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The Canadian Association of General Surgeons (CAGS) Board of Directors hosted a symposium to develop a Canadian strategy for surgical quality and safety at its mid-term meeting on Feb. 24, 2018. The following 6 principles outline the consensus of this symposium, which included diverse stakeholders and surgeon leaders across Canada: 1) a Canadian quality-improvement strategy for surgery is needed; 2) quality improvement requires continuous, active and intentional effort; 3) outcome measurement alone will not drive improvement; 4) increased focus on standardization and process improvement is necessary; 5) new, large electronic medical record systems pose challenges as well as benefits in Canadian hospitals; and 6) surgeons in remote and rural hospitals must be engaged using tailored approaches., The Canadian Association of General Surgeons (CAGS) Board of Directors hosted a symposium to develop a Canadian strategy for surgical quality and safety at its mid-term meeting on Feb. 24, [...]

Decisional confict represents a state of uncertainty regarding an action one must take. It is a concept inherent to shared decision-making and can help promote high-quality and patient-centred decisions in surgical care, leading to better outcomes. Specific elements may cause more uncertainty or decisional confict for patients: lack of knowledge about risks and benefits, poorly defined personal values about the importance of those risks and benefits, perception of a lack of support, unpredictable outcomes, or the impression that an inadequate decision has been made. Decisional confict can be measured in the surgical setting using the 16-item validated patient-reported Decisional Confict Scale (DCS). Better understanding of the reasons behind high decisional confict can help surgeons support high-quality decisions and lead to more satisfactory outcomes and less decisional regret., Patients' experiences, preferences and outcomes assessments have been guiding surgeons' approach to clinical care toward patient-centred care, which is defined as care that involves shared decision-making with patients while promoting [...]

Background: The effect of hospital specialization on the risk of hernia recurrence after inguinal hernia repair is not well described. Methods: We studied Ontario residents who had primary elective inguinal [...]

Is the hero role the best self-image for surgeons in the modern world? As Donald Berwick, founder of the Institute for Healthcare Improvement, has pointed out, health care is an exercise in interdependency, not personal heroism. In my president's address to the Canadian Association of General Surgeons, I examine the role of the surgeon as hero and citizen., Not long ago, driving along the side roads in my neighborhood, I saw what I thought was a traffic pylon on the street ahead. Drawing closer, I realized it was [...]

Background: Quality in health care can be evaluated using quality indicators (QIs). Elements contained in the surgical operative report are potential sources for QI data, but little is known about the completeness of the narrative operative report (NR). We evaluated the completeness of the NR for patients undergoing a pancreaticoduodenectomy. Methods: We reviewed NRs for patients undergoing a pancreaticoduodenectomy over a 1-year period. We extracted 79 variables related to patient and narrator characteristics, process of care measures, surgical technique and oncology-related outcomes by document analysis. Data were coded and evaluated for completeness. Results: We analyzed 74 NRs. The median number of variables reported was 43.5 (range 13-54). Variables related to surgical technique were most complete. Process of care and oncology-related variables were often omitted. Completeness of the NR was associated with longer operative duration. Conclusion: The NRs were often incomplete and of poor quality. Important elements, including process of care and oncology-related data, were frequently missing. Thus, the NR is an inadequate data source for QI. Development and use of alternative reporting methods, including standardized synoptic operative reports, should be encouraged to improve documentation of care and serve as a measure of quality of surgical care. Contexte : Il est possible d'evaluer la qualite des soins de sante au moyen d'indicateurs de qualite (IQ). Les elements contenus dans les notes operatoires (NO) sont une source potentielle de renseignements pouvant servir d'IQ, mais on en sait peu sur leur exhaustivite. Nous avons voulu evaluer l'exhaustivite des NO dans les dossiers de patients soumis a une pancreatoduodenectomie. Methodes : Nous avons passe en revue les NO dans les dossiers de patients soumis a une pancreatoduodenectomie sur une periode d'un an. Par analyse des documents, nous avons extrait 79 variables liees aux caracteristiques des patients et aux redacteurs des NO, aux mesures des protocoles operatoires, a la technique chirurgicale et aux resultats oncologiques. Nous avons encode et evalue ces donnees en fonction de leur exhaustivite. Resultats : Nous avons analyse les NO pour 74 interventions. Le nombre median de variables relevees etait de 43,5 (entre 13 et 54). Les variables liees au protocole de soins et les variables oncologiques etaient souvent omises. L'exhaustivite des NO etait proportionnelle a la duree de l'intervention. Conclusion : Les NO sont souvent incompletes et leur qualite laisse a desirer. Des elements importants, dont le protocole operatoire et les donnees oncologiques, etaient souvent manquants. Ainsi, les NO constituent une source inadequate de donnees en ce qui concerne les IQ. Il faudra encourager la mise au point et l'utilisation d'autres types de rapports, dont des synopsis operatoires standardises, pour mieux documenter les soins chirurgicaux prodigues et pour en evaluer la qualite., Quality improvement is an important component of health care systems. Quality in health care can be evaluated in terms of the structures, processes and outcomes of care. (1) Process and/or [...]

Background: In Canadian hospitals, which are typically financed by global annual budgets, overuse of operating rooms is a financial risk that is frequently managed by cancelling elective surgical procedures. It is uncertain how different scheduling rules affect the rate of elective surgery cancellations. Methods: We used discrete event simulation modelling to represent perioperative processes at a hospital in Toronto, Canada. We tested the effects of the following 3 scenarios on the number of surgical cancellations: scheduling surgeons' operating days based on their patients' average length of stay in hospital, sequencing surgical procedures by average duration and variance, and increasing the number of postsurgical ward beds. Results: The number of elective cancellations was reduced by scheduling surgeons whose patients had shorter average lengths of stay in hospital earlier in the week, sequencing shorter surgeries and those with less variance in duration earlier in the day, and by adding up to 2 additional beds to the postsurgical ward. Conclusion: Discrete event simulation modelling can be used to develop strategies for improving efficiency in operating rooms. Contexte : Dans les hopitaux canadiens, qui sont generalement finances par des budgets annuels globaux, la surutilisation des blocs operatoires comporte un risque financier qui est souvent gere par l'annulation des interventions chirurgicales non urgentes. On ignore comment les differentes regles de preparation des calendriers affectent le taux d'annulation des chirurgies non urgentes. Methodes : Nous avons utilise un modele de simulation d'evenements discrets pour representer les marches a suivre perioperatoires dans un hopital de Toronto, au Canada. Nous avons verifie les effets des 3 scenarios suivants sur le nombre de chirurgies annulees : preparation du calendrier des chirurgiens selon la duree moyenne de l'hospitalisation de leurs patients, enchainement des interventions chirurgicales selon leur duree moyenne et la variabilite de leur duree et augmentation du nombre de lits dans les unites postoperatoires. Resultats : Le nombre de chirurgies non urgentes annulees a diminue lorsqu'on a planifie les interventions des chirurgiens dont les patients sejournaient moins longtemps a l'hopital plus tot au cours de la semaine, lorsqu'on a programme les chirurgies plus breves et les chirurgies a duree moins variable plus tot au cours de la journee et lorsqu'on a ajoute 2 lits supplementaires a l'unite postoperatoire. Conclusion : Les modeles de simulation d'evenements discrets peuvent servir a developper des strategies pour ameliorer l'efficience des blocs operatoires., Operating rooms (ORs) are a hospital's largest cost centre and greatest source of revenue. (1) Consequently, there is substantial incentive to recognize greater efficiencies within OR management. (2) Operating room [...]

Objective: To determine whether an association existed between the Veterans Health Administration (VHA) medical team training and surgical outcomes. Study design: Retrospective cohort study. Setting: 108 VHA hospitals (74 with and 34 without team training). Intervention: Medical team training consisted of a 1-day session with nurses, surgeons and anesthesiologists in attendance, followed by 4 quarterly structured telephone interviews. Data sources: VHA Surgical Quality Improvement Program (VASQIP), which included 182 409 patients between 2006 and 2008. Main outcome measure: Postoperative mortality. Results: The 74 facilities in the training program experienced an 18% reduction in annual mortality (rate ratio [RR] 0.82, 95% confidence interval [CI] 0.760.91, p = 0.01) compared with a 7% decrease among the 34 facilities that had not yet undergone training (RR 0.93, 95% CI 0.80-1.06, p = 0.59). Risk-adjusted mortality at baseline was 17 per 1000 procedures per year for the trained and 15 per 1000 per year for the nontrained facilities. At the end of the study, the rates were 14 per 1000 per year for both groups. Propensity matching of the trained and nontrained groups demonstrated that the decline in risk-adjusted surgical mortality was about 50% greater in the trained (RR 1.49, 95% CI 1.10-2.07, p = 0.01) than in the nontrained group. A dose-response relationship for additional quarters of the training program was also demonstrated: for every quarter of the training program a reduction of 0.5 deaths per 1000 procedures occurred (95% CI 0.2-1.0, p = 0.001). Conclusion: Participation in the VHA Medical Team Training program was associated with lower surgical mortality., The term 'evidence-based medicine' was first coined by Sackett and colleagues as 'the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual [...]

We don't know exactly why people who had an inguinal hernia repair at the Shouldice Hospital had a much lower rate of surgery for recurrence than those who had hernias [...]

Measures of quality of life are used increasingly to evaluate the outcome of surgical care. Impairment in quality of life is major reason why patients seek surgical care, and changes in health-related quality of life are how patients assess the effect of treatment. Disease-specific measures focus on a particular health condition and are useful for detecting change resulting from treatment. Generic measures cover a wider spectrum of quality of life, provide a global assessment of a patient's overall health, and allow comparisons with other health conditions. Quality of life is not measured directly but is commonly sampled by using measurement scales in the form of questionnaires. The important properties of quality-of-life measurement scales are reliability, the extent to which a measure provides similar values for individuals with similar underlying quality of life; validity, the extent to which it measures what it purports to measure; responsiveness, the extent to which changes in correlate with true changes in quality of life; and sensitivity, the extent to which a measure can detect meaningful changes in quality of life. [ABSTRACT FROM AUTHOR]

Objective To determine whether the improved outcome of a surgical procedure in high volume hospitals is specific to the volume of the same procedure. Design and setting Analysis of secondary data in Ontario,Canada. Participants Patients having an oesophagectomy, colorectal resection for cancer, pancreaticoduodenectomy,major lung resection for cancer,or repair of an unruptured abdominal aortic aneurysm between 1994 and 1999. Main outcome measures Odds ratio for death within 30 days of surgery in relation to the hospital volume of the same surgical procedure and the hospital volume of the other four procedures.Estimates were adjusted for age,sex,and comorbidity and accounted for hospital level clustering. Results With the exception of colorectal resection,30 day mortality seemed to be inversely related not only to the hospital volume of the same procedure but also to the hospital volume of most of the other procedures.In some cases the effect of the volume of a different procedure was stronger than the effect of the volume of the same procedure.For example,the association of mortality from pancreaticoduodenectomy with hospital volume of lung resection (odds ratio for death in hospitals with a high volume of lung resection compared with low volume 0.36,95%confidence interval 0.23 to 0.57) was much stronger than the association of mortality from pancreaticoduodenectomy with hospital volume of pancreaticoduodenectomy (0.76,0.44 to 1.32). Conclusion The inverse association between high volume of procedure and risk of operative death is not specific to the volume of the procedure being studied. [ABSTRACT FROM AUTHOR]