NJR Surgical Performance Committee (SPC)
Chair’s report 2022/23 – Mr Peter Howard
The Surgical Performance Committee (SPC) comprises its Chair, and also the NJR Medical Director, RCC Chair, surgeon representatives from the RCC committee, Care Quality Commission (CQC) representatives, a patient representative, representation from the NJR Management Team and representatives of both Lot 1 and Lot 2 NJR contractors.
We have continued with the schedule of two data reviews each year, assessing performance over the previous five and ten years for both units and surgeons performing hip and knee joint replacement.
The Accountability and Transparency Model, first introduced in 2017, was recently updated to reflect changes throughout the year, and we work closely with the CQC and NHS Improvement to escalate issues where necessary. This year for the first time, hospitals who were at ‘alert level’ over five or ten years of data were notified that they may wish to review their outcome data to address any potential issues as early as possible.
NJR Annual Clinical Report and Consultant Level Report
Further changes and updates were made once again this year to the Annual Clinical Report (ACR) provided for all trusts, health boards and independent hospitals and also to the Consultant Level Report (CLR) provided for consultant surgeons. These reports are accessible through the NJR Connect – Data Services portal. In addition, as part of NJR Connect hospitals are now able to access a wider range of information around hospital performance via management feedback.
Changes to knee surgeon performance outcome monitoring
Following discussions with the British Association for Surgery of the Knee (BASK) and British Orthopaedic Association (BOA), our alarm process has been amended to identify surgeons who appear as potential outliers for their total knee replacement (TKR) practice data and/or their unicondylar knee (UKR) practice and/or their patello-femoral joint replacement (PFJ) data alone rather than just based on their overall knee practice. Units are now notified for these sub-strata, but also for their overall knee replacement outcomes.
As overall knee practice data for a surgeon may still indicate an imminent outlier status in the subgroups, (UKR/TKR), surgeons whose overall five and/or ten year knee practice data demonstrates outlier status have their results individually assessed. If no concerns, the surgeon will be notified as an ‘alert’ but if a potential problem is identified, notification as a potential alarm outlier will take place, as per the old process. The performance in “all knees” continues to be monitored and will appear in surgeons’ Annual Clinical Reports, however reaching alarm level no longer automatically triggers a notification involving the hospital’s medical director.
The surgeon Consultant Level Report (CLR) now contains funnel plot information about TKR and UKR practice separately, as well as data about overall knee practice.
For more information, see our website.
Persistent outlier status
If a surgeon or unit is identified as being a persistent outlier for either their 5-year or 10-year data and remained at this status for five years for 10-year data or three years for 5-year data, they and their medical director will be sent a further notification letter and asked to submit an update on progress against an action plan. This is then reviewed by the NJR Surgical Performance Committee and further recommendations given if necessary. Surgeons who have had up to two (consecutive or non-consecutive) periods of non-outlier performance during this five or three-year period are considered ‘persistent’. Hospitals that are not making progress to improve their status may be referred to the BOA for an Elective Care Review.
Usage of outlier implants
We currently write to surgeons to notify them if an implant/combination of implant used by them in the last twelve months has been identified by the NJR as having a higher‐than‐expected revision rate. The purpose of the alert is to ensure that surgeons are aware of the implant’s higher revision rate in primary procedures and to remind them to take this into account when making their implant choice. There may be legitimate reasons to use such an implant thereafter in certain complex cases, but alternatives should also be considered to avoid having an adverse impact on their patient(s). We will have already informed the MHRA about these implants.
We are continuing to alert surgeons and hospitals to the very rarely occurring mismatches in size, side and manufacturer. This alert process is well embedded and is monitored regularly by both the SPC and NJR Data Quality Committee. The implant scanning tool, available for hospitals to check implant compatibility in real time in theatre has been in use over the past year; as adoption by more hospitals increases, it is hoped this tool will help to reduce the numbers of “never events”.
During 2023/24, the NJR will be rolling out procedure outcomes at both trust and geographical level to help improve hospital performance. The NJR will also commence notifications to lead surgeons, in addition to those for consultant in charge.
The NJR plans to expand our Accountability and Transparency model to include elbow, shoulder and ankle performance metrics for all hospitals and surgeons.
The NJR Connect – Data Services reporting platform will be further developed to include
additional performance data for hospitals and surgeons to support quality improvement, which will include development of a new module to capture megaprosthesis devices used in tumour surgery.