All changed, changed utterly

QUALITY ASSESSMENT BY REGISTRARS - FIRST HAND, IN-DEPTH, ACCURATE AND
RESOURCE EFFECTIVE

We read with interest the article by Smith, highlighting serious
issues facing the medical profession and the need to implement mechanisms
to ensure high quality of care.

Accurate, on-going assessment is primary to quality control in health
care. The complex nature of modern medicine necessitates that such
quality assessment should come from within each speciality.

The use of statistical analysis to assess healthcare personnel is
fraught with inaccuracy, distortion and unacceptable risk to patients,
since a large number of failures are needed to constitute statistical
significance. Moreover, statistics can be tampered with. It is easy to
understand the temptation to do so when career and honour are at stake.
Undue importance to statistical analysis may also generate reluctance to
treat high-risk patients, for fear of adversely affecting morbidity and
mortality rates. This applies especially to highly specialised senior
clinicians, to whom are referred the cases with the most appalling
prognoses.

Perhaps the most effective instrument for improving clinical
performance is structured, constructive and critical feedback from
professional colleagues. However, limited resources and temporal
constraints preclude consultants assessing one another.

An alternative strategy involves the institution of ongoing formal
assessment of consultants by their registrars, possessed of considerable
clinical experience and acumen. Registrars rotate from firm to firm and
are thus in a position to effectively disseminate best knowledge and
practice amongst the consultants they work with. Moreover, a registrar has
the advantage of assessing a consultant over a six-month period. Such a
long-term review, with the advantages of depth and comprehensiveness may
well be superior to a short assessment by an external consultant.

It is recognised that assessment by multiple observers is essential
to obtain acceptable reliability . Political implications and personal
bias can also be minimised if every registrar passing through a firm is
required to assess the consultant and the responses averaged. Such a
system would also be time and resource effective. Most importantly, this
would ensure the retention of quality control within the medical
profession, preferable to its enforcement by external, non-medical
personnel.

For such a system to work, it is vital that an environment be created
in which senior clinicians do not feel insulted by the idea of being
assessed by their trainees, while junior doctors are free from the threat
of retribution from their consultants. An unbiased and open-minded
approach to this concept may facilitate the implementation of a highly
effective system of quality control in health care.

Co-author:
Dr. Sharmila J. Menon
Honorary Research Worker
Dept. of Human Resources
Yorkhill NHS Trust
Glasgow