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Keane OA, Chambers C, Brady CM, Rehberg J, Iyer S, Santore MT. Reducing Retained Foreign Objects in the Operating Room: A Quality Improvement Initiative. J Am Coll Surg 2023; 237:864-872. [PMID: 37638667 DOI: 10.1097/xcs.0000000000000847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2023]
Abstract
BACKGROUND Although the incidence of pediatric retained foreign objects (RFOs) during surgery is diminutive (1/32,000), RFOs are often the most common sentinel events reported. In 2021, our institution noted an increase in RFOs evidenced by a substantial decrease in days between events. We aimed to minimize the incidence of RFO which was measured as an increase of days between events at our institution by implementation of a Quality Improvement initiative. STUDY DESIGN This effort was conducted across 4 surgical centers within a tertiary children's healthcare system in December 2021. Patients undergoing surgery within this healthcare system across all surgical specialties were included. The quality improvement initiative was developed by a multidisciplinary team and included 6 steps focusing on quiet time, minimizing interruptions, and closed-loop communication during final surgical count. Seven Plan-Do-Study-Act cycles were used to test, refine, and implement the protocol. Adherence to the final surgical count protocol was monitored throughout the study period. RESULTS In 2021, before protocol implementation, average time between RFO events was 29 days. After implementation of our quality initiative, the final surgical count protocol, we improved to 451 days between RFO events by February 2023, exceeding the upper control limit (235 days). After implementation, the number of RFO events dropped from 7 in 2021 to 0 in 2022. Adherence to the final surgical count protocol implementation was 96.4% by the end of cycle 7. CONCLUSIONS RFOs during pediatric surgical procedures can be successfully reduced using quality improvement methodology focusing on standardizing the procedure of the final surgical count.
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Affiliation(s)
- Olivia A Keane
- From the Department of Surgery, Emory University, Atlanta, GA (Keane, Santore)
| | - Cindi Chambers
- From the Department of Surgery, Emory University, Atlanta, GA (Keane, Santore)
| | - Colin M Brady
- From the Department of Surgery, Emory University, Atlanta, GA (Keane, Santore)
| | - Jeff Rehberg
- From the Department of Surgery, Emory University, Atlanta, GA (Keane, Santore)
| | - Srikant Iyer
- From the Department of Surgery, Emory University, Atlanta, GA (Keane, Santore)
| | - Matthew T Santore
- From the Department of Surgery, Emory University, Atlanta, GA (Keane, Santore)
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2
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Silver CM, Yang AD, Shan Y, Love R, Prachand VN, Cradock KA, Johnson J, Halverson AL, Merkow RP, McGee MF, Bilimoria KY. Changes in Surgical Outcomes in a Statewide Quality Improvement Collaborative with Introduction of Simultaneous, Comprehensive Interventions. J Am Coll Surg 2023; 237:128-138. [PMID: 36919951 DOI: 10.1097/xcs.0000000000000679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
BACKGROUND Surgical quality improvement collaboratives (QICs) aim to improve patient outcomes through coaching, benchmarked data reporting, and other activities. Although other regional QICs have formed organically over time, it is unknown whether a comprehensive quality improvement program implemented simultaneously across hospitals at the formation of a QIC would improve patient outcomes. STUDY DESIGN Patients undergoing surgery at 48 hospitals in the Illinois Surgical Quality Improvement Collaborative (ISQIC) were included. Risk-adjusted rates of postoperative morbidity and mortality were compared from baseline to year 3. Difference-in-differences analyses compared ISQIC hospitals with hospitals in the NSQIP Participant Use File (PUF), which served as a control. RESULTS There were 180,582 patients who underwent surgery at ISQIC-participating hospitals. Inpatient procedures comprised 100,219 (55.5%) cases. By year 3, risk-adjusted rates of death or serious morbidity decreased in both ISQIC (relative reduction 25.0%, p < 0.001) and PUF hospitals (7.8%, p < 0.001). Adjusted difference-in-differences analysis revealed that ISQIC participation was associated with a significantly greater reduction in death or serious morbidity (odds ratio 0.94, 95% CI 0.90 to 0.99, p = 0.01) compared with PUF hospitals. Relative reductions in risk-adjusted rates of other outcomes were also seen in both ISQIC and PUF hospitals (morbidity 22.4% vs 6.4%; venous thromboembolism 20.0% vs 5.0%; superficial surgical site infection 27.3% vs 7.7%, all p < 0.05), although these difference-in-differences did not reach statistical significance. CONCLUSIONS Although complication rates decreased at both ISQIC and PUF hospitals, participation in ISQIC was associated with a significantly greater improvement in death or serious morbidity. These results underscore the potential of QICs to improve patient outcomes.
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Affiliation(s)
- Casey M Silver
- From the Illinois Surgical Quality Improvement Collaborative (ISQIC), Chicago, IL
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3
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Keane OA, Lally KP, Kelley-Quon LI. Rise of pediatric surgery collaboratives to facilitate quality improvement. Semin Pediatr Surg 2023; 32:151278. [PMID: 37156645 DOI: 10.1016/j.sempedsurg.2023.151278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
Broad changes in pediatric surgical care delivery are limited by the rarity of pediatric surgical diseases and the geographic dispersion of pediatric surgical care across different hospital types. Pediatric surgical collaboratives and consortiums can provide the patient sample size, research resources, and infrastructure to advance clinical care for children with who require surgery. Additionally, collaboratives can bring together experts and exemplar institutions to overcome barriers to pediatric surgical research to advance quality surgical care. Despite challenges to collaboration, many successful pediatric surgical collaboratives emerged in the last decade and continue to push the field forward towards high-quality, evidence-based care and improved outcomes. This review will discuss the need for continued research and quality improvement collaboratives in pediatric surgery, identify challenges faced when building collaboratives, and introduce future directions to expand impact.
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Affiliation(s)
- Olivia A Keane
- Division of Pediatric Surgery, Children's Hospital Los Angeles, 4650 Sunset Blvd, Department of Surgery, Mailstop #100, Los Angeles, CA 90027, USA; Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Kevin P Lally
- Department of Pediatric Surgery, McGovern Medical School at UT Health Houston and Children's Memorial Hermann Hospital, Houston, TX, USA
| | - Lorraine I Kelley-Quon
- Division of Pediatric Surgery, Children's Hospital Los Angeles, 4650 Sunset Blvd, Department of Surgery, Mailstop #100, Los Angeles, CA 90027, USA; Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA; Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
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Yap EN, Dusendang JR, Ng KP, Keny HV, Webb CA, Weyker PD, Thoma MS, Solomon MD, Herrinton LJ. Risk of cardiac events after elective versus urgent or emergent noncardiac surgery: Implications for quality measurement and improvement. J Clin Anesth 2023; 84:110994. [PMID: 36356394 DOI: 10.1016/j.jclinane.2022.110994] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 10/10/2022] [Accepted: 10/31/2022] [Indexed: 11/09/2022]
Abstract
INTRODUCTION Patient populations differ for elective vs urgent and emergent surgery. The effect of this difference on surgical outcome is not well understood and may be important for improving surgical safety. Our primary hypothesis was that there is an association of surgical acuity with risk of postoperative cardiac events. Secondarily, we examined elective vs urgent and emergent patients separately to understand patient characteristics that are associated with postoperative cardiac events. METHODS We performed a retrospective cohort study of patients ≥65 years undergoing noncardiac elective or urgent/emergent surgery. Logistic regression estimated the association of surgical acuity with a postoperative cardiac event, which was defined as myocardial infarction or cardiac arrest within 30 days of surgery. For the secondary analysis, we modeled the outcome after stratifying by acuity. RESULTS The study included 161,177 patients with 1014 cardiac events. The unadjusted risk of a postoperative cardiac event was 3.2 per 1000 among elective patients and 28.7 per 1000 among urgent and emergent patients (adjusted odds ratio 4.10, 95% confidence interval 3.56-4.72). After adjustment, increased age, higher baseline cardiac risk, peripheral vascular disease, hypertension, worse American Society of Anesthesiologist (ASA) physical classification, and longer operative time were associated with a postoperative cardiac event. Higher baseline cardiac risk was more strongly associated with postoperative cardiac events in elective patients. In contrast, worse ASA physical classification was more strongly associated with postoperative cardiac events in urgent and emergent patients. Black patients had higher odds of a postoperative cardiac event only in urgent and emergent patients compared to White patients. CONCLUSIONS Quality measurement and improvement to address postoperative cardiac risk should consider patients based on surgical acuity.
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Affiliation(s)
- Edward N Yap
- Department of Anesthesia, The Permanente Medical Group, USA; Department of Anesthesia and Perioperative Care, University of California, San Francisco, USA.
| | - Jennifer R Dusendang
- Division of Research, Kaiser Permanente Northern California, The Permanente Medical Group, USA
| | - Kevin P Ng
- Department of Anesthesia, The Permanente Medical Group, USA
| | - Hemant V Keny
- Department of Surgery, The Permanente Medical Group, USA
| | - Christopher A Webb
- Department of Anesthesia, The Permanente Medical Group, USA; Department of Anesthesia and Perioperative Care, University of California, San Francisco, USA
| | - Paul D Weyker
- Department of Anesthesia, The Permanente Medical Group, USA
| | - Mark S Thoma
- Department of Anesthesia, The Permanente Medical Group, USA; Department of Anesthesia and Perioperative Care, University of California, San Francisco, USA
| | - Matthew D Solomon
- Division of Research, Kaiser Permanente Northern California, The Permanente Medical Group, USA; Department of Cardiology, The Permanente Medical Group, USA
| | - Lisa J Herrinton
- Division of Research, Kaiser Permanente Northern California, The Permanente Medical Group, USA
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Scott AL, Howe WT, Bisel R. Reviewing High Reliability Team (HRT) Scholarship: A 21st Century Approach to Safety. SMALL GROUP RESEARCH 2022. [DOI: 10.1177/10464964221116349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
High reliability team (HRT) theorizing emerged from high reliability organization (HRO) theory and now represents a distinct subset of HRO literature. Seeking to capture the development and range of HRT research, a comprehensive literature review was conducted. This systematic review of HRT scholarship, the first of its kind, provides a foundation from which small group and team scholars across disciplines may reflect on key lessons and chart future research. This review includes 71 articles across 21 disciplines and incorporates historical reflection on HRT theory foundations, existing empirical support, critiques and rivals, theory extensions, and ideas for future scholarship efforts.
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Leung SN, Al-Omran M, Greco E, Hughes B, Qadura M, Wheatcroft M, Murray J, Mamdani M, de Mestral C. Harnessing the full potential of hospital-based data to support surgical quality improvement. BMJ Open Qual 2021; 10:bmjoq-2020-001178. [PMID: 34697037 PMCID: PMC8547498 DOI: 10.1136/bmjoq-2020-001178] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Accepted: 10/01/2021] [Indexed: 11/30/2022] Open
Abstract
Surgical departments commonly rely on third-party quality improvement registries. As electronic health data become increasingly integrated and accessible within an institution, alternatives to these platforms arise. We present the conceptualization and implementation of an in-house quality improvement platform that provides real-time reports, is less onerous on clinicians and is tailored to an institution’s priorities of care.
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Affiliation(s)
- Sean Nicholas Leung
- Department of Surgery, Unity Health Toronto - St Michael's Hospital, Toronto, Ontario, Canada.,Faculty of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Mohammed Al-Omran
- Department of Surgery, Unity Health Toronto - St Michael's Hospital, Toronto, Ontario, Canada.,Faculty of Medicine, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Elisa Greco
- Department of Surgery, Unity Health Toronto - St Michael's Hospital, Toronto, Ontario, Canada.,Faculty of Medicine, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Bertha Hughes
- Department of Surgery, Unity Health Toronto - St Michael's Hospital, Toronto, Ontario, Canada
| | - Mohammad Qadura
- Department of Surgery, Unity Health Toronto - St Michael's Hospital, Toronto, Ontario, Canada.,Faculty of Medicine, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Mark Wheatcroft
- Department of Surgery, Unity Health Toronto - St Michael's Hospital, Toronto, Ontario, Canada.,Faculty of Medicine, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Joshua Murray
- The Li Ka Shing Centre for Healthcare Analytics Research & Training, Unity Health Toronto - St Michael's Hospital, Toronto, Ontario, Canada
| | - Muhammad Mamdani
- The Li Ka Shing Centre for Healthcare Analytics Research & Training, Unity Health Toronto - St Michael's Hospital, Toronto, Ontario, Canada
| | - Charles de Mestral
- Department of Surgery, Unity Health Toronto - St Michael's Hospital, Toronto, Ontario, Canada .,Faculty of Medicine, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
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Chilakamarri P, Finn EB, Sather J, Sheth KN, Matouk C, Parwani V, Ulrich A, Davis M, Pham L, Chaudhry SI, Venkatesh AK. Failure Mode and Effect Analysis: Engineering Safer Neurocritical Care Transitions. Neurocrit Care 2021; 35:232-240. [PMID: 33403581 DOI: 10.1007/s12028-020-01160-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 11/18/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND/OBJECTIVE Inter-hospital patient transfers for neurocritical care are increasingly common due to increased regionalization for acute care, including stroke and intracerebral hemorrhage. This process of transfer is uniquely vulnerable to errors and risk given numerous handoffs involving multiple providers, from several disciplines, located at different institutions. We present failure mode and effect analysis (FMEA) as a systems engineering methodology that can be applied to neurocritical care transitions to reduce failures in communication and improve patient safety. Specifically, we describe our local implementation of FMEA to improve the safety of inter-hospital transfer for patients with intracerebral and subarachnoid hemorrhage as evidence of success. METHODS We describe the conceptual basis for and specific use-case example for each formal step of the FMEA process. We assembled a multi-disciplinary team, developed a process map of all components required for successful transfer, and identified "failure modes" or errors that hinder completion of each subprocess. A risk or hazard analysis was conducted for each failure mode, and ones of highest impact on patient safety and outcomes were identified and prioritized for implementation. Interventions were then developed and implemented into an action plan to redesign the process. Importantly, a comprehensive evaluation method was established to monitor outcomes and reimplement interventions to provide for continual improvement. RESULTS This intervention was associated with significant reductions in emergency department (ED) throughput (ED length of stay from 300 to 149 min, (p < .01), and improvements in inter-disciplinary communication (increase from pre-intervention (10%) to post- (64%) of inter-hospital transfers where the neurological intensive care unit and ED attendings discussed care for the patient prior to their arrival). CONCLUSIONS Application of the FMEA approach yielded meaningful and sustained process change for patients with neurocritical care needs. Utilization of FMEA as a change instrument for quality improvement is a powerful tool for programs looking to improve timely communication, resource utilization, and ultimately patient safety.
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Affiliation(s)
- Priyanka Chilakamarri
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
- Veteran Affairs Connecticut Healthcare System, West Haven, CT, USA
- Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Emily B Finn
- Yale Center for Healthcare Innovation, Redesign and Learning, New Haven, CT, USA
| | - John Sather
- Department of Emergency Medicine, Yale University School of Medicine, 464 Congress Ave. Suite 260, New Haven, CT, 06519, USA
| | - Kevin N Sheth
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Charles Matouk
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
| | - Vivek Parwani
- Department of Emergency Medicine, Yale University School of Medicine, 464 Congress Ave. Suite 260, New Haven, CT, 06519, USA
| | - Andrew Ulrich
- Department of Emergency Medicine, Yale University School of Medicine, 464 Congress Ave. Suite 260, New Haven, CT, 06519, USA
| | - Melissa Davis
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, CT, USA
| | - Laura Pham
- Yale New Haven Hospital Patient and Physician Access, New Haven, CT, USA
| | - Sarwat I Chaudhry
- Yale New Haven Hospital, Center for Outcomes Research and Evaluation, New Haven, CT, USA
| | - Arjun K Venkatesh
- Department of Emergency Medicine, Yale University School of Medicine, 464 Congress Ave. Suite 260, New Haven, CT, 06519, USA.
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Taylor MA, Hewes HA, Bolinger CD, Fenton SJ, Russell KW. Established Time Goals Can Increase the Efficiency of Trauma Resuscitation. Cureus 2020; 12:e9524. [PMID: 32905069 PMCID: PMC7466907 DOI: 10.7759/cureus.9524] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Introduction Our institution uses video review as a quality improvement tool. Starting in March 2018, we specifically focused on meeting certain time goals during trauma resuscitation aimed at decreasing time to final disposition. The purpose of this study was to evaluate the effect of establishing strict time goals on total time spent in the trauma bay by pediatric trauma patients. Materials and methods A retrospective review of all level I trauma activations at a level I pediatric trauma center between November 2017 and December 2018 was performed via manual review of the recorded trauma activations. Data on key time points such as time from arrival to transfer to gurney, to completion of primary survey, to chest x-ray, to Emergency Medical Services (EMS) report, to CT scan, and to disposition (CT or admission/operating room [OR] if no CT scan was performed) were analyzed and compared between the cohort of patients prior to implementation of the time goals with that after. The cohort of patients who presented between March 2018 and May 2018 were excluded to allow for time for the intervention to take effect. Results There were 13 level I trauma activations before implementation of the time goals and 41 after. There was a significant decrease in time to transfer to gurney (1.8 minutes vs. 1.0 minutes; p=0.02), to CT scan (18.8 minutes vs. 14.2 minutes; p=0.01), and to disposition (18.3 minutes vs. 14.9 minutes; p=0.047). There was no decrease in time to completion of primary survey, EMS report, or chest x-ray. Conclusions Utilizing video review in pediatric trauma as a quality improvement initiative with a focus on meeting specific time goals for key elements of the activation led to decreased total time in our trauma bay with critically ill patients.
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Affiliation(s)
- Mark A Taylor
- Department of Surgery, University of Utah Health, Salt Lake City, USA
| | - Hilary A Hewes
- Department of Emergency Medicine, Primary Children's Hospital, Salt Lake City, USA
| | - Carol D Bolinger
- Department of Pediatric Surgery, Primary Children's Hospital, Salt Lake City, USA
| | - Stephen J Fenton
- Department of Surgery, University of Utah Health, Salt Lake City, USA
| | - Katie W Russell
- Department of Surgery, University of Utah Health, Salt Lake City, USA
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9
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Chia MC, Yang AD. Utilizing Benchmarking to Reduce Adverse Outcomes. Jt Comm J Qual Patient Saf 2020; 46:183-184. [PMID: 32223904 DOI: 10.1016/j.jcjq.2020.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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10
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Beyranvand T, Aryankhesal A, Aghaei Hashjin A. Quality improvement in hospitals' surgery-related processes: A systematic review. Med J Islam Repub Iran 2019; 33:129. [PMID: 32280635 PMCID: PMC7137843 DOI: 10.34171/mjiri.33.129] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2019] [Indexed: 11/23/2022] Open
Abstract
Background: There is a growing global movement toward quality and safety in healthcare and quality improvement (QI) in general surgery. The fundamentals of QI begin with an understanding of the underlying theoretical framework. This study aims to provide an overview of the existing QI models and frameworks for general surgery. Methods: In this systematic review, published literature from January 2007 until September 2018 were retrieved from PubMed, Scopus, Web of Science and Embase databases, and Google Scholar using the MeSH terms related to QI and surgery. In total, 25 fulltext articles were finally included, and data extraction was based on research objectives. Results: Nine models were identified for QI in general surgery. These models were categorized into two main groups: (i) conceptual models or frameworks designed for QI in industry and applied in surgery, and (ii) those designed specifically for QI in surgery. Identified QI models were more used for improving postoperative processes and pre-hospital trauma care, identifying causes of prolonged periods of stay and lowering LOS index, improving surgical antimicrobial prophylaxis and antibiotics administrating during surgery process, reducing and controlling infections, reducing complications, reducing mortality and morbidity, reducing waiting times and start time delays, reducing variability and improving surgical clinic experience, reducing costs, improving operating room efficiency by removing processes that add no value, and lowering per-capita costs. Conclusion: According to the findings of this study, there are different models and frameworks with different aspects and dimensions for QI in surgery, which is recommended to use either of these models alone or with each other for specific circumstances. The use of these models in surgery is increasing, and it is recommended that these models could be used according to their functions in cases such as reducing the unnecessary use of resources, increasing the satisfaction of patients and their families with health care and improving the efficiency, safety and quality of healthcare in the surgical departments.
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Affiliation(s)
- Tina Beyranvand
- Department of Health Services Management, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Aidin Aryankhesal
- Department of Health Services Management, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Asgar Aghaei Hashjin
- Department of Health Services Management, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
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Stonko DP, O Neill DC, Dennis BM, Smith M, Gray J, Guillamondegui OD. Trauma Quality Improvement: Reducing Triage Errors by Automating the Level Assignment Process. JOURNAL OF SURGICAL EDUCATION 2018; 75:1551-1557. [PMID: 29656835 DOI: 10.1016/j.jsurg.2018.03.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Revised: 01/31/2018] [Accepted: 03/26/2018] [Indexed: 06/08/2023]
Abstract
BACKGROUND Trauma patients are triaged by the severity of their injury or need for intervention while en route to the trauma center according to trauma activation protocols that are institution specific. Significant research has been aimed at improving these protocols in order to optimize patient outcomes while striving for efficiency in care. However, it is known that patients are often undertriaged or overtriaged because protocol adherence remains imperfect. The goal of this quality improvement (QI) project was to improve this adherence, and thereby reduce the triage error. It was conducted as part of the formal undergraduate medical education curriculum at this institution. STUDY DESIGN A QI team was assembled and baseline data were collected, then 2 Plan-Do-Study-Act (PDSA) cycles were implemented sequentially. During the first cycle, a novel web tool was developed and implemented in order to automate the level assignment process (it takes EMS-provided data and automatically determines the level); the tool was based on the existing trauma activation protocol. The second PDSA cycle focused on improving triage accuracy in isolated, less than 10% total body surface area burns, which we identified to be a point of common error. Traumas were reviewed and tabulated at the end of each PDSA cycle, and triage accuracy was followed with a run chart. SETTING This study was performed at Vanderbilt University Medical Center and Medical School, which has a large level 1 trauma center covering over 75,000 square miles, and which sees urban, suburban, and rural trauma. PARTICIPANTS The baseline assessment period and each PDSA cycle lasted 2 weeks. During this time, all activated, adult, direct traumas were reviewed. There were 180 patients during the baseline period, 189 after the first test of change, and 150 after the second test of change. All were included in analysis. RESULTS Of 180 patients, 30 were inappropriately triaged during baseline analysis (3 undertriaged and 27 overtriaged) versus 16 of 189 (3 undertriaged and 13 overtriaged) following implementation of the web tool (p = 0.017 for combined errors). Overtriage dropped further from baseline to 10/150 after the second test of change (p = 0.005). The total number of triaged patients dropped from 92.3/week to 75.5/week after the second test of change. There was no statistically significant change in the undertriage rate. CONCLUSION The combination of web tool implementation and protocol refinement decreased the combined triage error rate by over 50% (from 16.7%-7.9%). We developed and tested a web tool that improved triage accuracy, and provided a sustainable method to enact future quality improvement. This web tool and QI framework would be easily expandable to other hospitals.
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Affiliation(s)
- David P Stonko
- Vanderbilt University School of Medicine, Nashville, Tennessee
| | | | - Bradley M Dennis
- Vanderbilt Division of Trauma and Surgical Critical Care, Nashville, Tennessee
| | - Melissa Smith
- Vanderbilt Division of Trauma and Surgical Critical Care, Nashville, Tennessee
| | - Jeffrey Gray
- Vanderbilt LifeFlight, Vanderbilt University Medical Center, Nashville, Tennessee
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Bozzay J, Bradley M, Kindvall A, Humphries A, Jessie E, Logeman J, Bailey J, Elster E, Rodriguez C. Review of an emergency general surgery process improvement program at a verified military trauma center. Surg Endosc 2018; 32:4321-4328. [PMID: 29967995 DOI: 10.1007/s00464-018-6303-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Accepted: 06/18/2018] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Decreasing combat-based admissions to our military facility have made it difficult to maintain a robust trauma process improvement (PI) program. Since emergency general surgery (EGS) and trauma patients share similarities, we merged the care of our EGS and trauma patients into one acute care surgery (ACS) team. An EGS PI program was developed based on trauma PI principles to facilitate continued identification of opportunities for improvement despite our decline in trauma admissions. Analysis of the first 18 months of combined ACS PI data is presented. METHODS EGS registry inclusion criteria was based on published Association for the Surgery of Trauma's recommendations. Program components and PI categories were based on our existing trauma PI program. Dedicated coordinators actively reviewed and cataloged patient care and outcomes. Deviations from standard practice patterns, unplanned interventions, and other complications were abstracted, categorized, and evaluated through levels of review similar to accepted trauma PI principles. Data for the first six quarters were collated and trends were analyzed. RESULTS Over 18 months, 696 EGS patients met registry inclusion criteria, with 468 patients (67%) undergoing operative intervention. Over the same time, 353 trauma patients were admitted with 158 undergoing operative intervention (56.4%). Of the 696 EGS patients and 353 trauma patients, 226 (32%) and 243 (69%) PI events were identified, respectively. Common events included unplanned therapies, re-admissions, and unplanned ICU admissions. Based on analysis of all events, four new areas for improvement initiatives were identified. Results of these initiatives included implementation of a multi-disciplinary EGS PI committee, consensus protocols, and departmental and hospital-wide actions. CONCLUSION In an 18-month period, integration of our EGS patients into a novel, combined ACS PI program facilitated recognition of an additional 226 PI events and provided a substrate for continued improvements in patient care.
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Affiliation(s)
- Joseph Bozzay
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD, 20889, USA.
| | - Matthew Bradley
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD, 20889, USA.,Naval Medical Research Center, Silver Spring, MD, USA
| | - Angela Kindvall
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD, 20889, USA
| | - Ashley Humphries
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD, 20889, USA
| | - Elliot Jessie
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD, 20889, USA
| | - Judy Logeman
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD, 20889, USA
| | - Jeffrey Bailey
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD, 20889, USA
| | - Eric Elster
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD, 20889, USA
| | - Carlos Rodriguez
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD, 20889, USA
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Honda AC, Bernardo VZ, Gerolamo MC, Davis MM. How Lean Six Sigma Principles Improve Hospital Performance. ACTA ACUST UNITED AC 2018. [DOI: 10.1080/10686967.2018.1436349] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- Ana Carolina Honda
- Sao Carlos School of Engineering, University of Sao Paulo, Avenida Trabalhador Sao Carlense, Sao Carlos, Brazil
| | - Vitor Zanetti Bernardo
- Sao Carlos School of Engineering, University of Sao Paulo, Avenida Trabalhador Sao Carlense, Sao Carlos, Brazil
| | - Mateus Cecílio Gerolamo
- Sao Carlos School of Engineering, University of Sao Paulo, Avenida Trabalhador Sao Carlense, Sao Carlos, Brazil
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Columbus AB, Morris MA, Lilley EJ, Harlow AF, Haider AH, Salim A, Havens JM. Critical differences between elective and emergency surgery: identifying domains for quality improvement in emergency general surgery. Surgery 2018; 163:832-838. [PMID: 29331398 DOI: 10.1016/j.surg.2017.11.017] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Revised: 09/19/2017] [Accepted: 11/11/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVE The objective of our study was to characterize providers' impressions of factors contributing to disproportionate rates of morbidity and mortality in emergency general surgery to identify targets for care quality improvement. BACKGROUND Emergency general surgery is characterized by a high-cost burden and disproportionate morbidity and mortality. Factors contributing to these observed disparities are not comprehensively understood and targets for quality improvement have not been formally developed. METHODS Using a grounded theory approach, emergency general surgery providers were recruited through purposive-criterion-based sampling to participate in semi-structured interviews and focus groups. Participants were asked to identify contributors to emergency general surgery outcomes, to define effective care for EGS patients, and to describe operating room team structure. Interviews were performed to thematic saturation. Transcripts were iteratively coded and analyzed within and across cases to identify emergent themes. Member checking was performed to establish credibility of the findings. RESULTS A total of 40 participants from 5 academic hospitals participated in either individual interviews (n = 25 [9 anesthesia, 12 surgery, 4 nursing]) or focus groups (n = 2 [15 nursing]). Emergency general surgery was characterized by an exceptionally high level of variability, which can be subcategorized as patient-variability (acute physiology and comorbidities) and system-variability (operating room resources and workforce). Multidisciplinary communication is identified as a modifier to variability in emergency general surgery; however, nursing is often left out of early communication exchanges. CONCLUSION Critical variability in emergency general surgery may impact outcomes. Patient-variability and system-variability, with focus on multidisciplinary communication, represent potential domains for quality improvement in this field.
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Affiliation(s)
- Alexandra B Columbus
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, MA.
| | - Megan A Morris
- Adult and Child Consortium for Health Outcomes Research and Delivery Science (ACCORDS), University of Colorado, Denver, Aurora, CO
| | - Elizabeth J Lilley
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, MA
| | - Alyssa F Harlow
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, MA
| | - Adil H Haider
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, MA; Brigham and Women's Hospital, Division of Trauma, Burns and Surgical Critical Care, Boston, MA
| | - Ali Salim
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, MA; Brigham and Women's Hospital, Division of Trauma, Burns and Surgical Critical Care, Boston, MA
| | - Joaquim M Havens
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, MA; Brigham and Women's Hospital, Division of Trauma, Burns and Surgical Critical Care, Boston, MA
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