Professional autonomy and surveillance: the case of public reporting in cardiac surgery

A qualitative study exploring risk perception in congenital cardiac surgery: the perspective of UK surgeons

INTRODUCTION

Managing risk is central to clinical care, yet most research focuses on patient perception, as opposed to how risk is enacted within the clinical setting by healthcare professionals.

AIM

To explore how surgical risk is perceived, encountered, and managed by congenital cardiac surgeons.

METHODS

Semi-structured interviews were conducted with 20 congenital cardiac surgeons representing every unit across England and Wales. All interviews were transcribed verbatim, with analysis based on the constant comparative approach.

FINDINGS

Three themes were identified, reflecting the interactions between personal, institutional, and political context in which risk is encountered and managed. First, "communicating risk" highlights the complexity and variability in methods employed by surgeons to balance legal/moral obligations with parental need and expectations. Universally, surgeons described the need for flexibility in their approach in order to meet the needs of individual patients. Second, "scrutiny and accountability" captures the spectrum of opinion arising from the binary nature of the outcomes collated and the way in which they are perceived to be interpreted. Third, "nature of the job" highlights the personal and professional implications of conveying and managing risk and the impact of recent policy changes on the way this is enacted.

CONCLUSION

Variations in approaches to communicating risk demonstrate a lack of consensus, compounded by insufficient evidence to determine or monitor a "best-care" approach. With current surgical outcomes suggesting little room for increasing survival rates, future care needs should shift to the "soft skills" in order to continue to drive improvements in parental and patient experience.

Perceived Burden Due to Registrations for Quality Monitoring and Improvement in Hospitals: A Mixed Methods Study

BACKGROUND

Quality indicators are registered to monitor and improve the quality of care. However, the number and effectiveness of quality indicators is under debate, and may influence the joy in work of physicians and nurses. Empirical data on the nature and consequences of the registration burden are lacking. The aim of this study was to identify and explore healthcare professionals' perceived burden due to quality registrations in hospitals, and the effect of this burden on their joy in work.

METHODS

A mixed methods observational study, including participative observations, a survey and semi-structured interviews in two academic hospitals and one teaching hospital in the Netherlands. Study participants were 371 healthcare professionals from an intensive care unit (ICU), a haematology department and others involved in the care of elderly patients and patients with prostate or gastrointestinal cancer.

RESULTS

On average, healthcare professionals spend 52.3 minutes per working day on quality registrations. The average number of quality measures per department is 91, with 1380 underlying variables. Overall, 57% are primarily registered for accountability purposes, 19% for institutional governance and 25% for quality improvement objectives. Only 36% were perceived as useful for improving quality in everyday practice. Eight types of registration burden were identified, such as an excessive number of quality registrations, and the lack of usefulness for improving quality and inefficiencies in the registration process. The time healthcare professionals spent on quality registrations was not correlated with any measure of joy in work. Perceived unreasonable registrations were negatively associated with healthcare professionals' joy in work (intrinsic motivation and autonomy). Healthcare professionals experienced quality registrations as diverting time from patient care and from actually improving quality.

CONCLUSION

Registering fewer quality indicators, but more of what really matters to healthcare professionals, is key to increasing the effectiveness of registrations for quality improvement and governance. Also the efficiency of quality registrations should be increased through staffing and information and communications technology solutions to reduce the registration burden experienced by nurses and physicians.

The modern hospital executive, micro improvements, and the rise of antimicrobial resistance

Antimicrobial resistance (AMR) is now recognised as a social, cultural, economic and political phenomenon, positioning the social sciences as central in responding to this global health threat. Yet efforts to address AMR within hospital settings, for example through antimicrobial stewardship (AMS) programs, continue to focus primarily on the prescribing practices of individual clinicians, often with little effect. There has been less attention to the role of healthcare administration, and managerialism therein, in explaining the limited progress to date in reining in antimicrobial misuse. To explore this, drawing on interviews with senior executives and managers from two Australian hospitals, we examine how these stakeholders navigate between management practice and AMR solutions, revealing that antimicrobial optimisation is frequently obscured by accountability structures attuned to other agendas. This has led, we argue, to the institutionalisation of micro-improvements that frequently 'tick the box' of having an AMS program, yet do little to effectively counteract rising AMR. Our analysis illustrates how sociological attention to the structural and ideological settings within which prescribing behaviour is carried out will be crucial to any attempts to successfully rein in AMR.

The impact of a spinal best practice tariff on compliance with the British Spine Registry

Aims

The British Spine Registry (BSR) was introduced in May 2012 to be used as a web-based database for spinal surgeries carried out across the UK. Use of this database has been encouraged but not compulsory, which has led to a variable level of engagement in the UK. In 2019 NHS England and NHS Improvement introduced a new Best Practice Tariff (BPT) to encourage input of spinal surgical data on the BSR. The aim of our study was to assess the impact of the spinal BPT on compliance with the recording of surgical data on the BSR.

Methods

A retrospective review of data was performed at a tertiary spinal centre between 2018 to 2020. Data were collated from electronic patient records, theatre operating lists, and trust-specific BSR data. Information from the BSR included operative procedures (mandatory), patient consent, email addresses, and demographic details. We also identified Healthcare Resource Groups (HRGs) which qualified for BPT.

Results

A total of 3,587 patients were included in our study. Of these, 1,684 patients were eligible for BPT. Between 2018 and 2019 269/974 (28%) records were complete on the BSR for those that would be eligible for BPT. Following introduction of BPT in 2019, 671/710 (95%) records were complete having filled in the mandatory data (p < 0.001). Patient consent to data collection also improved from 62% to 93%. Email details were present in 43% of patients compared with 68% following BPT introduction.

Conclusion

Our study found that following the introduction of a BPT, there was a statistically significant improvement in BSR record completion compliance in our unit. The BPT offers a financial incentive which can help generate further income for trusts. National data input into the BSR is important to assess patient outcome following spinal surgery. The BSR can also aid future research in spinal surgery.

Cite this article: Bone Jt Open 2021;2-3:198–201.

Collegiality as political work: Professions in today’s world of organizations

Collegiality is frequently portrayed as an inherent characteristic of professions, associated with normative expectations autonomously determined and regulated among peers. However, in advanced modernity other modes of governance responding to societal expectations and increasing state reliance on professional expertise often appear in tension with conditions of collegiality. This article argues that collegiality is not an immutable and inherent characteristic of the governance of professional work and organizations; rather, it is the result of the ability of a profession to operationalize the normative, relational, and structural requirements of collegiality at work. This article builds on different streams of scholarship to present a dynamic approach to collegiality based on political work by professionals to protect, maintain, and reformulate collegiality as a core set of principles governing work. Productive resistance and co-production are explored for their contribution to collegiality in this context, enabling accommodation between professions and organizations to achieve collective objectives and serving as a vector of change and adaptation of professional work in contemporary organizations. Engagement in co-production influences the ability to materialize collegiality at work, just as the maintenance and transformation of collegiality will operate in a context where professions participate and negotiate compromises with others legitimate modes of governance. Our arguments build on recent studies and hypotheses concerning the interface of professions and organizations to reveal the political work that underlies the affirmation and re-affirmation of collegiality as a mode of governance of work based on resistance and co-production.