Outcome monitoring to facilitate clinical governance; experience from a national programme in the independent sector.

BACKGROUND: Since 1998 BUPA has used the Short-Form 36 (SF-36) questionnaire to monitor changes in health status after adult elective surgery. Over 70 independent hospitals across the United Kingdom have collected data on over 100000 patient episodes. SF-36 is one of a number of tools that support clinical governance in the sector. Results are reported confidentially, putting the emphasis on supporting a learning culture. FORMULATION OF PROBLEMS APPARENT AT 3 YEARS: Feedback was sub-optimal: discussions with hospital staff and consultants revealed that the league tables were hard to interpret, and there was uncertainty about the definition of outlier results. The number of patients recruited to the survey was variable across the hospitals. No grouping of low-volume procedures met with agreement. ACTION PLAN FOR YEAR 4: Use 'Shewhart' control charts to distinguish common and special cause variation in results; substitute a condition-specific tool in one instance; adoption of an 'alert' process to prompt local audit of unusual results; use of a reminder letter to improve return rate of follow-up questionnaires; and focus programme on a list of 20 common procedures. Discuss these changes with the managerial and clinical leaders of each of BUPA's hospitals. CURRENT POSITION AT YEAR 5 : The use of Shewhart charts has been welcomed by managers and clinicians at BUPA's hospitals. The renewed confidence in the programme has encouraged constructive debate into allowing wider access to previously confidential results. Some changes in clinical practice have occurred.