Questions and Topics We Can Help You To Answer 
The front page of the Sydney Morning Herald of February 28, 2011, carried an exclusive headlined, "Thousands Hit as Hospitals Cancel Surgery" (Wallace, 2011).  It cited public records from NSW Health, the ministry responsible for monitoring New South Wales' state health system.  The records indicated that same-day surgery cancellations were "occurring regularly at three times the accepted standard."  Many patients showed up at public hospitals operated by area health services expecting to go into the operating room, only to be sent home after fasting and having blood samples sen to the lab.  In many instances, surgeries wee cancelled because the hospitals did not have beds waiting for the patients after their surgeries.

The article noted that the ministry's Surgery Dashboard," a monthly snapshot of key performance indicators, set a target of less than 2% for surgery cancellations.  This is a stretch or "aspirational" goal, and some NSW hospitals were not meeting the previous standard of less than 5%.

The Surgical Service Taskforce developed the dashboard, and NSW Health incorporated it into its Pre-Procedure Preparation Toolkit, a guideline issued by the ministry's Health Service Performance Improvement Branch.

The guideline indicators and targets were reviewed in November 2012, and the canceled surgeries target remained unchanged.

The reporter interviewed the chair of the local Australian Medical Association hospital practice committee, who was also a medical school faculty member.  He suggested that the problem was worse than indicated, because patients who wanted surgery but were never booked were not counted.  He observed that the benchmark percentage was "ambitious but clearly double or triple that figure is unacceptable."  He called a ministry plan to add 400 public hospital beds per year insufficient.  

The deputy director-general of NSW Health told the reporter that 40-45% of the cancellations were for "patient reasons," such as the patient not showing up or being ill on the day of surgery.  He also noted that there were multiple reason why hospitals could not accommodate surgery patients-when trauma patients unexpectedly tied up ICU beds, for example, or when necessary supplies and equipment were not available.  He noted that when the benchmark had been less than 5% nearly all the hospitals had met it, so it was raised to and "aspirational" level of less than 2% in 2007.

Data extracted from the monthly reports by the newspaper indicated that some hospitals were usually failing to meet the less than 5% target and few had come close to the less than 2% level on a consistent basis.  The same-day cancellation rate for six of the nine local hospitals was around 4%.  This suggests that almost 9,000 same-day surgeries are cancellation rate of 4-5% was typical of other Australian states and that 91% of elective surgeries were "completed on time." 


      **********TABLE 15-1 Key Surgical Performance Indicator**********
STATE LEVEL

Booked patient cancellations on the day of surgery for any reason    <2.0%
Patients canceled due to medical conditions (included above)            <1.0%

Suggested for local level

Patients through the pre-procedure preparation process                        100%
Percentage of patients processed by:                              Target locally determined
                Telephone interview
                General pre-admission clinic
                Multidisciplinary pre-admission clinic

Average time spent by patient in pre-admission clinic
                General (anesthetist and nurse)                                                  2 hours
                Multidisciplinary                                                                              4 hours

Other

Patients who "do no attend" on the day of surgery                                    <0.5%

                **********DISCUSSION QUESTIONS TO ANSWER**********

1.  Do the conclusions you draw from the case justify the headline?  Why or why not?
2. Evaluate the indicators shown in Table 15-1. These are not the only indicators. Others included the waiting time for elective surgery by urgency category.
3. What do you estimate is the avoidable rate of canceled surgeries, and how would you develop an indicator for that?
4. How would you factor in the biases of both the doctors and NSW Health?
5. How might you manage the phenomenon that raising the benchmarks to "aspirational" level means reporting more failure to the public?
6. Investigate the overlapping of private and public hospital systems in Australia.  How does this complicate the issues of performance evaluations and improvement? In New South Wales, the Department of Health regulates private facilities and also manages the public ones. What are the strengths and weaknesses of such arrangements?