I think in a broader sense (at a system level), a single disease entity might be a useful marker. I have asked myself the same questions over the years and our recent work on acute appendicitis in South Africa seems to suggest that using this single disease outcome as a quality matrix might allow one to compare the 'quality' of different system. Hope this is of interest to you. 

Clarke DL, Kong VY, Handley JJ, Aldous C. A concept paper: Using the outcomes of common surgical conditions as quality metrics to benchmark district surgical services in South Africa as part of a systematic quality improvement programme. S Afr J Surg. 2013; 51(3):84-6

in abdominal trauma it is essential to justify exploration .A stable patient without hollow viscus injury is maintained Non operatively     World Journal of Emergency Surgery 2013, 8:14 doi:10.1186/1749-7922-8-14

Non operative management of abdominal trauma – a 10 years review   *Corresponding author: Mohsin Raza [email protected]

Dr Mohsin Raza

Senior Consultant General Surgeon

Moderator -"Worldofaligs"

Moderator -"Abdomen & Chest Trauma" , yahoogroups.com

& Facilitator - "Breast Cancer awareness among Indian women"

[email protected]

I believe we need to differentiate between surgical quality as measured within a procedure and the subsequently related outcome. Measuring good patient outcome is naturally the preferred indicator of successful surgeries but patient outcome is naturally influenced by numerous variables making direct comparisons between surgical sites and studies difficult. An excellent operation may still lead to poor patient outcome depending on other external factors such as comorbidities, hospital organizational structure, quality of postoperative care etc. Measuring only the overarching end-point may thus not be useful in identifying areas that would benefit from improvement.

The question needs to be “what do I wish to measure?”, if it is the surgeon then quality markers could be consistently high technical skill as measured on global rating scales, procedure specific scales and using error metrics. For other factors in the operative phase you would need to look at measures of non-technical skills (team-based ratings or individual surgeon-based assessments) and markers of organizational flow.

If your interest is in the "organizational system" the measures of effective processes such as adherence to SOP's may be useful.

If you are more interested in the overall view of successful surgeries without an interest in differentiating between preoperative, operative and postoperative phases, then measures such as mortality and morbidity represent well established quality markers.

Excellent discussion,ours is a Joint Commission Accredited hospital.JCI has all the above mentioned guide lines.I feel the quality of surgery depends on various parameters like hospital infrastructure,various available sofisticated investigations,

preoperaive,post operative supporting team,observation units with specialists and finally most important anesthetist and surgeon factors.All these determine ALOS,mobity,mortality and other parameters mentioned in the previous discussions.

The standard and still valid approach of Donabedian (in the meantime nearly 50 yeras since first publication) differs the quality of the structure, process and outcome. It is important not to confuse these parameters. In the discussion of quality the perspective chosen is also very important - are we going to make our analysis from the point of view of the health system, insurance company, hospital administration, surgical department, individual surgeon or patient. In last years a discussion about quality of life, seen from the patient's perspective and estimated by validated questionnaires gains importance.

In general I would see the quality issue as a comparison between patient's expectations, coming to the surgeon, and the achieved result.

Thank you Pawel.

Asking our patients ist the best instrument for measuring our Quality. 

I do not agree that asking our patients ist the best instrument for measuring our Quality. All the above mentioned methods are objective and can be statistically compared and improved.

An Ideal good quality outcome from a surgery is one whose morbidity (both due to the underlying disease and to the type of operation ) is much better than the available evidence in that particular operation for that particular disease. In many operations for pain, patient quality questionnaire is very important.

Patient satisfaction is (an important) part of the overall quality measurement. Should be included in the package, questionnaires are fairly objective.

Quality should be measured throughout the whole length of stay in the hospital, as well as during preoperative and postoperative assessment and follow-up. There's no use in delivering excellent surgery, if the ICU cannot follow your standards, or if your patient has to wait for three hours for the postoperative consultation.

Very very excellent question! The same as what I want to ask.

It's true as indicated by above answers that in a broad sense, surgical quality could be evaluated by numerous layers of parameters: blood loss, postoperative recovery, pain, patient experience, you name it. I can assure you, viewing in this bird-view angle, it is impossible to evaluate surgical quality or the quality of a surgeon.

Answer my question first: what is a SURGEON? What makes you different from other physicians? What makes you proud of what you are doing?--- Yes! SURGERY! YOU ARE "FIXING" A LIVING PERSON AND SAVING LIFE WITH YOUR KNIFE AND NEEDLES!!!

A long time ago, it was said that a surgeon should have "eagle's eyes, a lion's heart, and women's hands". I was inspired by these words and struggled out of my country to come here to join the team of the best. I don't know how many of you guys still remember this verse, but I'm sure no one is paying any attention to it. However, from my "stupid" point of view, this is EXACTLY the parameters you MUST look for to qualify a surgery and a surgeon--- A profound vision into surgical science, a superior knowledge-based decision maker, and the finest skillful craftsman with prudent responsibility. This is the core parameter that decides the outcome of a surgery. This decides all other above mentioned measures. Yet you are asking: how to measure these?!

I tell you, it's very simple, but I'll ask: do you DARE and do you really CARE? All these properties boils down to only one element: "Surgical skill". If a surgeon, who loves surgery, looks at his operation from the point of view of a craftsman, he would die to make his surgery flawless. And a flawless operation will beat all the indirect measurements like hospital stay, patient feeling, what-so-ever! In such an advanced world, this is very easy to achieve: every surgery should be recorded with video and sound, then reviewed anonymously by a board of superior surgeons. Scores placed on intraoperative bleeding, intraoperative decision making, collateral damage level, surgical cleanliness, intraoperative patient status, suturing skill, tying skill, incision skill, fine movement of instruments, etc. I'll assure you, if you really do so, you will see a tremendous difference between our current attendings. You will be shocked to see why some guy is still working here! How he was selected to be a surgeon!? So answer my question: do you dare to?

Quality control by this means would be most efficient and cost-effective, because this catches problems in ahead, instead of wasting resources to "manage" them after they do occur, which though is the requirement of "evidence-based-medicine", correct? :) LOL

Unfortunately, the quality of surgeons is drifting downwards these years globally. We have a saying: " to attend to the superficials and neglect the essentials". Way too much emphasis placed on candidates' communication skills and their ability to handle textbook knowledge or even their research experiences, but ignoring the most important part of a surgeon: his potential on mastering surgical skills. We are producing more speakers instead of doers. I was told that surgical skill is not viewed as an essential part of surgery......

I think ( or rather know) that Jane Blazbey is working on core outcome sets for surgery andthese are being introduced in a number of surgical specialities. Jane and her fellows have done quite a lot of work in this field and makes a clear point that outcome data needs to rigourously validated if it is to be used. Personnal opinion while usually well educated and with excellant intent only demonstrates the paucity of academic rigour which very occasionaly clouds surgical academia.

Michael, let me disagree.. The outcome control, which of course is to be performed in a well defined way with precise definition, is crucial for our, surgical view. But the patient does not go to a hospital to get a core set, he/she goes there to get a problem solved. Surgery and medicine are services, in a service situation the satisfaction of the master (patient) is crucial. Core sets are important for comparison and training of the servants (surgeons). The translation between outcome measured as i.e. a core set and the patients satisfaction is not automatic. 25 lymph nodes during a TME are much better outcome than 15, but it still does not mean, that the patient has got a better result and is more satisfied.

if the question was about how to measure quality of CLINICAL service in Surgery, similar measures has been used in most hospitals mentioned briefly by Ewen Griffiths. Those are variables generated from the prospective of healthcare providers. I support augments that patient's comments and evaluation should also be included, as the life quality of surgical patients should be taken seriously into the equation.

Dear Ewen;

I think that surgeons satisfaction at the end of the operation is the good quality measure.

Outcome is the good quality measure

I think the amount of adhesion formation after surgery and the time required for the patient to go back to the normal life should be included too. 

I am agree with Ewen, that variables currently in use to audit any surgical unit can show much variation from Hosp to Hosp and Country to Country.  However these variables are still valuable when used to evaluate same Surgical Unit on different time. 

Quality is the client´s perception of a product. As it was previosly highlighted by Pawel Mroczkowski, medicine and surgery are services provided by healthcare personnel. Outcomes are crucial indicators. But it is also the satisfaction of the client that doctors have to learn to deal with.

Clearly it depends on your out look and who you ask. Put a patient hat on and small variations in length of stay make no difference when you care if you are fixed or not. Patients value communicatiuon skills and yet I cannot talk your hernia better. Finanacial directors like cheap surgeons and that has validity too. Quality therefore has to be broken down into domains and each measured. A composite

Thanks everyone.   A very useful discussion.   

I've found this document very helpful.

http://www.kingsfund.org.uk/sites/files/kf/field/field_document/Outcomes-choosing-and-using-indicators-the-king%27s-fund-aug-20121.pdf

Cheers

Ewen

If my patient is happy and I am satisfied with it ,I would call it a good outcome . I should be able to say to the image what I see in the mirror "Hey, you did your best and the result is obvious" and should get sound sleep. After all I am a human being and make my best effort with what I am bestowed with , with only patient outcome as a focus.

These are my quality measures among so many variables like, team, infrastructure, organisational limitations, patient factors etc.

Very pertinant question,undoutedly out comes are best measure .Having said that good quality measure in surgery depends on many factors if we devide them into 1. Patient factors

2.surgeon’s

3.Hospital

4.In countrys like India Place also matters example fecilities in Tier one cities differs.