The national identification of high performing providers in surgery is of prime importance to patients, surgeons and commissioners of healthcare. This thesis explores how high performance is identified, defined and measured nationally and attempts to identify the factors that underlie high performance in colorectal cancer surgery during the peri-operative period.
An introduction into the determinants of high performance in surgery as well as defining quality as it pertains to surgery is then undertaken. Identification of available national data sources and metrics for national performance are then identified. Comparison is made between voluntary and compulsory reporting systems highlighting greater capture of peri-operative mortality in compulsory reporting datasets.
A novel marker that reflects outcome following complication management is developed. This marker is based on re-operations and is derived from compulsory reporting datasets. The use of non-operative re-interventions is then assessed in oesophago-gastric cancer resections as proof of concept. An appraisal of all colorectal cancer units in England is then undertaken using a panel of metrics demonstrating that analysis on a single marker alone may be too simplistic.
Identifying factors that pertain to high performance beyond those available from routinely available datasets using a novel methodological approach called HiPer (High Performance) is performed. The interview based methodology identified rich qualitative factors in a group of colorectal cancer units worldwide that may be causal in their performance status.
Finally, results from the interview study were related to hard outcome data from each unit which demonstrated some correlation between the HiPer methodology and the outcome data in the final section of the feasibility study. The implications of this may be that a dual approach of analysing routinely collected data with a more qualitative HiPer style methodology may help us better understand how high performing units achieve their results.