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Putting It All Together: Clinical Quality Improvement Examples: Agency for Healthcare Research and Quality, Improving Surgical Care and Recovery

Key Points The Agency for Healthcare Research and Quality (AHRQ) Safety Program for Improving Surgical Care and Recovery (ISCR) was launched in 2016 and aimed to accelerate adoption of enhanced recovery principles across five surgical areas using the principles of the comprehensive unit-based safety program (CUSP). CUSP is an implementation framework that emphasizes leadership support and frontline engagement to support meaningful improvement. It has been effective…

Perioperative Medicine for Older People: Translating a Geriatrician-Led Perioperative Care Model From an Inner London Teaching Hospital to a District General Hospital

Key Points The perioperative medicine for older people (POPS) team at Guy's and St Thomas’ National Health Service (NHS) Trust (GSTT) has pioneered an award-winning perioperative medicine service model and informed the development of similar services in the United Kingdom. National roll-out of POPS services has been slow, particularly in smaller and more financially challenged hospitals. A mixed methods study was used to evaluate the translation…

Optimizing Value in Perioperative Medicine and the High Value Practice Academic Alliance: A Case-Based Study on Preoperative Assessment

Key Points Perioperative care provides opportunities for the reduction of low-value testing and treatment, in line with evidence-based guidelines. Quality improvement (QI) projects focused on perioperative care can have a significant impact on patient outcomes and health system performance. There are particular considerations that can arise in designing and implementing a perioperative medicine QI project, such as the need for multidisciplinary engagement across different specialty areas.…

Using Real-World Data for Improvement—The Seattle Children’s Example

Key Points Perioperative opioid-sparing protocols for children are feasible. Standardized anesthesia protocols and accessible real-world data displayed as statistical process control charts can inform rapid PDSA (Plan-Do-Study-Act) cycles. Challenges to improvement work can be overcome using technology, data, communication, education, time, and a culture that emphasizes willingness to change. Introduction Seattle Children's Bellevue Clinic and Surgery Center (Bellevue) is a stand-alone pediatric clinic and ambulatory surgery…

Perioperative Quality Improvement Programme

Key Points The Perioperative Quality Improvement Programme (PQIP) is a multidisciplinary initiative to evaluate the quality of care and outcomes of patients undergoing surgery in the UK National Health Service (NHS). PQIP enrolls patients undergoing major noncardiac surgery and measures complications, failure to rescue, and patient-reported outcomes. PQIP aims to develop a high-quality database of perioperative risk and process and outcome data. PQIP aims to support…

Quality Improvement in Emergency Surgery: Learning From Two Large-Scale Programs to Reduce Mortality After Emergency Laparotomy

Key Points Emergency laparotomy is a common high morbidity and high mortality procedure. Significant efforts have been made within the UK to improve the care of patients needing an emergency laparotomy. The EPOCH (Enhanced Perioperative Care for High-Risk Surgical Patients) trial and the Emergency Laparotomy Collaborative (ELC) work offer many important lessons on effective perioperative quality improvement (QI). These include: Keep the improvement intervention simple and…

The Perioperative Brain Health Initiative

Key Points Perioperative neurocognitive disorders represent a major public health issue. The Perioperative Brain Health Initiative (PBHI) aims to improve brain health in surgical patients through systematic improvements in awareness and clinical practice. Preliminary evidence suggests that implementation of perioperative brain health programs optimizes clinical practice for supporting neurocognitive health. Introduction The Perioperative Brain Health Initiative (PBHI), first conceived in 2015 by the American Society of…

Health Services Research

Key Points The origin of health services research is discussed. Quantitative tools, including cross-sectional, cohort, case-control, and difference-in-difference study designs, are briefly reviewed. Qualitative tools, such as focus groups, surveys, and interviews, are covered. Examples of study designs in perioperative care are used to highlight how health services research can be transformational. Introduction to Health Services Research In the wake of World War II and the…

Pain Care Pathways and Patient Reported Outcomes

Key Points Overprescribing of opioids and new persistent opioid use after surgery are common problems. Granular data involving patient-reported outcomes and clinical behaviors are critical to inform pain care pathways. A remarkable number of stakeholders are involved in pain management for even the simplest surgical procedures; all must be included in pathway development. Evidence-based and iterative pain care pathways can profoundly reduce the prescription and consumption…

Enhanced Recovery After Surgery Protocols — Implementation Across a US Health System: System-Level Principles

Key Points Enhanced Recovery After Surgery (ERAS) is a series of evidence-based protocols that improve outcomes after surgery by optimizing patients before surgery, reduce stress and injury during surgery, and promote rapid return of preoperative function. ERAS pathways can be used as a framework for all health system surgical perioperative care pathways to reduce length of stay, improve quality, reduce variance, and improve patient satisfaction. Executive…

The Michigan Urological Surgery Improvement Collaborative (MUSIC) Reducing Operative Complications From Kidney Stones (ROCKS) Quality Initiative

Key Points A significant proportion of unplanned healthcare encounters after stone surgery (ureteroscopy) are avoidable. Improvement in patient education decreases the rate of postoperative emergency department visits after ureteroscopy. Nonopioid pain pathways in appropriate patients are safe and feasible without increasing the rates of unplanned postoperative healthcare encounters. Providing outcomes data to individual physicians and practices can help motivate changes in behavior to align with best…

Quality Improvement Through the Lens of the Multicenter Perioperative Outcomes Group

Key Points Anesthesiology Performance Improvement and Reporting Exchange (ASPIRE), the quality improvement (QI) arm of the Multicenter Perioperative Outcomes Group (MPOG) and part of the family of Blue Cross Blue Shield Michigan (BCBSM) Collaborative Quality Initiatives (CQIs), works to overcome barriers to accessing information needed for practice analysis and improvement. Mechanisms that ASPIRE uses to promote practice change include participation in unblinded performance review sessions, the…

Implementation of Enhanced Recovery for Colorectal Surgery: A Real-World Example of Quality Improvement

Key Points Enhanced recovery protocols for colorectal surgery have been widely adopted because of their success in reducing length of hospital stay and complications. Quality improvement efforts, including enhanced recovery, face significant barriers requiring persistence and redirection to achieve desired outcomes. Acknowledgments The authors thank Geri Johnston, MSN for her dedication to the ER program as coordinator and for providing data for this chapter. You’re Reading…

An International Perspective on Training and Setting Standards in Perioperative Medicine

Key Points Perioperative medicine/care is multidisciplinary and covers the whole pathway from moment of contemplation of surgery to full recovery. Perioperative medicine and perioperative care are synonymous in many countries (but not all). Base training (e.g., nurse, physician, or physiotherapist) will be a factor in determining scope of practice and thus training, but the knowledge base is common. A common curriculum has been codified and published…

Excellent Perioperative Patient Experience

Key Points Patient experience in the perioperative setting is increasingly important, driven by the growing complexity of medicine and aging of the population. The same principles of high reliability that have markedly improved safety can be used to improve patient experience. Key focuses should be coordination, empathy, communication, and cleanliness. Patient experience has become an increasingly important focus in health care over the last 20 years,…

Establishing and Running Quality Collaboratives: The Michigan Experience

Key Points Healthcare quality is high, and costs are low in Michigan. The Continuous Quality Improvement (CQI) platform is a statewide learning health system that informs a physician-led, value-based reimbursement scheme. The quality agenda in Michigan is outsourced to the physician community and bolstered by a robust value-based scheme that is informed by high-quality registry data that is actionable. Financial incentives are important drivers of quality…

Leadership in Perioperative Quality

Key Points The leader can help set the culture and the vision for the organization. Effective leadership creates “psychological safety” for all team members to perform optimally. Classic change models are described with the key first step being creating urgency. In perioperative care, urgency came originally from the demonstration of patient harm. Effective leadership is key to creating an environment for innovation. To ensure high-quality care…

Techniques for Creating Urgency

Key points Urgency is not always about going fast. Provide some breathing room and allow the team to co-create their own ideas for success. The ideal temperature for forward change is in the “productive range of distress,” not too hot and not too cold. The combination of data and stories is unbeatable. They create human impact. Consider the acronym: STAT ( S tories, ideal T emperature,…

Stakeholder Engagement

Key points Psychological safety and “humble inquiry” are the foundation and scaffolding for successful, productive, learning teams. A strong team is even stronger when interpersonal relationships are valued. Mental rehearsal and planning an engagement strategy before important meetings are important skills. Understand the importance of continuous engagement and take steps to ensure it happens, such as by using regular feedback and celebrating success. Consider the acronym…

Social Aspects of Change in Perioperative Care and the Importance of Context

Key points The importance of context to the fate of healthcare improvement is well acknowledged but inconsistently studied and understood. Social scientific methods and theories offer an important resource for understanding contextual and social influences. Conceptual frameworks help to provide a structured approach to anticipating and accounting for a wide range of contextual influences in planning, delivering, and evaluating improvement. The complexity of the social world…