In Australian clinical governance, patient-reported outcomes are now expected to sit alongside other quality measures as standard evidence – not supplementary, not aspirational, but part of how boards and executives allocate resources and evaluate care. The problem is that the procedures where that expectation matters most are also the ones where it’s least likely to be met. Complex, technically demanding surgery is where structural success and patient-experienced benefit can diverge most sharply: an imaging-confirmed fusion doesn’t confirm that the pain driving the procedure has resolved. Achieving routine electronic PROM collection at scale – across four hospitals, with dedicated IT systems, defined workflows, and multi-site coordination – marks only the current frontier of what’s feasible in the most logistically accommodating settings in Australian surgical care. Complex, lower-volume procedures sit beyond it.
Australian surgical quality frameworks have progressively incorporated patient-reported outcome measures as a recognised standard, with structured PROM collection present in orthopaedic and cardiac surgical registries and embedded within the NSQHS standards framework. Yet the Australian Commission on Safety and Quality in Health Care – the national body responsible for health safety and quality standards and for issuing the National Model for Clinical Governance – reports in its stakeholder interviews that “the level of PROMs awareness and use varies widely” and that system-level use is “more challenging… at this early stage.”
The 2026 National Model for Clinical Governance sets the governance environment in which that unevenness is now expected to close. A practical implementation guide released this year gives boards and executives structured tools to embed quality monitoring in everyday practice. Within that framework, a structural metric – an imaging-confirmed fusion, a stable radiographic result – records what surgery achieved physically but not whether it achieved what motivated it. The Commission’s governance model makes the expected standard explicit: “As part of a learning culture, the board and executive act on patient-reported experience and outcome measures, alongside other measures of quality, and allocate resources to improve care.” Where complex, lower-volume procedures remain outside routine PROM capture, that expectation becomes a governance gap, not merely a data gap.
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Feasibility Achieved, Infrastructure Required
NSW’s Agency for Clinical Innovation runs a statewide Patient Reported Measures Program designed to support health services in collecting and using PROMs “at the point of care,” backed by implementation resources and training. As a standing program rather than a one-off study, it signals that scaling patient-reported measurement is a system design challenge – dependent on durable capability-building, standard workflows, and a defined feedback loop for results.
Emeritus Professor Meg E. Morris, Director of La Trobe University’s Academic and Research Collaborative in Health in a joint appointment with Healthscope’s Victorian Rehabilitation Centre in Melbourne, built the AusPROM programme to test what that infrastructure looks like at the hospital level for elective surgery. As first and corresponding author of the AusPROM protocol, Morris led a multi-site programme using the QoR-15 patient-reported outcome measure, administered electronically before surgery and at one and four weeks post-surgery across four Australian hospitals. The approximately 20,000 survey invitations and 6,000 responses established both technical feasibility and workable response rates at scale, with SMS administration outperforming email – showing that how a survey reaches a patient is as much an infrastructure decision as which survey is used.
QoR-15 scores declined one week after surgery and returned close to baseline by four weeks, confirming the instrument could detect genuine recovery trajectories across diverse elective procedures. Morris identifies where this model meets its practical boundary: routine PROM collection demands dedicated IT systems, clinical workflows, and staff time to send surveys, follow up non-respondents, and channel results back into clinical and governance discussions. That infrastructure cost is real, and it cannot be distributed at the same per-patient rate when procedure volumes fall – the defining condition of complex, lower-volume surgical settings.
The Category Where Divergence Matters Most
Complex, lower-volume surgical procedures – including complex spinal reconstruction – sit outside the collection infrastructure that programmes like AusPROM have built. In those settings, operative indications depend heavily on patient-reported symptoms: pain severity, functional limitation, quality of daily life. A confirmed structural outcome does not reliably indicate whether those symptoms resolved. An imaging-confirmed fusion may coexist with persistent pain; a stable radiographic result may reflect procedural success while a patient’s functional status remains unchanged. When only structural data is collected, that divergence is invisible to the quality evaluation process.
Leigh Atkinson and Andrew Zacest – spine specialists writing in the Medical Journal of Australia, from the Wesley Pain and Spine Centre in Brisbane and the Department of Neurosurgery at the Royal Adelaide Hospital respectively – make the point directly: “Imaging findings of structural change of osteoarthritis do not correlate with pain production.” Two patients with identical scans can have entirely different pain experiences. A quality system reading only the scan cannot tell which is which – and without patient-reported data, it has no mechanism to try.
The gap is most consequential where measurement is rarest. In high-volume elective surgery, structural-versus-patient-reported divergence can surface at the programme level because data accumulates quickly across large patient numbers. In lower-volume, technically demanding procedures, without patient-reported follow-up, the quality system has no way to determine whether a pattern of structural success is accompanied by patient-experienced benefit. Without patient-reported data, the accumulated case record cannot show whether the conditions being selected for surgery reliably produce the outcomes that justified operating in the first place.
What Both Numbers Together Reveal
The Australian Spine Registry’s 2023 annual report shows dual measurement already operating at system scale in Australian spine surgery: the registry collects PROMs pre-operatively and at 6, 12, and 24 months post-surgery, framing them as evidence of patient-perceived function and quality of life alongside clinical data.
Atlantoaxial osteoarthritis reconstruction sits at the edge of the settings that structured PROM collection programmes have reached: low in volume, technically demanding, and among the procedure types where structural and patient-experienced outcomes can diverge most sharply without either being measured against the other. Dr Timothy Steel, a neurosurgeon at St Vincent’s Private and Public Hospitals in Sydney, has documented both dimensions across a complex cervical reconstruction pathway for this condition.
Outcomes reported across 23 patients treated between 2005 and 2015 recorded a 95.5% radiographic fusion rate, VAS pain scores reducing from 9.4 to 2.9, and a Neck Disability Index falling from 72.2 to 18.9. The figure that no structural metric can supply is the 91% patient willingness to repeat surgery – a judgement about whether the outcome matched the expectation that made operating the rational choice. In a procedure category where that kind of data is rarely collected at all, the convergence of structural and experienced benefit is only visible because both were measured.
The willingness-to-repeat figure records patient judgement about whether the outcome matched the expectation that motivated surgery – a determination no imaging result can make. In this pathway, the two dimensions converge: high structural success alongside high patient-reported satisfaction. That convergence is only visible because both were measured. A pathway recording only the fusion rate carries no mechanism to detect a mismatch, and no basis for evaluating whether the operative indication was validated by the experienced outcome. For a technically demanding procedure in a category where structured PROM collection remains rare, what is measured determines what the quality system can see.
Redefining What the System Must See
Complex, lower-volume surgical procedures face a compounded version of the infrastructure problem. The per-patient cost of PROM collection, administration, and reporting is harder to absorb when throughput is low – which means the case for building dedicated systems is most difficult to make in the settings that need dual-metric evidence most. And when structural and patient-reported results diverge within a small patient group, the quality system also needs interpretive frameworks to understand what that divergence signals for operative indications over time. Neither requirement resolves itself by choosing a better questionnaire.
What Australian surgical quality frameworks are moving toward is a system in which patient-experienced outcomes hold equivalent standing to structural results – not as supplementary research data appended to clinical records, but as standard evidence of whether surgery delivered on its purpose. A confirmed scan tells one part of the story. What it cannot tell is whether surgery achieved what made it the rational choice in the first place.
Operational resourcing is the commonly dominant barrier – not conceptual opposition to patient-reported data, but the practical weight of systems, workflows, and staff time that collection requires. The ACSQHC stakeholder interviews report considerable support for PROMs among Australian clinicians while identifying workflow and system requirements as persistent constraints on collection and reporting. A peer-reviewed Australian co-design study on aggregate patient-reported data separately finds resource and time constraints as the most-cited barrier theme.
The governance framework is ahead of the infrastructure: the standard exists, the capacity to meet it in complex, low-volume settings is still being built. Interpretive and measurement concerns remain relevant – particularly when structural and patient-reported results diverge – but they are a secondary obstacle. Steel’s pathway shows that pairing structural and patient-reported outcomes is achievable within a technically demanding procedure. Morris’s AusPROM work establishes that large-scale electronic PROM collection can be made routine in elective surgery when the infrastructure is deliberately built. The quality system cannot close a gap it is not resourced to see.
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