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Background Incorporation of quality improvement (QI) training is essential to meet the milestones set forth by the Accreditation Council for Graduate Medical Education. However, there is no standardized curriculum. Objective We aimed to create a QI curriculum through the integration of didactics and team-based learning via the completion of resident-led QI projects. Methods An institutional review board–approved QI curriculum consisting of four interactive workshops was developed. The workshops introduced the various components of QI, with a focus on Plan-Do-Study-Act. Anonymous and voluntary precurriculum and postcurriculum surveys were administered during the study period in 2018. Results Fifty surgical residents participated in the curriculum, and four QI projects were completed, with 23 residents completing both precurriculum and postcurriculum surveys. Following the curriculum, residents were more confident in their ability to design a QI project (5.7 ± 2.6 versus 7.1 ± 1.9, P = 0.02), write a problem statement (6.7 ± 2.5 versus 7.8 ± 1.1, P = 0.04), and write an aim statement (6.7 ± 2.6 versus 7.8 ± 1.2, P = 0.04). Residents also improved in perceived ability to lead a QI project (5.6 ± 2.9 versus 6.9 ± 1.9, P = 0.05), knowing the steps to complete a QI project (6.0 ± 2.8 versus 7.4 ± 1.7, P = 0.04), and familiarity with QI terminology (5.6 ± 2.6 versus 7.0 ± 1.9, P = 0.03). Conclusions We found that the curriculum was a success and was well received. In addition, there was an improvement in perceived competency and confidence surrounding some of the steps necessary to complete a QI endeavor.

Enhanced recovery is a concept that has been embraced by some surgical specialties with resultant improvements in complication rates, readmissions, length of stay, and costs. While bariatric surgery is typically a pathway-driven specialty, there is a large amount of variability regarding perioperative care practices among bariatric surgery programs nationally. Enhanced recovery offers the possibility of decreasing this variability across practice settings by implementing evidence-based protocols that minimize surgical stress, maintain homeostasis, and minimize opioid use in all bariatric surgery programs. Protocols such as this also challenge surgical dogma and practices that are not supported by evidence such as “NPO after midnight,” the use of bowel preps, the use of drains and catheters, and routine imaging studies or prolonged periods without oral intake after surgery. Evidence is emerging to support the safety and effectiveness of specific components of enhanced recovery for this unique population, and, as implementation increases, the field of bariatric surgery will continue to be the leader in quality and patient safety among all surgical specialties.

The American Society for Metabolic and Bariatric Surgery (ASMBS) publishes position statements in response to numerous inquiries made to the society by patients, physicians, society members, hospitals, and others regarding a particular topic relevant to the field. In these statements, available data are summarized, and recommendations for treatment are made based on current knowledge, expert opinion, and published peer-reviewed scientific evidence available at the time. The ASMBS leadership also collaborates with other medical societies to develop and publish practice guidelines that are relevant to the care of the bariatric surgery patient. This chapter summarizes the current position statements of the ASMBS.

OBJECTIVE There is no standardized method of communication regarding the arrival of outside hospital (OSH) transfers at our institution. We utilized quality improvement methodologies to enhance sign-out, benefiting both resident workflow and patient care. DESIGN A dynamic census log of pending OSH transfers was created. Total number of OSH transfers (with or without prior notification), time to admission orders, and resident self-reported preparedness in receiving/triaging OSH admissions were measured before and after implementation of the census log tool. SETTING Quaternary referral hospital in Cleveland, Ohio. PARTICIPANTS The census log was made available to General Surgery residents on receiving surgical teams. After the data collection period, it was made available to all residents in the program. RESULTS A total of 93 patients were transferred to receiving surgical teams during our 13-week study period. Resident notification of the OSH transfer prior to patient's arrival increased from 44.7% pre- to 70.3% postimplementation of the tool (p = 0.03). When residents received prior notification of pending transfers, time to place admission orders decreased from 81.2 ± 79.9 minutes to 40.4 ± 36.8 minutes (p = 0.0029). Junior residents’ self-reported preparedness in admitting an OSH transfer did not significantly differ when they received prior notification versus when they did not. In contrast, senior residents’ self-reported higher levels of preparedness in the instances where they received prior notification of a pending transfer. CONCLUSIONS In light of the recent Clinical Learning Environment Review program set forth by the Accreditation Council for Graduate Medical Education, trainees are expected to engage in improvement processes as it relates to patient safety and transitions of care. The development and implementation of our tool demonstrate that quality improvement methodologies can be effectively applied to resident workflow challenges, improving both trainee education and patient care.

Familial adenomatous polyposis (FAP) is a hereditary colon cancer syndrome that involves multiple extracolonic organs, including the thyroid. Several studies have estimated the rate of thyroid cancer in FAP to occur at five times the rate of the general population, but no current consensus defines screening for thyroid cancer in this cohort. This study seeks to define the features of benign and malignant thyroid disease in FAP patients, to compare thyroid cancer cases found through screening with those found incidentally, and to propose disease surveillance recommendations.Prospective screening for early thyroid cancer detection with thyroid ultrasound (US) was performed on FAP patients at the time of annual colonoscopy since November 2008. Clinical and US data were reviewed to characterize the observed thyroid nodules. Nonscreening-detected cases (NSD) were found through review of the colon cancer registry database.Eighteen NSD were found, compared with 15 screening-detected (SD) cases, out of 205 total patients screened (Mage=42 years; 55% female). The mean tumor size was larger in the NSD group than the SD group (p=0.04), and they tended to demonstrate more positive lymph nodes and more complications than the SD group. In the screened cohort, at least one thyroid nodule was detected in 106 (51.7%) patients, with 90% of these seen on initial exam. A total of 40/106 (37.7%) patients required fine-needle aspiration biopsy of a dominant nodule (Msize=14 mm), and 28/40 (70%) of these were performed at the first US visit. Suspicious US features were present in 16/40 (40%) patients, including five sub-centimeter nodules. Cytology and/or nodule US was abnormal in 15/205 screened patients, leading to surgery and revealing 14 papillary and one medullary thyroid cancer.Given the age and sex distribution of the screened cohort, this study reveals a higher-than-expected prevalence of both benign and malignant thyroid disease in the FAP population. Additionally, SD cases seemed to consist of smaller-sized cancers that required less radical therapy compared to NSD cases. Since it was found that the initial US in the screening program accounted for the majority of detected nodules (90%) and biopsies (70%), baseline and subsequent thyroid US surveillance is recommended in all FAP patients.