Introduction

In the developed world there is a ‘Quality Chasm’ between the quality of care that can be achieved and the quality and consistency of care that is being delivered. Several types of quality problems have been documented including, undue variation within services, underuse of services, overuse of services, misuse of services, and regional or ethnic disparities. Health care’s problems with safety and quality are often because it relies on outdated systems of work. Only by re-designing systems of care including the use of information technology and automated decision support will consistently improved quality of care be delivered. Both in the United States of America (USA)1 and in the United Kingdom (UK)2 major reports have highlighted these problems and charted a route to higher quality health care in the future.

These reports defined the aims for health care systems as providing safe, effective, patient-centered, timely treatment and doing so efficiently and equitably. The design principles for achieving this include: continuous relationships, evidence-based decision making, customization based on patient need, patient control, shared knowledge, and safety as a system property. In addition the health system should not waste resources or patients’ time and clinicians and institutions must cooperate and communicate to share appropriate information.

The focus of medical training has traditionally been on the central role of the doctor–patient relationship. There has been a lack of attention on the system infrastructure that supports that relationship and informs correct decision making. Each group of health care staff is typically trained separately and this can compromise the effectiveness of teams and slow the changes in roles that are needed as practice changes.

It is widely recognized that individuals and organizations can only improve performance by incorporating measures of processes and outcomes into daily work.

Defining what data needs to be collected and how this should be used and shared is therefore at the heart of high quality health care.

Cataract surgery – do we have a high quality system?

Do the above general comments on health care apply to assessment and surgery of patients with cataracts?

The vast majority of ophthalmologists and their staff in the USA, UK, and other developed countries still use paper records. This means that vital health information is poorly organized, inconsistently recorded, and often illegible. Data cannot be easily retrieved or shared in a timely fashion and it is enormously time consuming or impossible to aggregate data from multiple patients to audit the outcome of surgery. As a consequence few surgeons have a detailed understanding of their successes or complications and how they are performing relative to their peers or benchmark standards published in the literature.

Such lack of knowledge of clinical outcomes and care processes inevitably means that the quality of cataract surgery is lower than it otherwise could be. It can therefore be concluded that on a population basis the provision of cataract surgery suffers from the same failings identified for the whole health care system.

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