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2.1.2 Measuring quality and outcomes

Further resources in this section 

  • Be committed to quality improvement in the interest of patient care as a core part of your clinical duties. You should contribute to clinical governance systems that strengthen day-to-day quality management and effective service delivery.
  • Submit all your activity data to national audits and databases relevant to your practice and present the results at appraisal for review against the national benchmark.
  • Take prompt action to understand the risks and ensure patient safety when your patient outcome results through audit, peer review or routinely collected data fall outside the accepted norm. Engage in conversation with your appraiser to identify the nature and basis of the concern and cooperate in relevant local investigations. You should follow the audit provider’s policy for managing outliers.
  • Keep an accurate and accessible record of all your surgical activity wherever this takes place, including outcomes and complications, bearing in mind patient confidentiality and complying with the Data Protection Act 1998. Where available, you should liaise with your Trust to obtain an analysis of routinely collected data for index procedures identified by the relevant surgical specialty association.
  • Play an active role in ensuring that your audit returns and outcome results accurately reflect your practice by being routinely involved in checking and quality-assuring the data attributed to you and your team.
  • Take part regularly in morbidity and mortality and audit meetings.
  • Be familiar with local processes and agreed thresholds for recording adverse incidents and keep a record of incidents in which you have been directly involved. You should report such incidents to those responsible in your Trust and, where relevant, to a local audit meeting.
  • Make full use of local electronic systems for reporting incidents and adverse events. You should reflect on adverse incidents in which you have been directly involved and present them for discussion at appraisal.
  • Take part in national enquiries, for example the National Confidential Enquiry into Patient Outcome and Death. You should submit your patient outcome data to relevant national databases.

« Previous: 2.1.1 Ensuring consistency in patient safety
Next: 2.2 Respond to risks to safety »


Title/Links Author Published Date
Morbidity and Mortality Meetings – A Guide to Good Practice RCS 2015

Morbidity and Mortality Meetings - Templates and Tools

RCS 2015
Maintaining Patients' Trust: Modern Medical Professionalism Society of Cardiothoracic Surgery 2011
Using Outcomes Information for Revalidation RCS 2011
Morbidity and Mortality Conference Manual Imperial College London and Oregon Health and Science University 2012

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