Using national audit data to drive greater patient safety and quality of care for joint replacement patients
Please note: This article is an update to the one featured in the December edition (Vol 5 / Issue 4) of The Journal of Trauma and Orthopaedics
The National Joint Registry for England, Wales, Northern Ireland and the Isle of Man (NJR) was established in 2002, it monitors the performance of implants, the effectiveness of different types of joint replacement surgery and provides evidence to improve clinical standards — all with an absolute focus on patient outcomes. NJR medical director, Mr Martyn Porter, outlines how the registry’s data is driving even greater patient safety and quality of care for joint replacement patients.
Monitoring outcomes is the NJR’s core function. As well as being a fundamental driver to improve patient centred care, NJR data now provides an important source of evidence for regulators to inform their judgements about services, such as the Care Quality Commission and NHS Improvement. During 2017, we have further reviewed how the NJR monitors implant and surgeon performance as part of the development of a new NJR Accountability and Transparency Model.
A huge amount of work has gone into this review, including significant consultation between the NJR, regulators and the profession. Undertaking such a comprehensive review of the NJR’s monitoring processes has enhanced relationships, ensuring that national audit is being integrated across a regulatory and professional framework.
Unmistakably, the NJR’s scrutiny has led to increased patient safety with poorly performing devices removed from the market and has turned a spotlight on poor surgical practice. However, it is important for a registry the size of the NJR to routinely review its processes and ensure we are continuing to best serve patients.
So what is new about the NJR’s Accountability and Transparency Model? Firstly, as part of the new model ‘prevention’ is now a key element. Implemented for the first time this year, Alert (borderline) notifications were issued, acting to prevent surgeons from becoming Alarm (outlier) status by alerting them to deteriorating outcomes at an earlier stage and thus enabling them to correct substandard practices and reduce or eliminate poor outcomes. This new function will also be extended at the hospital-level and should ensure even greater public confidence in the NJR’s monitoring processes as we aim to reduce or eliminate poor outcomes in joint replacement overtime.
Secondly, formulating an agreed process to allow an appropriate review of hospitals that fall below expected performance thresholds has been an important development of the new model. As we are now working even more closely with healthcare regulators and the profession, through the British Orthopaedic Association, we can ensure that all hospitals are fully engaged with the registry and are submitting timely and accurate data. Doing so demonstrably improves outcomes for patients and allows the NJR to monitor poor performance more accurately. The enhanced monitoring processes should help encourage hospital management to place a stronger importance on national audit data.
Importantly from a patient perspective, this way of working will provide a holistic view of surgical performance which will guide even more informed patient choice. This collaborative approach will ensure that hospitals are managed in a clear and robust manner, driven through agreed roles and relationships between the NJR, regulators and the profession.
Looking ahead, ‘practitioner reflection’ will also become a key pillar in the NJR’s monitoring process. Formalising and monitoring the use of national audit data as part of a surgeon’s annual appraisal and revalidation is a bold new approach. Once embedded this will inform the appraisal process in a constructive way by allowing joint replacement surgeons a unique mechanism to demonstrate and record, via the National Joint Registry, that they have reviewed their performance data and, importantly, reflected upon the results. Furthermore, this is something that we hope can be rolled out across the health service to encourage best practice behaviour and drive a positive professional culture - with a clear focus on patient safety.
It is important that the public has confidence that all surgeons who carry out joint replacement procedures review their performance data in a structured and accountable way. We are at an exciting juncture and once implemented it will be ground-breaking for the NHS and for patient safety and reassurance.
In the data-driven change happening across the orthopaedic sector, I hope that the processes outlined here demonstrate how the NJR is supporting surgeons to keep within safe performance limits. Whilst standards in British orthopaedics are high, surgeons must continue to use the NJR’s rich dataset to see important determinants that influence the outcome and longevity of joint replacement procedures, evaluating where additional benefits for patients can be maximised. Crucially, this includes reviewing one’s own practice by reflecting upon individual performance data.
I would encourage healthcare professionals working in this field to explore all the further information and supporting documents relating to the NJR’s Accountability and Transparency Model via the NJR’s website here.