1. Purpose
Ophthalmology is one of the most measurable parts of medicine: the vision a patient ends up with, how close the lens power landed to target, and the rate of complications can all be counted and compared against national figures. A service that measures its own results, compares them honestly and acts on outliers is a well-led service. This policy sets out how the Service audits its visual outcomes and complications and uses them to improve.
The Service must verify this policy against current Royal College of Ophthalmologists audit standards and benchmarks before adoption.
2. Sources to verify before adoption
- Royal College of Ophthalmologists, National Ophthalmology Database audit and cataract outcome benchmarks: https://www.rcophth.ac.uk/
- Getting It Right First Time (GIRFT) ophthalmology: https://gettingitrightfirsttime.co.uk/
- Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Regulation 17 (good governance) and Regulation 12 (safe care and treatment): https://www.legislation.gov.uk/uksi/2014/2936/regulation/17
3. Scope
This policy applies to:
- the outcomes and complications of the procedures the Service performs, including cataract surgery, intravitreal injection, laser and minor surgery
- the surgeons and clinicians who perform them
- the clinical governance process that reviews the results
4. What the Service measures
The Service agrees and records the measures relevant to the procedures it offers. For cataract surgery these typically include:
- the rate of posterior capsule rupture or vitreous loss
- visual acuity outcomes, including the proportion achieving a good corrected and uncorrected acuity
- refractive accuracy, meaning the proportion of eyes within a stated range of the target refraction
- the endophthalmitis rate
- other complication rates, such as retinal detachment, cystoid macular oedema, or a return to theatre
For intravitreal injection the measures include the endophthalmitis rate and other injection-related complications. The Service confirms its measures and the way it defines them against current Royal College of Ophthalmologists standards, so its figures can be compared.
5. Benchmarking and per-surgeon results
- the Service compares its results against current national benchmarks, not only against itself over time
- results are reviewed by surgeon as well as for the service as a whole, because an aggregate figure can hide an individual outlier
- the Service holds enough data per surgeon to make a fair comparison, and is careful about case-mix, so a surgeon who takes on more complex cases is judged fairly
6. Acting on outliers and unexpected outcomes
- where a surgeon's or the service's results sit outside the expected range, the Service looks into why, supportively and promptly, rather than waiting for the next annual review
- an unexpected individual outcome, such as a large refractive surprise or a serious complication, is reviewed at the time, with the lens calculation, the biometry and the technique checked
- where a problem is found, the Service acts: this may mean a change to practice, additional training or supervision, a change of equipment or technique, or a pause while the cause is understood
- support for a clinician whose results are an outlier is handled fairly and follows the Service's people and appraisal processes
7. Patient-reported outcomes
The Service seeks the patient's own view of the result where it can, because the number on the chart is not the whole story. Patient-reported outcomes and feedback are reviewed alongside the clinical measures.
8. Recording and governance
- outcome and complication data is recorded accurately and kept up to date
- the data is reviewed at the clinical governance meeting on a stated cadence, with attendance and decisions recorded
- learning that warrants a change produces improvement actions, tracked to completion with evidence
- serious complications are also logged as patient-safety incidents and run through the incident process, so single events and patterns are both seen
9. Audit cadence
The Service checks, on a stated cadence, that:
- the agreed outcome and complication measures are being collected and defined consistently
- results are benchmarked against national figures and reviewed by surgeon as well as overall
- outliers and unexpected outcomes are investigated promptly and acted on
- improvement actions from outcome review are completed with evidence
The Registered Manager and the lead surgeon review the results and record the improvement actions that follow.