The complication rates being measured are:

  • • Dislocation of the hip joint within 365 days of surgery

  • • Infection of the joint within 365 days of surgery

  • • Deep vein thrombosis/pulmonary embolism within 90 days of surgery

  • • Death within 90 days of surgery

  • • Early revision of prothesis (within 3 years of primary operation)

Since its inception, the policy of the SAP has been to provide high quality data on activity and complications which can then be used at a local level to promote change and assist Consultant appraisal. Simple monitoring of activity and quality may influence clinical practise but can be insufficient to create significant change. With the support of the SCOT committee, SAP introduced a feedback and review system at NHS Board and Consultant level to look at quality issues. See flowchart for an account of how this process works.
Action plan template in word An electronic version of the Action Plan template used in this process is available here

From 2003 to 2009, Shewhart control chart methodology were used to present complication data and identify any unusual variation. In the control chart, the 5-year aggregated outcomes for NHS Boards or Consultants were casemix-adjusted and plotted in relation to three standard deviations above and below the mean. If an NHS Board or Consultant was outside this statistical limit they were identified as outliers, and our Clinical Governance remit required that we provide them with this information and asked that they review their complications.

In 2010 we started using CUSUM methodology to allow us to identify unusual runs of complications more quickly. See CUSUM information for more details.

Analyses of latest complication rates, number of outliers and responses from outliers can be found in our latest annual report.

Strategy for change

When outliers are identified, NHS Boards and Consultants are asked to undertake local reviews that investigate the reasons for these results and report back to SAP. The introduction of a new technique, a new implant or particular case mix issues may be identified. The Scottish Arthroplasty Steering Committee (SASC) grades responses as Exemplary, Excellent, Satisfactory or Less than satisfactory, and provides feedback. If the response is unsatisfactory, a resubmission addressing any discrepancy is requested. This process is administered by the SAP analysts throughout so that outliers are not identifiable by members of SASC. SAP continues to monitor performance and will contact outliers again if complication rates remain unusually high.

The purpose of reviewing outliers is to emphasise quality improvement, and not to attribute blame. The aim of the review process is to continue to encourage local review of clinical practice and data quality, both of which contribute to the continual improvement of patient care.