1. Clinical Governance

Variation in clinical practice and health outcomes

Action 1.28

The health service organisation has systems to:

a. Monitor variation in practice against expected health outcomes

b. Provide feedback to clinicians on variation in practice and health outcomes

c. Review performance against external measures

d. Support clinicians to take part in clinical review of their practice

e. Use information on unwarranted clinical variation to inform improvements in safety and quality systems

f. Record the risks identified from unwarranted clinical variation in the risk management system

Intent

Clinical practice levels of activity, processes of care and outcomes are reviewed regularly and compared with data on performance from external sources and other similar health service organisations.

Reflective questions

How does the health service organisation use both external and internal systems for monitoring and improving clinical and patient outcomes?

How does the health service organisation interact with clinicians regarding their clinical practice and the health outcomes of their patients?

Key tasks

  • Identify key external data collections, registries, audits or reports that cover the specific areas of clinical practice relevant to patients, or procedures or services offered by the organisation
  • Support and encourage clinicians to participate in national and state or territory clinical quality registries
  • In collaboration with clinicians, review clinical practice data from the organisation, and compare them with data from similar geographic areas or health service organisations
  • Identify any areas of practice that vary from best practice, that show widely differing practice within the organisation or that vary from practice in similar services
  • Investigate the reasons for any variation and identify whether it is unwarranted variation in the safety and quality of care
  • Identify actions to ensure that practice changes align with best practice
  • Consider issues of inappropriate resource allocation (including workforce) to ensure that practice changes align with best practice
  • Identify any areas of risk and act to mitigate them
  • Review the schedule of data and reports provided to the governing body and clinicians to ensure that they are comprehensive and relevant, and cover actions taken to align practice with desired care.

Strategies for improvement

Hospitals

People expect to receive care that is appropriate for their needs and informed by evidence. However, use of healthcare interventions and outcomes of care vary for different populations, across geographic areas, and among services and clinicians. Understanding this variation is critical to improving the quality, value and appropriateness of health care. Some variation is desirable and warranted – it reflects differences in peoples’ healthcare needs. If variation is unwarranted, it signals that people are not getting appropriate care.

Review the data

Examining variation in care from that provided by similar services is an important first step in identifying and addressing any unwarranted variation. Identify internal and external data sources, and select quality metrics that are relevant to the population served and the services provided.

Review the data to see whether the organisation’s performance varies from known best practice or from the performance of similar organisations. Investigate any outlying data to identify whether any of the variation is warranted, and implement possible approaches to deal with unwarranted variation. Compare the service’s data with data from peer services; data from other organisations; or state, territory or national performance data.

Data derived from the clinical care standards indicators can be used to show variation and improvement in clinical practice.

The clinical and management teams should be responsible for analysing these data, and for:

  • Identifying issues, and solutions to deal with them
  • Disseminating information about any unwarranted variation, and how it will be addressed
  • Acting to make changes to care if required
  • Reporting actions taken to reduce unwarranted variation and ongoing performance to the governing body, through the clinical governance framework, and to other relevant organisations.

Analyse information on unwarranted clinical variation for opportunities to improve safety and quality. Support clinicians to take part in the data analysis, and encourage them to review and, if necessary, change their practice in light of the findings.

Use clinical quality registries

Australia currently has limited capacity to measure and monitor the degree to which health care benefits the patient (effectiveness), and how closely that care aligns with evidence-based practice and patient preferences (appropriateness). Clinical quality registries monitor and report on the appropriateness and effectiveness of health care, but only a small number of data collections currently capture and report process and outcomes data for specific clinical conditions or interventions.

Clinical quality registries are organisations that systematically monitor the quality (appropriateness and effectiveness) of health care, within specific clinical domains, by routinely collecting, analysing and reporting health-related information. The information is used to identify benchmarks and marked outcome variance, and inform improvements in healthcare quality.1

A number of well-established clinical quality registries operate in Australia, to which hospitals contribute information. Examples are:

  • Australia and New Zealand Intensive Care Society Adult Patient Database
  • Australian and New Zealand Dialysis and Transplant Database
  • Australian Orthopaedic Association National Joint Replacement Registry
  • Australasian Cardiac Outcomes Registry
  • Australian and New Zealand Neonatal Network
  • Victorian Prostate Cancer Registry
  • Victorian State Trauma Registry

Organisations should ensure that they contribute data to established clinical registries and, if possible, use the information generated from clinical quality registers as part of their data analysis.

Clinical registries are usually established and maintained by specialist groups. The clinical governance committee should investigate the clinical registries that are relevant to the organisation.

The Commission has developed a framework for Australian clinical quality registries in collaboration with states, territories and expert registry groups, to reduce the gap in the measurement of healthcare quality and inform improvements in patient care.

More information on variation in healthcare provision across Australia is available in the Australian Atlas of Healthcare Variation.

Examples of evidence

Select only examples currently in use:

  • Policy documents that identify the external clinical quality systems that the health service organisation contributes to and encourages its clinicians to take part in
  • Reports on data analyses that are used to identify variation in clinical practice and areas of risk associated with variation in clinical practice
  • Reports that compare clinical practice and outcomes with those of similar services or peer organisations
  • Reports on comparative data analysis from meetings involving clinicians that identify potential reasons for any variation, further investigations that may be needed and potential areas of risk associated with variation in clinical practice
  • Comparative data analysis on clinical variation and the outcomes associated with care using external sources such as the Australian Atlas of Healthcare Variation, or data provided by, or shared with, external organisations such as clinical quality registries, the Health Roundtable, peer organisations, and states and territories
  • Committee and meeting records in which reports on clinical variation or appropriateness of practice were discussed, and clinicians assessed interventions and managed changes in practice
  • Audit results of clinical practice against the recommended best-practice guidelines, pathways or clinical care standards, and reports on findings that are provided to all relevant clinicians, managers and committees
  • Records of clinical participation in morbidity and mortality reviews, external audits of clinical care, and external clinical registries
  • Risk management system that includes actions to manage identified risks associated with unwarranted variation
  • Quality improvement system that includes actions to deal with identified issues
  • Examples of improvement activities that have been implemented and evaluated to reduce unwarranted variation.
Day Procedure Services

People expect to receive care that is appropriate for their needs and informed by evidence. However, use of healthcare interventions and outcomes of care vary for different populations, across geographic areas, and among services and clinicians. Understanding this variation is critical to improving the quality, value and appropriateness of health care. Some variation is desirable and warranted – it reflects differences in people’s healthcare needs. If variation is unwarranted, it signals that people are not getting appropriate care.

Review the data

Examining variation in care from that provided by similar services is an important first step in identifying and addressing any unwarranted variation. Identify internal and external data sources, and select quality metrics that are relevant to the population served and the services provided.

Review the data to see whether the organisation’s performance varies from known best practice or from the performance of similar organisations. Investigate any outlying data to identify whether any of the variation is warranted, and implement possible approaches to deal with unwarranted variation. Compare the service’s data with data from peer services; data from other organisations; or state, territory or national performance data.

Data derived from the clinical care standards indicators can be used to show variation and improvement in clinical practice.

The clinical and management teams should be responsible for analysing these data, and for:

  • Identifying issues, and solutions to deal with them
  • Disseminating information about any unwarranted variation, and how it will be addressed
  • Acting to make changes to care, if required
  • Reporting actions taken to reduce unwarranted variation and ongoing performance to the governing body, through the clinical governance framework, and to other relevant organisations.

Analyse information on unwarranted clinical variation for opportunities to improve safety and quality. Support clinicians to take part in the data analysis, and encourage them to review and, if necessary, change their practice in light of the findings.

Use clinical quality registries

Australia currently has limited capacity to measure and monitor the degree to which health care benefits the patient (effectiveness), and how closely that care aligns with evidence-based practice and patient preferences (appropriateness). Clinical quality registries monitor and report on the appropriateness and effectiveness of health care, but only a small number of data collections currently capture and report process and outcomes data for specific clinical conditions or interventions.

Clinical quality registries are organisations that systematically monitor the quality (appropriateness and effectiveness) of health care, within specific clinical domains, by routinely collecting, analysing and reporting health-related information. The information is used to identify benchmarks and marked outcome variance, and inform improvements in healthcare quality.1

A number of well-established clinical quality registries operate in Australia, to which hospitals contribute information. Examples are:

  • Australian and New Zealand Intensive Care Society Adult Patient Database
  • Australia and New Zealand Dialysis and Transplant Database
  • Australian Orthopaedic Association National Joint Replacement Registry
  • Australasian Cardiac Outcomes Registry
  • Australian and New Zealand Neonatal Network
  • Victorian Prostate Cancer Registry
  • Victorian State Trauma Registry.

Day procedure services should ensure that they contribute data to established clinical registries and, if possible, use the information generated from clinical quality registers as part of their data analysis.

Clinical registries are usually established and maintained by specialist groups. The clinical governance group should investigate the clinical registries that are relevant to the organisation.

The Commission has developed a framework for Australian clinical quality registries in collaboration with states, territories and expert registry groups, to reduce the gap in the measurement of healthcare quality and inform improvements in patient care.

More information on variation in healthcare provision across Australia is available in the Australian Atlas of Healthcare Variation.

Examples of evidence

Select only examples currently in use:

  • Policy documents that identify the external clinical quality systems that the health service organisation contributes to and encourages its clinicians to take part in
  • Reports on data analyses that are used to identify variation in clinical practice and areas of risk associated with variation in clinical practice
  • Reports that compare clinical practice and outcomes with those of similar services or peer organisations
  • Reports on comparative data analysis from meetings involving clinicians that identify potential reasons for any variation, further investigations that may be needed and potential areas of risk associated with variation in clinical practice
  • Comparative data analysis on clinical variation and the outcomes associated with care using external sources such as the Australian Atlas of Healthcare Variation, or data provided by, or shared with, external organisations such as clinical quality registries, the Health Roundtable, peer organisations, and states and territories
  • Committee and meeting records in which reports on clinical variation or appropriateness of practice were discussed, and clinicians assessed interventions and managed changes in practice
  • Audit results of clinical practice against the recommended best-practice guidelines, pathways or clinical care standards, and reports on findings that are provided to all relevant clinicians, managers and committees
  • Records of clinical participation in morbidity and mortality reviews, external audits of clinical care, and external clinical registries
  • Risk management system that includes actions to manage identified risks associated with unwarranted variation
  • Quality improvement system that includes actions to deal with identified issues
  • Examples of improvement activities that have been implemented and evaluated to reduce unwarranted variation.
MPS & Small Hospitals

MPSs or small hospitals that are part of a local health network or private hospital group should adopt or adapt the established processes and practices to monitor variation in practice.

Small hospitals that are not part of a local health network or private hospital group should develop or adapt processes to:

  • Identify key external data collections, registries, audits or reports that cover the specific areas of clinical practice relevant to high-risk patients, or procedures or services offered by the organisation
  • Support and encourage clinicians to participate in national and state or territory clinical quality registries
  • In collaboration with clinicians, review clinical practice data from the organisation, and compare them with data from similar geographic areas or health service organisations
  • Identify any areas of practice that vary from best practice, that show widely differing practice within the organisation or that vary from practice in similar services
  • Investigate the reasons for any variation, and identify whether it is unwarranted variation in the safety and quality of care
  • Identify actions to ensure that practice changes align with best practice
  • Consider issues of inappropriate resource allocation (including workforce) to ensure that practice changes align with best practice
  • Identify any areas of risk and act to mitigate them
  • Review the schedule of data and reports provided to the governing body and clinicians to ensure that it is comprehensive and relevant, and covers actions taken to align practice with desired care.

More information on variation in healthcare provision across Australia is available in the Australian Atlas of Healthcare Variation.

Examples of evidence

Select only examples currently in use:

  • Policy documents that identify the external clinical quality systems that the health service organisation contributes to and encourages its clinicians to take part in
  • Reports on data analyses that are used to identify variation in clinical practice and areas of risk associated with variation in clinical practice
  • Reports that compare clinical practice and outcomes with those of similar services or peer organisations
  • Reports on comparative data analysis from meetings involving clinicians that identify potential reasons for any variation, further investigations that may be needed and potential areas of risk associated with variation in clinical practice
  • Comparative data analysis on clinical variation and the outcomes associated with care using external sources such as the Australian Atlas of Healthcare Variation, or data provided by, or shared with, external organisations such as clinical quality registries, the Health Roundtable, peer organisations, and states and territories
  • Committee and meeting records in which reports on clinical variation or appropriateness of practice were discussed, and clinicians assessed interventions and managed changes in practice
  • Audit results of clinical practice against the recommended best-practice guidelines, pathways or clinical care standards, and reports on findings that are provided to all relevant clinicians, managers and committees
  • Records of clinical participation in morbidity and mortality reviews, external audits of clinical care, and external clinical registries
  • Risk management system that includes actions to manage identified risks associated with unwarranted variation
  • Quality improvement system that includes actions to deal with identified issues
  • Examples of improvement activities that have been implemented and evaluated to reduce unwarranted variation.
Last updated 21st June, 2018 at 10:49pm
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References

Australian Commission on Safety and Quality in Health Care. Framework for Australian clinical quality registries. Sydney: ACSQHC; 2014 (accessed Sep 2017).