INPUT Number and % of DS units by public and private ownership by integrated partially integrated freestanding

Transcription

1 5 FACT SHEET OF EACH ESSENTIAL DS INDICATOR 5.1 Fact sheet of the following ESSENTIAL SET OF DS INDICATORS AT NATIONAL/REGIONAL LEVEL INPUT Number and % of DS units by public and private ownership by integrated partially integrated freestanding ACCESS Median waiting time for overall list of basket procedures and for each basket procedure OUTPUT % of elective surgery performed as DS for the overall list of elective basket procedures and each elective basket procedure OUTCOME Case fatality ratio within 30 days for patients undergoing any of elective basket procedure % DS unplanned overnight admission % of DS admissions returned to the OR within one week SAFETY % of DS admissions who experienced a wrong site, wrong side, wrong patient, wrong procedure or wrong implant COST AND PRODUCTIVITY Expenditure on DS care as absolute value and % of total health expenditure 35

2 Number and % of DS units OECD; Caisse Nationale d Assurance Maladie des Travailleurs Salariés (France) Domain Effectiveness Patient-centeredness Efficiency Safety Indicator type Input Process Output Outcome Number and % of DS units Understanding the presence of DS within surgical departments Number of surgery units Number of DS units including child surgeons including child surgeons All operational units with activities surgery Operational units with activities surgery dedicated to the procedures basket (see Appendix A) performed as DS Stratification by: 1. Public and private 2. Financed by National Health service/insurance and out of pocket disbursement 3. Integrated, partially integrated and freestanding 4. Procedure (see Appendix A) The highest possible scores are desirable Level of Health Care Delivery Hospital, Regional and National Data source Administrative data Survey 36

3 Median waiting time for overall list of basket procedures : Smith I et al. Anaesthesia 2006: 61: Stoop AP et al. Health Policy 2005; 73:41-51 Project European Community Health Indicators Monitoring (ECHIM) Domain Effectiveness Patient-centeredness Efficiency Safety Access Indicator type Input Process Output Outcome The time patients have to wait on a waiting surgical list to be eligible for operations that are suitable for DS, according to the IAAS. It is supposed to have a median waiting time for each DS procedure based on the ICD9CM. DS has the potential to reduce waiting times for surgery, and in this way improves patients access to surgical treatments. An efficient DS programme should be able to shorten waiting times across its referral region. Total number of basket procedure provided detailed rules DS. Sum of the days expected from patients subjected to the procedures identified. Total number of basket procedure (see Appendix A) performed as DS. Sum of the days expected from patients subjected to the procedures identified. Stratification by: each basket procedure Lower mean waiting times reflect availability, improve access and efficiency of DS programmes Level of Health Care Delivery Hospital, Regional and National Data source Administrative data Survey National governments and public agencies 37

4 % of elective surgery performed as DS for the overall list of elective basket procedures : Brebbia G et al. Int J Surg 2008; 6:S59-S64 : OECD Health Data 2009: statistics and Indicators for 30 Countries. Organisation for Economic Co-Operation and Development, Institute for Research and Information in Health Economics, 2009 ( Jarrett PM, Staniszewski A. The development of ambulatory surgery and future challenges. In: DS, Development and Practice. Lemos P, Jarrett P, Philip B (eds) IAAS Classica Artes Graficas, 2006 Domain Effectiveness Patient-centeredness Efficiency Safety Access Indicator type Input Process Output Outcome Percentage of the total number of non-critical surgical procedures performed as DS Reflects DS growth at local and national level. It represents a benchmark and a target to be pursued. It also identifies the access of patients to DS programmes. Total number of non-critical surgical procedures performed as inpatient and DS. Total number of non-critical surgical procedures performed as DS. all non-critical surgery discharges, age 18 years and older, with procedures basket (see Appendix A) Non-critical surgery discharges, age 18 years and older, with procedures basket (see Appendix A) performed as DS Stratification by: each elective basket procedure The highest possible scores are desirable All DS programmes whatever the type of care setting used Level of Health Care Delivery DS unit, Hospital, Regional and National Data source Administrative data Survey Organisation for Economic Co-Operation and Development - OECD 38

5 Case fatality ratio within 30 days for patients undergoing any of elective basket procedure : Chukmaitov AS et al. J Ambul Care Manage, 2008 ; 31 : Engbaek J et al. Acta Anasthesiol Scand 2006 ; 50 :911-9 Fleisher LA et al. Arch Surg 2004; 139:67-72 Warner MA et al. JAMA, 1993;270: : American Society of Anesthesiology (ASA) Committee on Ambulatory Surgical Care, 2003 Clinical Resource and Audit Group (Scotland) Domain Effectiveness Patient-centeredness Efficiency Safety Access Indicator type Input Process Output Outcome All deaths within the first 30 days after ambulatory surgery programmes should be registered and analysed This indicator represents the most important measure of effectiveness and safety. All patients submitted to surgery on a DS basis All deaths within 30 days after a DS procedure. All discharges DS, age 18 years and older, with basket procedure code Number of deaths within 30 days after a procedure among cases meeting the inclusion and exclusion rules for the denominator Level D of scientific evidence (based on different expert opinions) Stratification by: each elective basket procedure Deaths are rare in DS. So, it is expected to have mortality close to 0% referred to the majority of procedures, both in public and private healthcare institutions. Level of Health Care Delivery DS unit, Hospital, Regional and National Data source Administrative data Survey Recommended by The American Society of Anaesthesiologists (ASA) 39

6 % DS unplanned overnight admission Aldwinckle RJ, Montgomery JE. Anaesthesia 2004; 59: Ali A et al. J Minim Access Surg 2009; 5: Ansell GL, Montgomery JE. Br J Anaesth 2004; 92: Bettelli G. Minerva Anestesiol 2009; 75: Blacoe DA et al. Anaesthesia 2008; 63: Calland JF et al. Ann Surg 2001; 233: Coley KC et al. J Clin Anesth 2002; 14: Crew JP et al. Ann R Col Surg Engl 1997; 79: Fortier J et al. Can J Anaesth 1998; 45: Ganesan S et al. Ann R Coll Surg Engl 2000; 82: Gold BS et al. JAMA 1989; 262: Greenburg AG et al. Am J Surg 1996; 172: Gurusamy K et al. Br J Surg 2008; 95: Hogg RP et al. Clin Otolaryngol 1999; 24: Johnson CD, Jarrett PEM. Ann R Coll Surg Engl 1990; 72: Mandal A et al. Ann R Coll Surg Engl 2005; 87: Margovsky A. Aust NZ J Surg 2000; 70: Marshall SI, Chung F. Anesth Analg 1999; 88: Mingus ML et al. J Clin Anesth 1997; 9: Papaceit J et al. Gac Sanit 2003; 17: Rudkin GE et al. Anaesth Intens Care 1996; 24: Shah RK et al. Laryngoscope 2008; 118: Singh G et al. BMC Ear Nose Throat Disord 2004; 4: 2 - Strong NP et al. Br J Ophthalmol 1991; 75: Trottier DC et al. J Can Chir 2009; 52: ASA Committee on Ambulatory Surgical Care and Task Force on Office Based Anesthesia. Outcome indicators for office-based and ambulatory surgery 2003 ( - Australian Council on Healthcare Standards. Australasian Clinical Indicator Report : determining the potential to improve quality of care, 9th edn ( - Lemos P, Regalado AM. Patient outcomes and clinical indicators for ambulatory surgery. In: DS, Development and Practice. Lemos P, Jarrett P, Philip B (eds). IAAS. Clássica Artes Gráficas, Manual unidad de cirugía mayor ambulatoria, estándares y recomendaciones. Gobierno de España, Ministerio de Sanidad y Consumo ( Domain Effectiveness Patient-centeredness Efficiency Safety Indicator type Input Process Output Outcome Denominator Inclusions/Exclusions Numerator Inclusions/Exclusions Evidence Supporting the Criterion Allowance for Patient Factors Unplanned overnight admission for DS patients. This indicator reflects possible problems in the performance of procedures, in the appropriate selection of patients or in the proper management of operating times. Number of patients submitted to DS. Number of patients who had an unplanned overnight admission following a DS procedure. all DS discharges, age 18 years and older, with procedures basket (see Appendix A) DS discharges, age 18 years and older, with procedures basket (see Appendix A) who had an unplanned overnight admission. Level D of scientific evidence (based on different expert opinions). Stratification by: each elective basket procedure Lower scores are desirable. Overall, the expected rate of unplanned overnight admission whatever the reason averages 1% in most DS centres. It might be expectable to be higher for more complex procedures (higher case-mix ratios). All DS programmes whatever the type of care setting used. DS unit, Hospital, Regional and National Level of Health Care Delivery Data source Administrative data Survey International Association for Ambulatory Surgery (IAAS) 40

7 % of DS admissions returned to the OR within one week Ansell GL, Montgomery JE. Br J Anaesth 2004; 92: 71-4 Bettelli G. Minerva Anestesiol 2009; 75: Coley KC et al. J Clin Anesth 2002; 14: Fleisher LA et al. Arch Surg 2004; 139: Gurusamy K et al. Br J Surg 2008; 95: Lewis C, Bryson J. Ann R Coll Surg Engl 1998; 80: Marshall SI, Chung F. Anesth Analg 1999; 88: Mezei G, Chung F. Ann Surg 1999; 230: Singh G et al. BMC Ear Nose Throat Disord 2004; 4: 2 - Lemos P, Regalado AM. Patient outcomes and clinical indicators for ambulatory surgery. In: Day Surgery, Development and Practice. Lemos P, Jarrett P, Philip B (eds). IAAS. Clássica Artes Gráficas, Manual unidad de cirugía mayor ambulatoria, estándares y recomendaciones. Gobierno de España, Ministerio de Sanidad y Consumo ( Domain Effectiveness Patient-centeredness Efficiency Safety Equity Timeliness Access Indicator type Input Process Output Outcome Admission to hospital in the first 7 days postoperatively of a day surgery patient that was previously discharged home. This indicator may reflect possible problems in the performance of procedures, or in the appropriate selection of patients for management in a day surgery unit, that translate in acute or emergency situations presenting in the first 24 hours after surgery and deserve hospital admission. It might also indicate problems in the appropriate discharge from DSU. Number of patients submitted to day surgery. Number of patients admitted to hospital in the first 7 days postoperatively, that were previously discharged home from a day surgery programme. No exclusions. No exclusions. Not applicable. Not applicable. of Level D of scientific evidence (based on different expert opinions). Quality Not applicable. Lower scores are desirable. All day surgery programmes whatever the type of care setting used. Level of Health Care Delivery On a National Level. Data source Administrative data Survey Recommended by the International Association for Ambulatory Surgery (IAAS) 41

8 % of DS admissions who experienced a wrong site, wrong side, wrong patient, wrong procedure, or wrong implant Safety of ambulatory surgery Aker J Perianesth Nurs 2001; 16 (6): Pages: Office surgery safety and the Florida moratoria. Clayman MA, Caffee HH Ann Plast Surg 2006; 56 (1): Pages: National Quality Measures Clearinghouse (U.S.A.) Domain Effectiveness Patient-centeredness Efficiency Safety Indicator type Input Process Output Outcome This measure is used to assess the percentage of Ambulatory Surgery Center (ASC) admissions who experienced a wrong site, wrong side, wrong patient, wrong procedure, or wrong implant. "Surgery performed on the wrong body part," "surgery performed on the wrong patient," and "wrong surgical procedure performed on a patient" have all been endorsed as serious reportable surgical events by the National Quality Forum (NQF). This safety indicator serves as an indirect measure of providers' adherence to the international guidelines (so called Universal Protocol) for eliminating wrong site, wrong procedure, wrong person surgery. All DS admissions, age 18 years and older, with basket procedure (see Appendix A) DS admissions, age 18 year and older, for a basket procedure (see Appendix A) experiencing a wrong site, wrong side, wrong patient, wrong procedure, or wrong implant. All DS admissions, age 18 years and older, with basket procedure (see Appendix A) DS admissions*, age 18 year and older, for a basket procedure (see Appendix A) experiencing a wrong** site, wrong side, wrong patient, wrong procedure, or wrong implant. *Admission: Completion of registration upon entry into the facility; **Wrong: Not in accordance with intended site, side, patient, procedure or implant. Stratification by: each elective basket procedure Better quality is associated with a lower score Level of Health Care Delivery DS unit, Hospital, Regional and National Data source Administrative data Survey The National Quality Measures Clearinghouse (NQMC) AHRQ 42

9 Expenditure on DS care as % of total health expenditure Elective Care Improvement Indicators (UK) Domain Effectiveness Patient-centeredness Efficiency Safety Indicator type Input Process Output Outcome Expenditure on DS care as percentage of total health expenditure A relevant expenditure for DS indicates that this setting for surgical intervention has been introduced in the patterns of care. In addiction it suggests a better use of resources as DS is a more efficient way to perform surgical interventions compared to traditional surgery (for the basket procedures). Total expenditure on health is defined as the sum of expenditure on activities that through application of medical, paramedical, and nursing knowledge and technology has the goals of: - Promoting health and preventing disease; - Curing illness and reducing premature mortality; - Caring for persons affected by chronic illness who require nursing care; - Caring for persons with health-related impairments, disability, and handicaps who require nursing care; - Assisting patients to die with dignity; - Providing and administering public health; - Providing and administering health programmes, health insurance and other funding arrangements. of Quality Total expenditure on DS comprises medical and paramedical services delivered to outpatients. An out-patient not formally admitted to the facility (physician s private office, hospital outpatient centre or ambulatory-care centre) and does not stay overnight. An out-patient is thus a person who goes to a health care facility for a consultation/treatment, and who leaves the facility within several hours from the start of the consultation without being admitted to the facility as a patient. It should be noted that the term out-patient used in the SHA has a wider meaning compared to some national reporting systems where this term is limited to care in out-patient wards of hospitals. In the SHA, all visitors to ambulatory care facilities that are not day cases or over-the-night cases are considered out-patients. Nothing Nothing Total expenditure on health Total expenditure for basket procedure performed as DS Stratification by: each elective basket procedure The higher the better Level of Health Care Delivery DS unit, Hospital, Regional and National Data source Administrative data Survey Eurostat, OCSE 43

10 5.2 Fact sheet of the following ESSENTIAL SET OF DS INDICATORS AT DS UNIT LEVEL ACCESS Median waiting time for overall list of basket procedures and for each basket procedure PROCESS % of patients who have received a pre-anaesthesia assessment before DS OUTPUT Number (and % for non free standing units) of elective surgery performed as DS for the overall list of elective basket procedures and each elective basket procedure OUTCOME Case fatality ratio within 30 days for patients undergoing any of elective basket procedure % DS unplanned overnight admission % unplanned re-admission to a hospital or an acute care facility within one week SAFETY % of DS admissions who experienced a wrong site, wrong side, wrong patient, wrong procedure or wrong implant % DS surgical wound infection SATISFACTION/RESPONSIVENESS % patients of patients overall satisfied COST AND PRODUCTIVITY % cancellations of surgical procedures without notification by the patient ("failed to arrive" or "did not attend") % cancellations of the booked procedure after arrival at the day surgery centre/unit 44

11 Median waiting time for overall list of basket procedures : Smith I et al. Anaesthesia 2006: 61: Stoop AP et al. Health Policy 2005; 73:41-51 Project European Community Health Indicators Monitoring (ECHIM) Domain Effectiveness Patient-centeredness Efficiency Safety Access Indicator type Input Process Output Outcome The time patients have to wait on a waiting surgical list to be eligible for operations that are suitable for DS, according to the IAAS. It is supposed to have a median waiting time for each DS procedure based on the ICD9CM. DS has the potential to reduce waiting times for surgery, and in this way improves patients access to surgical treatments. An efficient DS programme should be able to shorten waiting times across its referral region. Total number of basket procedure provided detailed rules DS. Sum of the days expected from patients subjected to the procedures identified. Total number of basket procedure (see Appendix A) performed as DS. Sum of the days expected from patients subjected to the procedures identified. Stratification by: each basket procedure Lower mean waiting times reflect availability, improve access and efficiency of DS programmes Level of Health Care Delivery Hospital, Regional and National 45 Data source Administrative data Survey National governments and public agencies

12 % of patients who have received a pre-anaesthesia assessment before DS : McGory ML et al. Ann Surg, 2009; 250: Smith I et al. Anaesthesia, 2006;61: Papaceit J. Gac Sanit, 2003; 17: : Healthcare Commission. Acute hospital portfolio review, DS July 2005 DS, Revised Edition February The Anaesthesia Team, Revised Edition. March Domain Effectiveness Patient-centeredness Efficiency Safety Indicator type Input Process Output Outcome All patients should be seen in advance of their surgery by someone trained in pre-assessment for DS Carried out to ensure that only suitable patients are offered DS. This is aimed to reduce cancellations, promote efficient bed usage, start education of the patient and their carers, and optimize clinical outcomes for the patients All patients schedule for DS programmes Patients seen in pre-anaesthesia assessment before DS programmes All patients schedule for all procedures basket (see Appendix A) performed as DS Patients seen in pre-anaesthesia assessment before DS programmes (all procedures basket in DS) Level D of scientific evidence (based on different expert opinions) Stratification by: Procedure (Procedure OECD) The highest possible scores are desirable Level of Health Care Delivery Hospital, Regional and National Data source Administrative data Survey Identifies the organization(s) that used the indicator 46

13 Number (and % for non free standing units) of elective surgery performed as DS for the overall list of elective basket procedures and each elective basket procedure : Brebbia G et al. Int J Surg 2008; 6:S59-S64 : OECD Health Data 2009: statistics and Indicators for 30 Countries. Organisation for Economic Co-Operation and Development, Institute for Research and Information in Health Economics, 2009 ( Jarrett PM, Staniszewski A. The development of ambulatory surgery and future challenges. In: DS, Development and Practice. Lemos P, Jarrett P, Philip B (eds) IAAS Classica Artes Graficas, 2006 Domain Effectiveness Patient-centeredness Efficiency Safety Access Indicator type Input Process Output Outcome Percentage of the total number of non-critical surgical procedures performed as DS Reflects DS growth at local and national level. It represents a benchmark and a target to be pursued. It also identifies the access of patients to DS programmes. Total number of non-critical surgical procedures performed as inpatient and DS. Total number of non-critical surgical procedures performed as DS. all non-critical surgery discharges, age 18 years and older, with procedures basket (see Appendix A) Non-critical surgery discharges, age 18 years and older, with procedures basket (see Appendix A) performed as DS Stratification by: each elective basket procedure The highest possible scores are desirable All DS programmes whatever the type of care setting used Level of Health Care Delivery DS unit, Hospital, Regional and National Data source Administrative data Survey Organisation for Economic Co-Operation and Development - OECD 47

14 Case fatality ratio within 30 days for patients undergoing any of elective basket procedure : Chukmaitov AS et al. J Ambul Care Manage, 2008 ; 31 : Engbaek J et al. Acta Anasthesiol Scand 2006 ; 50 :911-9 Fleisher LA et al. Arch Surg 2004; 139:67-72 Warner MA et al. JAMA, 1993;270: : American Society of Anesthesiology (ASA) Committee on Ambulatory Surgical Care, 2003 Clinical Resource and Audit Group (Scotland) Domain Effectiveness Patient-centeredness Efficiency Safety Access Indicator type Input Process Output Outcome All deaths within the first 30 days after ambulatory surgery programmes should be registered and analysed This indicator represents the most important measure of effectiveness and safety. All patients submitted to surgery on a DS basis All deaths within 30 days after a DS procedure. All discharges DS, age 18 years and older, with basket procedure code Number of deaths within 30 days after a procedure among cases meeting the inclusion and exclusion rules for the denominator Level D of scientific evidence (based on different expert opinions) Stratification by: each elective basket procedure Deaths are rare in DS. So, it is expected to have mortality close to 0% referred to the majority of procedures, both in public and private healthcare institutions. Level of Health Care Delivery DS unit, Hospital, Regional and National Data source Administrative data Survey Recommended by The American Society of Anaesthesiologists (ASA) 48

15 % DS unplanned overnight admission Aldwinckle RJ, Montgomery JE. Anaesthesia 2004; 59: Ali A et al. J Minim Access Surg 2009; 5: Ansell GL, Montgomery JE. Br J Anaesth 2004; 92: Bettelli G. Minerva Anestesiol 2009; 75: Blacoe DA et al. Anaesthesia 2008; 63: Calland JF et al. Ann Surg 2001; 233: Coley KC et al. J Clin Anesth 2002; 14: Crew JP et al. Ann R Col Surg Engl 1997; 79: Fortier J et al. Can J Anaesth 1998; 45: Ganesan S et al. Ann R Coll Surg Engl 2000; 82: Gold BS et al. JAMA 1989; 262: Greenburg AG et al. Am J Surg 1996; 172: Gurusamy K et al. Br J Surg 2008; 95: Hogg RP et al. Clin Otolaryngol 1999; 24: Johnson CD, Jarrett PEM. Ann R Coll Surg Engl 1990; 72: Mandal A et al. Ann R Coll Surg Engl 2005; 87: Margovsky A. Aust NZ J Surg 2000; 70: Marshall SI, Chung F. Anesth Analg 1999; 88: Mingus ML et al. J Clin Anesth 1997; 9: Papaceit J et al. Gac Sanit 2003; 17: Rudkin GE et al. Anaesth Intens Care 1996; 24: Shah RK et al. Laryngoscope 2008; 118: Singh G et al. BMC Ear Nose Throat Disord 2004; 4: 2 - Strong NP et al. Br J Ophthalmol 1991; 75: Trottier DC et al. J Can Chir 2009; 52: ASA Committee on Ambulatory Surgical Care and Task Force on Office Based Anesthesia. Outcome indicators for office-based and ambulatory surgery 2003 ( - Australian Council on Healthcare Standards. Australasian Clinical Indicator Report : determining the potential to improve quality of care, 9th edn ( - Lemos P, Regalado AM. Patient outcomes and clinical indicators for ambulatory surgery. In: DS, Development and Practice. Lemos P, Jarrett P, Philip B (eds). IAAS. Clássica Artes Gráficas, Manual unidad de cirugía mayor ambulatoria, estándares y recomendaciones. Gobierno de España, Ministerio de Sanidad y Consumo ( Domain Effectiveness Patient-centeredness Efficiency Safety Indicator type Input Process Output Outcome Denominator Inclusions/Exclusions Numerator Inclusions/Exclusions Evidence Supporting the Criterion Allowance for Patient Factors Unplanned overnight admission for DS patients. This indicator reflects possible problems in the performance of procedures, in the appropriate selection of patients or in the proper management of operating times. Number of patients submitted to DS. Number of patients who had an unplanned overnight admission following a DS procedure. all DS discharges, age 18 years and older, with procedures basket (see Appendix A) DS discharges, age 18 years and older, with procedures basket (see Appendix A) who had an unplanned overnight admission. Level D of scientific evidence (based on different expert opinions). Stratification by: each elective basket procedure Lower scores are desirable. Overall, the expected rate of unplanned overnight admission whatever the reason averages 1% in most DS centres. It might be expectable to be higher for more complex procedures (higher case-mix ratios). All DS programmes whatever the type of care setting used. DS unit, Hospital, Regional and National Level of Health Care Delivery Data source Administrative data Survey International Association for Ambulatory Surgery (IAAS) 49

16 % unplanned re-admission to a hospital or an acute care facility within one week Ansell GL, Montgomery JE. Br J Anaesth 2004; 92: 71-4 Bettelli G. Minerva Anestesiol 2009; 75: Coley KC et al. J Clin Anesth 2002; 14: Fleisher LA et al. Arch Surg 2004; 139: Gurusamy K et al. Br J Surg 2008; 95: Lewis C, Bryson J. Ann R Coll Surg Engl 1998; 80: Marshall SI, Chung F. Anesth Analg 1999; 88: Mezei G, Chung F. Ann Surg 1999; 230: Singh G et al. BMC Ear Nose Throat Disord 2004; 4: 2 - Lemos P, Regalado AM. Patient outcomes and clinical indicators for ambulatory surgery. In: Day Surgery, Development and Practice. Lemos P, Jarrett P, Philip B (eds). IAAS. Clássica Artes Gráficas, Manual unidad de cirugía mayor ambulatoria, estándares y recomendaciones. Gobierno de España, Ministerio de Sanidad y Consumo ( Domain Effectiveness Patient-centeredness Efficiency Safety Equity Timeliness Access Indicator type Input Process Output Outcome Admission to hospital in the first 7 days postoperatively of a day surgery patient that was previously discharged home. This indicator may reflect possible problems in the performance of procedures, or in the appropriate selection of patients for management in a day surgery unit, that translate in acute or emergency situations presenting in the first 7 days after surgery and deserve hospital admission. It might also indicate problems in the appropriate discharge from DSU. Number of patients submitted to day surgery. Number of patients admitted to hospital in the first 7 days postoperatively, that were previously discharged home from a day surgery programme. No exclusions. No exclusions. Not applicable. Not applicable. of Level D of scientific evidence (based on different expert opinions). Quality Not applicable. Lower scores are desirable. All day surgery programmes whatever the type of care setting used. Level of Health Care Delivery On a National Level. Data source Administrative data Survey Recommended by the International Association for Ambulatory Surgery (IAAS) 50

17 % of DS admissions who experienced a wrong site, wrong side, wrong patient, wrong procedure, or wrong implant Safety of ambulatory surgery Aker J Perianesth Nurs 2001; 16 (6): Pages: Office surgery safety and the Florida moratoria. Clayman MA, Caffee HH Plast Surg 2006; 56 (1): Pages: National Quality Measures Clearinghouse (U.S.A.) Domain Effectiveness Patient-centeredness Efficiency Safety Indicator type Input Process Output Outcome This measure is used to assess the percentage of Ambulatory Surgery Center (ASC) admissions who experienced a wrong site, wrong side, wrong patient, wrong procedure, or wrong implant. "Surgery performed on the wrong body part," "surgery performed on the wrong patient," and "wrong surgical procedure performed on a patient" have all been endorsed as serious reportable surgical events by the National Quality Forum (NQF). This safety indicator serves as an indirect measure of providers' adherence to the international guidelines (so called Universal Protocol) for eliminating wrong site, wrong procedure, wrong person surgery. All DS admissions, age 18 years and older, with basket procedure (see Appendix A) DS admissions, age 18 year and older, for a basket procedure (see Appendix A) experiencing a wrong site, wrong side, wrong patient, wrong procedure, or wrong implant. All DS admissions, age 18 years and older, with basket procedure (see Appendix A) DS admissions*, age 18 year and older, for a basket procedure (see Appendix A) experiencing a wrong** site, wrong side, wrong patient, wrong procedure, or wrong implant. *Admission: Completion of registration upon entry into the facility; **Wrong: Not in accordance with intended site, side, patient, procedure or implant. Stratification by: each elective basket procedure Better quality is associated with a lower score Level of Health Care Delivery DS unit, Hospital, Regional and National Data source Administrative data Survey The National Quality Measures Clearinghouse (NQMC) AHRQ Ann 51

18 % surgical wound infection Comprehensive surveillance of surgical wound infections in outpatient and inpatient surgery Manian FA, Meyer L Infect Control Hosp Epidemiol 1990; 11 (10): Pages: Adjunctive use of monthly physician questionnaires for surveillance of surgical site infections after hospital discharge and in ambulatory surgical patients: report of a seven-year experience Manian FA, Meyer L Am J Infect Control 1997; 25 (5): Pages: The American Society of Anesthesiologists (USA) The Information Center of NHS (UK) Domain Effectiveness Patient-centeredness Efficiency Safety Indicator type Input Process Output Outcome Percentage of surgical wound infection in DS (for every basket procedure) Wound infection is one of the most common complication in surgical procedures. It is crucial to monitor whether the rate of such infections after DS interventions remains lower than the rate of infections for the same surgical interventions performed in hospitalized settings. Gold standards indicates that DS should have better outcomes on this. Number of DS Number of surgical wound infection during DS all surgical operation with basket procedures performed as DS (see Appendix A) all surgical operation with basket procedures performed as DS (see Appendix A) in which a wound infection appeared Stratification by: each elective basket procedure The lowest possible score is desirable. Level of Health Care Delivery Hospital, Regional and National Data source Administrative data Survey Identifies the organization(s) that used the indicator 52

19 16 - Number and % of patients satisfied Patient satisfaction following day surgery. Lemos P, Pinto A, Morais G, Pereira J, Loureiro R, Teixeira S, Nunes CS J Clin Anesth 2009; 21 (3): Pages: Measuring the three process segments of a customer's service experience for an out-patient surgery center. Wicks AM, Chin WW Int J Health Care Qual Assur 2008; 21 (1): Pages: International Association for Ambulatory Surgery The American Society of Anesthesiologists (USA) Elective Care Improvement Indicators (UK) Domain Effectiveness Patient-centeredness Efficiency Safety Indicator type Input Process Output Outcome Number and percentage of patients satisfied Patients satisfaction is one of the expected outcomes of any medical/surgical procedure. Literature indicates that patients satisfaction is higher for DS procedures compared to traditional surgery. An high rate of satisfaction depends mainly on the post operative management of the patients (pain, vomiting, etc.) and on the perception that being at home does not mean to be abandoned. Number of patients in DS Number of patients satisfied in DS Number of patients in DS Number of patients satisfied and performed in DS with a basket procedure (see Appendix A) Risk adjustement: Not applicable Stratification by: each elective basket procedure The highest possible score is desirable. Level of Health Care Delivery Hospital, Regional and National Data source Administrative data Survey Identifies the organization(s) that used the indicator 53

20 % cancellations of surgical procedures without notification by the patient ( failed to arrive or did not attend ) Non-attendance at the colorectal clinic: a prospective audit. Corfield L, Schizas A, Noorani A, Williams A Ann R Coll Surg Engl 2008; 90 (5): Pages: International Association for Ambulatory Surgery Royal Australian College of Surgeons National Quality Measures Clearinghouse (U.S.A.) Domain Effectiveness Patient-centeredness Efficiency Safety Equity Timeliness Indicator type Input Process Output Outcome Level of Health Care Delivery Percentage of patients fail to appear for administrative reasons, patient s decision, onset of acute or intercurrent disease, for other reasons As DS interventions are scheduled in a very tight way, it is relevant to avoid last minute cancellations. Proper communication to patients during pre-anaesthesia consultation and a reminder 2-3 days before are necessary. Number of patients with appointments in DS Number of cancellations due to non-appearance of patients in DS Number of patients with appointments in DS with basket procedures (see Appendix A) Appointments cancelled in DS with basket procedures (see Appendix A) Stratification by: each elective basket procedure The lowest possible score is desirable Data source Administrative data Survey Identifies the organization(s) that used the indicator 54

21 Cancellation of the booked procedure after arrival at the day surgery centre/unit : Brebbia G et al. Int J Surg 2008: 6: S59-S64 Strong NP et al. Br J Ophtalmol 1991:71:: Papaceit J et al. Gac Sanit 2003; 17: Lemos P, Regalado AM. Patient outcomes and clinical indicators for ambulatory surgery. In: Day Surgery, Development and Practice. Lemos P, Jarrett P, Philip B (eds). IAAS. Clássica Artes Gráficas, 2006ASA Committee on Ambulatory Surgery Care and task force on office bases anesthesia. Outcome indicators for office-based International Association for Ambulatory Surgery Royal Australian College of Surgeons National Quality Measures Clearinghouse (U.S.A.) Domain Effectiveness Patient-centeredness Efficiency Safety Indicator type Input Process Output Outcome Cancellation of a booked procedure after the patient s arrival at the DS unit. It reflects the quality of the pre-operative assessment of the patient and the quality of information provided. Number of patients who arrive at the DS unit for a booked procedure Number of patients booked into a DS unit, whose procedure is cancelled after their arrival at the facility Number of patients who arrive at the DS unit for a booked basket procedure (see Appendix A) Number of patients who arrive at the DS unit for a booked basket procedure (see Appendix A), whose procedure is cancelled after their arrival at the facility Level D of scientific evidence (based on different expert opinions) Stratification by: 1. each elective basket procedure 2. Reason for cancellation (Pre-existing medical condition, Acute medical condition,organisational reasons) The lowest possible score is desirable All DS programmes whatever the type of care setting used DS unit, Hospital, Regional and National Level of Health Care Delivery Data source Administrative data Survey Recommended by the International Association for Ambulatory Surgery (IAAS), the American Society of Anesthesiologists (ASA) Committee on Ambulatory Surgical Care, and the Australian Council on Healthcare Standards. 55

22 5.3 Fact sheet of the following IDEAL SET OF DS INDICATORS AT NATIONAL/REGIONAL LEVEL INPUT Number and ratio of theatres fully dedicated to DS / total available theatres ACCESS Median waiting time for overall list of basket procedures and for each basket procedure PROCESS % of patients who have received a pre-anaesthesia assessment before DS OUTPUT % of elective surgery performed as DS by overall list of basket procedures and each basket procedure OUTCOME Case fatality ratio within 30 days for patients undergoing any of elective basket procedure % unplanned overnight admission by cause Surgical Anaesthetic/medical Social/administrative % unplanned returns to the OR within 24 hours % unplanned re-admission to a hospital within one week SAFETY % of DS admissions who experienced a wrong site, wrong side, wrong patient, wrong procedure or wrong implant % of DS admissions with surgical wound infection % of DS admissions with post-operative sepsis PATIENTS' SATISFACTION AND RESPONSIVENESS % patients overall satisfied with DS COST AND PRODUCTIVITY Expenditure on Day Surgery care as absolute value and % of total health expenditure 56

23 Indicator name Number and ratio of theatres fully dedicated to DS / total available theatres Ambulatory surgery centers: same standards; different venues. Geier A, Gelardi- Slosburg D AORN J 2009; 89 (3): Pages: Hospital resources used for inpatient and ambulatory surgery Kitz DS, Slusarz- Ladden C, Lecky JH. Anesthesiology 1988; 69 (3): Pages : Elective Care Improvement Indicators (UK) Domain Effectiveness Patient-centeredness Efficiency Safety Indicator type Input Process Output Outcome Number and percentage of available theatres to DS Understanding the theatres assignation within surgical departments Number of available theatres Number of available theatres fully dedicated to DS All theatres Theatres dedicated to the procedures basket (see Appendix A) performed as DS Stratification by: Procedure (see Appendix A ) The highest possible scores are desirable Level of Health Care Delivery Hospital, Regional and National Data source Administrative data Survey Identifies the organization(s) that used the indicator 57

24 Median waiting time for overall list of basket procedures : Smith I et al. Anaesthesia 2006: 61: Stoop AP et al. Health Policy 2005; 73:41-51 Project European Community Health Indicators Monitoring (ECHIM) Domain Effectiveness Patient-centeredness Efficiency Safety Access Indicator type Input Process Output Outcome The time patients have to wait on a waiting surgical list to be eligible for operations that are suitable for DS, according to the IAAS. It is supposed to have a median waiting time for each DS procedure based on the ICD9CM. DS has the potential to reduce waiting times for surgery, and in this way improves patients access to surgical treatments. An efficient DS programme should be able to shorten waiting times across its referral region. Total number of basket procedure provided detailed rules DS. Sum of the days expected from patients subjected to the procedures identified. Total number of basket procedure (see Appendix A) performed as DS. Sum of the days expected from patients subjected to the procedures identified. Stratification by: each basket procedure Lower mean waiting times reflect availability, improve access and efficiency of DS programmes Level of Health Care Delivery Hospital, Regional and National Data source Administrative data Survey National governments and public agencies 58

25 % of patients who have received a pre-anaesthesia assessment before DS : McGory ML et al. Ann Surg, 2009; 250: Smith I et al. Anaesthesia, 2006;61: Papaceit J. Gac Sanit, 2003; 17: : Healthcare Commission. Acute hospital portfolio review, DS July 2005 DS, Revised Edition February The Anaesthesia Team, Revised Edition. March Domain Effectiveness Patient-centeredness Efficiency Safety Indicator type Input Process Output Outcome All patients should be seen in advance of their surgery by someone trained in pre-assessment for DS Carried out to ensure that only suitable patients are offered DS. This is aimed to reduce cancellations, promote efficient bed usage, start education of the patient and their carers, and optimize clinical outcomes for the patients All patients schedule for DS programmes Patients seen in pre-anaesthesia assessment before DS programmes All patients schedule for all procedures basket (see Appendix A) performed as DS Patients seen in pre-anaesthesia assessment before DS programmes (all procedures basket in DS) Level D of scientific evidence (based on different expert opinions) Stratification by: Procedure (Procedure OECD) The highest possible scores are desirable Level of Health Care Delivery Hospital, Regional and National Data source Administrative data Survey Identifies the organization(s) that used the indicator 59

26 % of elective surgery performed as DS for the overall list of elective basket procedures : Brebbia G et al. Int J Surg 2008; 6:S59-S64 : OECD Health Data 2009: statistics and Indicators for 30 Countries. Organisation for Economic Co-Operation and Development, Institute for Research and Information in Health Economics, 2009 ( Jarrett PM, Staniszewski A. The development of ambulatory surgery and future challenges. In: DS, Development and Practice. Lemos P, Jarrett P, Philip B (eds) IAAS Classica Artes Graficas, 2006 Domain Effectiveness Patient-centeredness Efficiency Safety Access Indicator type Input Process Output Outcome Percentage of the total number of non-critical surgical procedures performed as DS Reflects DS growth at local and national level. It represents a benchmark and a target to be pursued. It also identifies the access of patients to DS programmes. Total number of non-critical surgical procedures performed as inpatient and DS. Total number of non-critical surgical procedures performed as DS. all non-critical surgery discharges, age 18 years and older, with procedures basket (see Appendix A) Non-critical surgery discharges, age 18 years and older, with procedures basket (see Appendix A) performed as DS Stratification by: each elective basket procedure The highest possible scores are desirable All DS programmes whatever the type of care setting used Level of Health Care Delivery DS unit, Hospital, Regional and National Data source Administrative data Survey Organisation for Economic Co-Operation and Development - OECD 60

27 Case fatality ratio within 30 days for patients undergoing any of elective basket procedure : Chukmaitov AS et al. J Ambul Care Manage, 2008 ; 31 : Engbaek J et al. Acta Anasthesiol Scand 2006 ; 50 :911-9 Fleisher LA et al. Arch Surg 2004; 139:67-72 Warner MA et al. JAMA, 1993;270: : American Society of Anesthesiology (ASA) Committee on Ambulatory Surgical Care, 2003 Clinical Resource and Audit Group (Scotland) Domain Effectiveness Patient-centeredness Efficiency Safety Access Indicator type Input Process Output Outcome All deaths within the first 30 days after ambulatory surgery programmes should be registered and analysed This indicator represents the most important measure of effectiveness and safety. All patients submitted to surgery on a DS basis All deaths within 30 days after a DS procedure. All discharges DS, age 18 years and older, with basket procedure code Number of deaths within 30 days after a procedure among cases meeting the inclusion and exclusion rules for the denominator Level D of scientific evidence (based on different expert opinions) Stratification by: each elective basket procedure Deaths are rare in DS. So, it is expected to have mortality close to 0% referred to the majority of procedures, both in public and private healthcare institutions. Level of Health Care Delivery DS unit, Hospital, Regional and National Data source Administrative data Survey Recommended by The American Society of Anaesthesiologists (ASA) 61

28 % DS unplanned overnight admission Aldwinckle RJ, Montgomery JE. Anaesthesia 2004; 59: Ali A et al. J Minim Access Surg 2009; 5: Ansell GL, Montgomery JE. Br J Anaesth 2004; 92: Bettelli G. Minerva Anestesiol 2009; 75: Blacoe DA et al. Anaesthesia 2008; 63: Calland JF et al. Ann Surg 2001; 233: Coley KC et al. J Clin Anesth 2002; 14: Crew JP et al. Ann R Col Surg Engl 1997; 79: Fortier J et al. Can J Anaesth 1998; 45: Ganesan S et al. Ann R Coll Surg Engl 2000; 82: Gold BS et al. JAMA 1989; 262: Greenburg AG et al. Am J Surg 1996; 172: Gurusamy K et al. Br J Surg 2008; 95: Hogg RP et al. Clin Otolaryngol 1999; 24: Johnson CD, Jarrett PEM. Ann R Coll Surg Engl 1990; 72: Mandal A et al. Ann R Coll Surg Engl 2005; 87: Margovsky A. Aust NZ J Surg 2000; 70: Marshall SI, Chung F. Anesth Analg 1999; 88: Mingus ML et al. J Clin Anesth 1997; 9: Papaceit J et al. Gac Sanit 2003; 17: Rudkin GE et al. Anaesth Intens Care 1996; 24: Shah RK et al. Laryngoscope 2008; 118: Singh G et al. BMC Ear Nose Throat Disord 2004; 4: 2 - Strong NP et al. Br J Ophthalmol 1991; 75: Trottier DC et al. J Can Chir 2009; 52: ASA Committee on Ambulatory Surgical Care and Task Force on Office Based Anesthesia. Outcome indicators for office-based and ambulatory surgery 2003 ( - Australian Council on Healthcare Standards. Australasian Clinical Indicator Report : determining the potential to improve quality of care, 9th edn ( - Lemos P, Regalado AM. Patient outcomes and clinical indicators for ambulatory surgery. In: DS, Development and Practice. Lemos P, Jarrett P, Philip B (eds). IAAS. Clássica Artes Gráficas, Manual unidad de cirugía mayor ambulatoria, estándares y recomendaciones. Gobierno de España, Ministerio de Sanidad y Consumo ( Domain Effectiveness Patient-centeredness Efficiency Safety Indicator type Input Process Output Outcome Denominator Inclusions/Exclusions Numerator Inclusions/Exclusions Evidence Supporting the Criterion Allowance for Patient Factors Unplanned overnight admission for DS patients. This indicator reflects possible problems in the performance of procedures, in the appropriate selection of patients or in the proper management of operating times. Number of patients submitted to DS. Number of patients who had an unplanned overnight admission following a DS procedure. all DS discharges, age 18 years and older, with procedures basket (see Appendix A) DS discharges, age 18 years and older, with procedures basket (see Appendix A) who had an unplanned overnight admission. Level D of scientific evidence (based on different expert opinions). Stratification by: Cause (Surgical, Anaesthetic/medical and Social/administrative) Lower scores are desirable. Overall, the expected rate of unplanned overnight admission whatever the reason averages 1% in most DS centres. It might be expectable to be higher for more complex procedures (higher case-mix ratios). All DS programmes whatever the type of care setting used. Level of Health Care Delivery DS unit, Hospital, Regional and National Data source Administrative data Survey International Association for Ambulatory Surgery (IAAS) 62

29 % unplanned returns to the OR within 24 hours Ansell GL, Montgomery JE. Br J Anaesth 2004; 92: 71-4 Bettelli G. Minerva Anestesiol 2009; 75: Coley KC et al. J Clin Anesth 2002; 14: Fleisher LA et al. Arch Surg 2004; 139: Gurusamy K et al. Br J Surg 2008; 95: Lewis C, Bryson J. Ann R Coll Surg Engl 1998; 80: Marshall SI, Chung F. Anesth Analg 1999; 88: Mezei G, Chung F. Ann Surg 1999; 230: Singh G et al. BMC Ear Nose Throat Disord 2004; 4: 2 - Lemos P, Regalado AM. Patient outcomes and clinical indicators for ambulatory surgery. In: Day Surgery, Development and Practice. Lemos P, Jarrett P, Philip B (eds). IAAS. Clássica Artes Gráficas, Manual unidad de cirugía mayor ambulatoria, estándares y recomendaciones. Gobierno de España, Ministerio de Sanidad y Consumo ( Domain Effectiveness Patient-centeredness Efficiency Safety Equity Timeliness Access Indicator type Input Process Output Outcome unplanned returns to the OR within 24 hours This indicator may reflect possible problems in the performance of procedures, or in the appropriate selection of patients for management in a day surgery unit, that translate in acute or emergency situations presenting in the first 24 hours after surgery and deserve hospital admission. It might also indicate problems in the appropriate discharge from DSU. Number of patients submitted to day surgery. Number of patients re-admitted to the OR in the 24 hours postoperatively, that were previously discharged home from a day surgery programme. No exclusions. No exclusions. Not applicable. Not applicable. of Level D of scientific evidence (based on different expert opinions). Quality Not applicable. Lower scores are desirable. All day surgery programmes whatever the type of care setting used. Level of Health Care Delivery On a National Level. Data source Administrative data Survey Recommended by the International Association for Ambulatory Surgery (IAAS) 63