The American Journal of Surgery (2015) 210, 211-218
Clinical Science
Identifying quality markers and improvement measures for ward-based surgical care: a semistructured interview study Philip H. Pucher, M.D., Ph.D., M.R.C.S.a,*, Rajesh Aggarwal, M.B.B.S., M.A., Ph.D.b,c, Pritam Singh, M.B.B.S., M.A., M.R.C.S.a, Muaaz Tahir, B.Sc.a, Ara Darzi, M.D., K.B.E.a a
Department of Surgery and Cancer, St. Mary’s Hospital, Imperial College London, London, UK; Department of Surgery and cArnold & Blema Steinberg Medical Simulation Centre, Faculty of Medicine, McGill University, Montreal, Canada
b
KEYWORDS: Surgery; Ward round; Postoperative care; Quality improvement; Patient round
Abstract BACKGROUND: The surgical ward round (WR) represents the primary interface between the clinical team and the patient and is integral to the quality of postoperative care and subsequent patient outcomes. This study aims to explore key issues pertaining to the surgical WR, defining challenges in current practice, and identifying potential means of quality assessment and improvement. METHODS: A qualitative, semistructured interview-based approach was adopted, including patients, nurses, interns, residents, and attendings. RESULTS: Twenty-five interview subjects were recruited across 8 hospitals. Twenty-three of the 25 (92%) subjects believed that there was significant variation in the quality of WRs and that this affected patient care. Lack of thoroughness (18/25, 72%) and poor communication (12/25, 48%) were the most commonly identified causes. Nontechnical skills such as communication (25/25, 100%) were seen as crucial to WR quality. Quality markers for surgical WRs were identified. Simulation-based training was recommended (13/25, 52%) to improve performance. CONCLUSIONS: Clinical staff and patients alike perceive there to be significant variability in current surgical WR practice. Further development of interventions to assess and improve surgeons’ performance is necessary to standardize and improve WRs and patient care. Ó 2015 Elsevier Inc. All rights reserved.
There were no relevant financial relationships or any sources of support in the form of grants, equipment, or drugs. Rajesh Aggarwal receives consulting fees from Applied Medical. The authors declare no conflicts of interest. Presented at the International Conference on Residency Education, October 2014, Toronto, Ontario. * Corresponding author. Tel.: 144-203-312-6666; fax: 144-203-312-6309. E-mail address: [email protected] Manuscript received July 25, 2014; revised manuscript October 18, 2014 0002-9610/$ - see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.amjsurg.2014.11.013
212 Modern surgical expertise demands more than technical ability. Variations in hospital mortality rates have been shown to be reflective of differences in the quality of postoperative patient care, rather than solely quality of surgery itself.1,2 This variability, and its effect on surgical outcomes,3,4 continues to drive research seeking to identify and improve underlying causative factors.3,5–7 In part because of the nature of the recorded data available for retrospective analysis, much of the current body of research in this domain has focused on structural variables such as nurse staffing levels5 or operative volume7; much less is known about the role of care processes taking place at the bedside. The surgical ward round (WR) represents the primary interface between the clinical team and the patient, typically involving a daily review of patient progress and prescription of the management plan for continued patient care. The WR is therefore integral to the quality of postoperative care and the determination of patient outcomes. Despite such a critical role, however, little scientific knowledge on this topic currently exists. Previous research relating to surgical WRs has considered staff and patient viewpoints on the subject,8–10 or assessed individual aspects of the WR such as documentation11 or patient timing.12 These largely anecdotal and subjective data have suggested the existence of significant variability underlying the quality of care provided during the surgical WR. A recent single-center observational study of surgical WRs demonstrated significant variation in WR conduct, wherein less thorough patient assessment was found to be significantly associated with a higher incidence of preventable complications.13 Such findings highlight the need to improve WR quality, and postoperative care in general. Increasingly, there has been recognition of the importance of WRs and nontechnical skills for surgical training. Team-based skills have recently been introduced as part of the American College of Surgeons Surgery Resident Skills Curriculum in the United States.14 Meanwhile, several studies have reported the effectiveness of nontechnical skills training programs in improving surgical outcomes.15–17 These have focused primarily on the operating room environment, rather than the postoperative phase of care. In the UK, the Royal College of Physicians and the Royal College of Nursing recently joint issued a white paper calling specifically for a refocusing of priorities on WRs as a key point of care for quality improvement.18 Crucially, however, this lacked specific guidance on how to address this training gap, reflecting the current dearth of knowledge in this area. Research to explore, assess, and improve surgical WRs must consider the large number of stakeholder groups involveddto address all sides of this multifaceted process, as well as to ensure consideration of potential confounders. Although the primary surgeon will determine the course of patient care during the WR, they are not alone in determining outcomes. Management decisions are made with input from junior clinicians, care delivered by nursing staff, and experienced by patients, all of whom contribute significantly to the quality of patient care.
The American Journal of Surgery, Vol 210, No 2, August 2015 The aim of this study was to explore key issues pertaining to the surgical WR. Semistructured interviews were conducted, with interviewees asked to identify perceived causes of problems in current WR practice, suggest markers by which WR quality might be quantified, and how practice in future might be improved.
Methods A qualitative, semistructured interview-based approach was adopted to explore issues around surgical WRs and postoperative care. An institutional research ethics committee approved the study.
Subjects Interviewees were selected to represent the multidisciplinary roles involved in a general surgical ward round, and to give voice to all major stakeholders in postoperative care: patients, nurses, interns, residents, and attendings. A sample size of 25 interviewees was selected, based on the methods of a previous interview study which sought to explore the related field of surgical handover and information transfer, in which Nagpal et al19,20 achieved thematic saturation with 18 multidisciplinary participants. Interviewees were purposively sampled for a broad range of backgrounds and experience levels, with patients identified from the inpatient register of a single tertiary academic surgical center and considered for inclusion in the study if they had undergone a general surgical procedure during their current admission.
Setting To ensure patients would be well enough to participate in an interview, and to minimize any concerns that the interview might affect their care, subject interviews were limited to the day of, or day before, planned discharge. Interviews took place in a private office in the general surgical ward, with an independent interviewer who was identified as a researcher, and not a member of the surgical care team.
Interview process Subjects were interviewed using a predetermined, semistructured interview protocol which was developed and piloted before use in the final subject interviews. The interview protocol covered the following topics with reference to ward-based care in general surgery, with a focus on clinician-led processes: Introduction and demographic details Identifying current problems in ward-based surgical care (ie, variability) Defining the surgical WR Required skill set Identifying quality markers for WRs Improving surgical WR quality
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Data analysis
staff, some are bad with both. So we see huge variation, yes.’’ (subject 24, attending)
Recorded interviews were anonymized and transcribed by a third party not familiar with the participants. Identifying phrases and names were removed. Anonymized transcripts were then analyzed by a member of the research team, with emerging themes recorded until thematic saturation was reached. A second blinded researcher also analyzed 20% of transcripts, selected using a computergenerated randomization sequence, to ensure reliability of theme extraction. Themes mentioned by each subject were coded by both researchers independently, overarching theme content unified between reviewers via consensus discussion within the research team, and reliability of thematic extraction compared using Cohen’s kappa. Statistical analysis was performed using IBM SPSS 21 (IBM Corp, Armonk, NY). A P value of less than .05 was considered statistically significant.
The most common cause identified was the degree of thoroughness with which the WR was conducted (18/25, 72%), followed by poor communication (12/25, 48%) and the lack of a structured approach (9/25, 36%): ‘‘If you’re not thorough, then you can miss things that are easy to sort out in the beginning, but if you let them drag on then it can be much harder to sort them out or the patient can get sicker before you really realize that there’s a problem.’’ (subject 10, intern)
Defining the surgical ward round In response to being asked to define their expectations of the surgical WR, generally similar themes were identified by the majority of subjects interviewed. The WR was defined as a process of patient assessment (25/25, 100%), during which patient progress was reviewed (18/25, 72%) and a management plan defined (23/25, 92%). It was felt to represent a forum for communication with the patient (16/ 25, 64%) and for communication within the multidisciplinary clinical team (13/25, 52%):
Results Twenty-five interview subjects were recruited from 8 hospitals across southern England, UKd2 tertiary academic centers (16/25 subjects, 64%) and 6 community hospitals (9/25 subjects, 36%)dwith varying levels of experience (Table 1). Response rate was 100%, with all approached interviewees agreeing to participate in the study. Median interview duration was 21 (interquartile range 17 to 27) minutes (range 11 to 55 minutes). A total of 562 minutes were transcribed and coded by independent raters as described above. Inter-rater reliability of coding was very good, as measured by Cohen’s kappa (.724, P , .001). Themes for each interview subheading were summarized and are presented below.
‘‘[The purpose of the WR] is to assess the progress of the patient in regard to their treatment. That means picking up problems which may or may not be anticipated, the patient’s concerns, their worries. And all that information should be passed across . through the other members of the team.’’ (subject 24, attending)
Required skill set Interviewees identified clinicians’ skills which they deemed critical to the conduct of high-quality WRs. Above all, communication was identified as the most important (25/25, 100%), with implications for both clinical performance as well as patient experience:
Current problems in ward-based care Almost all subjects (23/25, 92%), including all clinical staff (20/20, 100%), believed that there was significant variation in the quality of surgical WRs, and that this had the potential to affect patient care (Table 2):
‘‘Communication is essential . professionalism generally follows’’ (subject 2, attending) ‘‘Some people, you really feel like you’re working as a team . sometimes you feel that you’re completely not, which is not very nice because you’re the [nurse] who’s there the whole time. And you pick up on the way the patients feel because they notice straight away . it’s
‘‘. There are differences in quality and activity. Some [clinicians] are good with the complex amount of information which needs to be processed, some are not. Some are good with patients, some are good with
Table 1
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Participant demographics
Attendings Residents Interns Nurses Patients
n
Male:Female
Academic:Community
Experience in role (median, range)
5 5 5 5 5
4:1 3:2 2:3 2:3 3:2
4:1 2:3 1:4 5:0 4:1
9 (1 to 22) years PGY 7 (5 to 10) PGY 1 (1 to 1) 9 (2 to 20) years 21 (3 to 35) inpatient days
PGY 5 postgraduate year.
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Table 2
Interviewees’ opinions on current WR practice
Variation exists and affects care Causes of variation in WR quality Thoroughness of round Communication quality Structured approach Team approach Expectations of the WR Patient assessment Define management plan Review progress Communication with patient Communication with team Required skill set Communication skills Patient assessment/history taking Diagnostic ability/knowledge Teamwork/multidisciplinary cooperation Leadership and management skills
n (%)
Attending
Resident
Intern
Nurse
Patient
23 (92%)
5
5
5
5
3
18 12 9 9
(72%) (48%) (36%) (36%)
4 3 2 2
5 1 2 1
5 2 1 3
3 3 3 3
1 3 1 0
25 23 18 16 13
(100%) (92%) (72%) (64%) (52%)
5 5 4 4 4
5 5 5 4 4
5 5 3 2 2
5 5 4 2 3
5 3 2 4 0
25 18 17 11 10
(100%) (72%) (68%) (44%) (40%)
5 5 4 3 2
5 5 4 2 5
5 5 3 2 2
5 3 4 2 0
5 4 2 2 1
WR 5 ward round.
not very nice to hear ‘oh they weren’t very nice were they?’’’ (subject 4, nurse)
Related skills such as history taking and patient assessment (18/25, 72%) were also cited, as well as teamwork (11/ 25, 44%), leadership, and management skills (10/25, 40%).
Identifying quality markers for ward rounds Subjects identified a number of processes which would be expected to be included in the ideal WR, in the context of an unwell postoperative patient. These were felt to potentially be used as markers of WR quality (Table 3). Processes were divided into processes of patient assessment and management. Assessment tasks included physical examination (21/25, 84%), taking a recent history from the patient (21/25, 84%), and checking of vital sign charts (21/25, 84%). Management tasks included defining further investigations or interventions necessary (19/25, 76%), dietary status (14/25, 56%), and ensuring appropriate documentation (13/25, 52%). In reference to processes determining patient management during the WR, there was a marked divide between clinical staff and patients. Although there was broad agreement between clinical staff, which named a median of 6 themes (range 2 to 9), patients named far fewer tasks, 2 (1 to 4), possibly reflecting a lack of clinical knowledge by lay patients in this domain. Most frequently named by patients was the expectation that the management plan be communicated to the patient (3/5, 60%). This varied between patients, however, with some patients less interested in the details of their ongoing care, whereas others wished to have full and active involvement:
‘‘I’m not too bothered [about knowing what’s going on with me in hospital]’’ (subject 19, patient) ‘‘I want to know everything. Partly because if I know everything, I can push to keep the plan. Like I knew about [my prescribed diet], so I had to call the junior doctor because the caterer didn’t know anything about it. Every time it turns out they need to take blood, I say ‘what for?’’’ (subject 21, patient)
None of the patient interviewees expressed a desire to explicitly not be told of their ongoing management.
Improving surgical ward round quality All subjects agreed that measures to improve surgical WR quality were needed, with a number of potential interventions identified (Table 4). The most commonly mentioned intervention was to implement scenario- or simulation-based training (13/25, 52%): ‘‘You could simulate a ward round . the benefit is that you could reproduce the same patients so you could create the complex patients that you wouldn’t otherwise have, necessarily, when someone is watching you [during routine clinical practice]. And you’ve got to remember [during a clinical teaching WR] you’ve got a patient here, do you want to start scaring them . going through the vast array of complications you can get? It’s not really appropriate to do that in front of the patient.’’ (subject 8, resident)
Checklists and proformas for WRs were also named as a potential intervention (12/25, 48%). Some interviewees strongly advocated this approach, citing the empowering nature of checklists and the potential for these to ensure basic essential tasks are reliably completed (subject 3,
P.H. Pucher et al. Table 3
Quality improvement for surgical ward care
215
Identified markers for ward round quality
Patient assessment Physical examination History from patient Status charts (ie, vitals, fluid balance) Prescription chart Pathology and laboratory results Review medical notes Radiology results History from nurse VTE prophylaxis Assess analgesia Patient management Investigations or interventions Dietary status Appropriate documentation Communicate plan to nursing staff Appropriate prescribing Blood tests if required Discharge planning Communicate plan to team Communicate plan to patient
n (%)
Attending
Resident
Intern
Nurse
Patient
21 21 21 19 18 17 17 12 9 6
(84%) (84%) (84%) (76%) (72%) (68%) (68%) (48%) (36%) (24%)
4 4 5 5 4 3 4 3 2 0
5 5 5 4 5 4 5 4 4 1
5 5 4 4 5 4 5 0 3 3
4 3 5 5 3 3 3 3 0 0
3 4 2 1 1 3 0 2 0 2
19 14 13 12 12 11 10 9 8
(76%) (56%) (52%) (48%) (48%) (44%) (40%) (36%) (32%)
5 2 4 1 3 2 1 1 1
5 4 4 4 2 3 3 3 2
5 3 2 2 4 4 1 2 1
4 3 3 4 3 1 3 2 1
0 2 0 1 0 1 2 1 3
VTE 5 venous thromboembolism prophylaxis.
attending). However, others argued that checklists did not allow the necessary flexibility for different WRs between, for example, unwell postoperative patients or fully recovered patients about to be discharged (subject 7, resident). Another concern raised was that checklists might limit clinicians’ own free interpretation of the patient by enforcing narrow prompts (subject 24, attending). In addition to training interventions, the need for a formalized system of trainee WR assessment was specifically mentioned by 7 of the 25 (28%) subjects. Others mentioned the need for top-down cultural change to improve the quality of WRs and training overall (7/25, 28%). Modifications to structural factors were also identified, such as staffing levels to increase the amount of clinician time available for WRs (2/25, 8%).
Comments This study presents an exploration of the current problems, and solutions, pertaining to the practice of surgical Table 4
WRs. It identifies potential quality markers which might be used to measure, and interventions with which to improve, this critical process of postoperative care. Additionally, this study offers a novel perspective, with all stakeholder groups involved in the surgical WRdattendings, residents, interns, nurses, and patientsdincluded in such a study for the first time. The results of this study indicate clear agreement across all interviewees, from diverse backgrounds and 8 different hospitals, that current WR practice contains levels of variability which potentially place patients at risk. This finding is in agreement with the previously described observational study of surgical WRs,13 and places further emphasis on the need for assessment and improvement of WRs. To address these issues, this study first sought to define various parties’ expectations of the WR, as well as the skill set required to meet these. These expectations included patient assessment, management, progress review, and communication with both patient and clinical team, broadly in agreement with the definition of WRs set out by the
Recommendations for quality improvement and training
Simulation- or scenario-based training Checklist or proforma Definition of standardized approach Regular formalized trainee assessment Top-down cultural change Communication training Increase staffing and time available
n (%)
Attending
Resident
Intern
Nurse
Patient
13 12 8 7 7 2 2
3 2 3 2 1 1 0
3 3 1 2 1 0 1
3 4 2 2 2 0 0
2 1 2 1 1 1 1
2 2 0 0 1 0 0
(52%) (48%) (32%) (28%) (28%) (8%) (8%)
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Royal College of Physicians/Royal College of Nursing joint statement.18 The skill set identified by interviewees, which emphasizes nontechnical skills such as communication, teamwork, and leadership skills, is reflective of the growing perceptual shift of surgical training in general, to expand the focus of training beyond operative skill alone. A number of potential subprocesses, which might be used to assess WR quality, were identified in this study, with broad agreement among interviewees. Although not all processes may apply to all patients (ie, not all patients might have radiological investigations, or require specific dietary plans), it is intuitive that patients will always benefit from a comparatively more thorough assessment. Indeed, a ‘‘lack of thoroughness’’ was identified in interviews as a major perceived source of variability in WR quality: ‘‘More senior [clinicians], these ones tend to take a little more time looking at all the information. They do actually come up with more jobs for us to do as juniors . They can trouble-shoot problems before they really start and I think that’s what keeps [patients] safe.’’ (subject 14, intern)
Such statements suggest the use of thoroughness of assessment as a marker of WR quality. A similar conclusion has been inferred by Silber etal21 in their cohort study analysis of over 4.5 million patients, linking more aggressive postoperative treatment strategies to a reduction in failure to rescue metrics. The processes identified in this study may act as a guide in defining thoroughness. This approach has been initially validated by the Surgical Ward Care Assessment Tool,13,22 an assessment tool which assesses completion of generic care processes such as evaluation of charts, prescriptions, and venous thromboembolism prophylaxis, to measure surgical WR performance. One area in which a lack of agreement was seen among interviewees was the discussion of the agreed management plan with the patient. Sixty percent of the patients (3/5) expressed a strong wish to be told of their management plan, contrasting with only 25% (5/20) of clinical interviewees who named this as a necessary part of WRs. In the modern era of patient choice and patient-related outcome measures, such a disconnect serves only to further highlight the need for increased awareness and training in this area of care. The importance of patient involvement in their own care cannot be understated. As illustrated by the quote from subject 21 (in the Results section), patient understanding of their care may contribute substantially to their clinical progress, and play a role in reducing medical error and improving outcomes. Although some patients may not desire the same level of detailed information, it is important that all be given the options to receive it. Finally, this study identified a number of potential interventions for WR improvement, including simulationbased training. The benefits of simulation, allowing trainees to train in a high-fidelity, controlled environment, with the elimination of risk of patient harm, has resulted in the wide uptake of simulation-based training for technical skills in
surgery, with an established body of evidence demonstrating its efficacy.23–25 The results of this interview study suggest that there is a perceived need for the application of simulation specifically for WR training. A recent survey of North American program directors has supported the increased adoption of simulation generally to train surgeons’ nontechnical skills.26 Although ward simulation is a relatively recent concept,22 initial studies have demonstrated its validity for use in both assessment,27 as well as improvement,28 of trainee WR performance. Other recommendations identified by interviewees in this study, such as regular trainee assessment and communication training, would be well suited for incorporation into a simulation-based training scheme or curriculum in future. Checklists or proformas were named as a further potential intervention to improve care. However, despite support from 12 of the 25 (48%) interviewees, several subjects also stated their objection to the use of checklists in this area of care. These cited the perceived necessary variation and flexibility of WRs between patients, according to their physiological status and level of clinical concern, which could not be accommodated by uniform checklists. Checklists, in the form of daily goals sheets, have been effectively used to improve communication quality in the context of intensive care units (ICUs).29,30 However, the ICU environment represents a highly standardized level of patient care; it is possible, therefore, that principles which work in the ICU setting may be inappropriate to transfer to the context of surgical ward care. Despite this, the standardization and improvement of patient assessment in the acutely unwell is clearly desirable. While controlled exposure to such a patient cohort for training purposes would be impossible in vivo, this would be well suited to a simulated environment. The breadth of stakeholder groups interviewed in this study, while a methodological strength, has resulted in a relatively small number of interviewees per group. Despite this limitation, thematic saturation was reached, with broadly similar recommendations from all groups. Although a larger sample size might have allowed greater differentiation between groups, this was not the primary aim of this study, which was to explore ideas and perceptions across groups on the topic of surgical WR practice. Despite a study population based within the UK, the findings here relate to the generic care process of the WR which may be assumed to be conducted in a similar fashion in other medical systems; the findings of this study suggest topics for future development applicable to modern healthcare systems in general. In conclusion, this study suggests that clinical staff and patients alike perceive there to be significant variability in current surgical WR practice, which places patients at risk and affects care. It highlights nontechnical skills, rather than medical knowledge, as a target for improvement of care. Interviewees identified perceived quality markers which may be used for assessment of WR quality. Further
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development of interventions, such as ward simulation, to assess and improve surgeons’ and surgical trainees’ performance is needed to standardize and improve both WRs patient care.
References 1. Hull L, Arora S, Aggarwal R, et al. The impact of nontechnical skills on technical performance in surgery: a systematic review. J Am Coll Surg 2012;214:214–30. 2. Sharma B, Mishra A, Aggarwal R, et al. Non-technical skills assessment in surgery. Surg Oncol 2011;20:169–77. 3. Ghaferi AA, Osborne NH, Birkmeyer JD, et al. Hospital characteristics associated with failure to rescue from complications after pancreatectomy. J Am Coll Surg 2010;211:325–30. 4. Silber JH, Williams SV, Krakauer H, et al. Hospital and patient characteristics associated with death after surgery. A study of adverse occurrence and failure to rescue. Med Care 1992;30:615–29. 5. Aiken LH, Cimiotti JP, Sloane DM, et al. Effects of nurse staffing and nurse education on patient deaths in hospitals with different nurse work environments. Med Care 2011;49:1047–53. 6. Friese CR, Earle CC, Silber JH, et al. Hospital characteristics, clinical severity, and outcomes for surgical oncology patients. Surgery 2010; 147:602–9. 7. Ghaferi AA, Birkmeyer JD, Dimick JB. Hospital volume and failure to rescue with high-risk surgery. Med Care 2011;49:1076–81. 8. Mahar P, Lake H, Waxman BP. Patient perceptions of the surgical ward round. ANZ J Surg 2009;79:584–5. 9. Montague ML, Hussain SS. Patient perceptions of the otolaryngology ward round in a teaching hospital. J Laryngol Otol 2006;120:314–8. 10. Birtwistle L, Houghton JM, Rostill H. A review of a surgical ward round in a large paediatric hospital: does it achieve its aims? Med Educ 2000;34:398–403. 11. Fernando KJ, Siriwardena AK. Standards of documentation of the surgeon-patient consultation in current surgical practice. Br J Surg 2001;88:309–12. 12. Creamer GL, Dahl A, Perumal D, et al. Anatomy of the ward round: the time spent in different activities. ANZ J Surg 2010; 80:930–2. 13. Pucher PH, Aggarwal R, Darzi A. Surgical ward round quality and impact on variable patient outcomes. Ann Surg 2014;259:222–6. 14. American College of Surgeons. ACS/APDS Surgery Resident Skills Curriculum. Available at: http://www.facs.org/education/surgicalskills. html. Accessed November 1, 2013.
217 15. Ortiz H, Wibe A, Ciga MA, et al. Impact of a multidisciplinary team training programme on rectal cancer outcomes in Spain. Colorectal Dis 2013;15:544–51. 16. Armour Forse R, Bramble JD, McQuillan R. Team training can improve operating room performance. Surgery 2011;150:771–8. 17. McCulloch P, Mishra A, Handa A, et al. The effects of aviationstyle non-technical skills training on technical performance and outcome in the operating theatre. Qual Saf Health Care 2009;18: 109–15. 18. Royal College of Physicians, Royal College of Nursing. Ward Rounds in Medicine: Principles for Best Practice. London: Royal College of Physicians; 2012. 19. Nagpal K, Arora S, Abboudi M, et al. Postoperative handover: problems, pitfalls, and prevention of error. Ann Surg 2010;252: 171–6. 20. Nagpal K, Arora S, Vats A, et al. Failures in communication and information transfer across the surgical care pathway: interview study. BMJ Qual Saf 2012;21:843–9. 21. Silber JH, Kaestner R, Even-Shoshan O, et al. Aggressive treatment style and surgical outcomes. Health Serv Res 2010;45:1872–92. 22. Pucher PH, Darzi A, Aggarwal R. Simulation for ward processes of surgical care. Am J Surg 2013;206:96–102. 23. Orzech N, Palter VN, Reznick RK, et al. A comparison of 2 ex vivo training curricula for advanced laparoscopic skills: a randomized controlled trial. Ann Surg 2012;255:833–9. 24. Palter VN, Orzech N, Reznick RK, et al. Validation of a structured training and assessment curriculum for technical skill acquisition in minimally invasive surgery: a randomized controlled trial. Ann Surg 2013;257:224–30. 25. Crochet P, Aggarwal R, Dubb SS, et al. Deliberate practice on a virtual reality laparoscopic simulator enhances the quality of surgical technical skills. Ann Surg 2011;253:1216–22. 26. Dedy NJ, Zevin B, Bonrath EM, et al. Current concepts of team training in surgical residency: a survey of North American program directors. J Surg Educ 2013;70:578–84. 27. Pucher PH, Aggarwal R, Srisatkunam T, et al. Validation of the simulated ward environment for assessment of ward-based surgical care. Ann Surg 2014;259:215–21. 28. Pucher PH, Aggarwal R, Singh P, et al. Ward simulation to improve surgical ward round performance: a randomised controlled trial of a simulation-based curriculum. Ann Surg 2014;260:236–43. 29. Pronovost P, Berenholtz S, Dorman T, et al. Improving communication in the ICU using daily goals. J Crit Care 2003;18:71–5. 30. Agarwal S, Frankel L, Tourner S, et al. Improving communication in a pediatric intensive care unit using daily patient goal sheets. J Crit Care 2008;23:227–35.
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Appendix Semistructured interview template Identification of quality markers for ward rounds and postoperative care
Semistructured interview framework 1. Demographics, introduction
2. Identifying the problem
3. Define WR process and sub-processes 4. Define required skill set
5. Identify quality markers
6. How to improve practice
7. Final points?
‘‘We are conducting research looking at measuring and improving surgical care outside of the operating room. The daily ward round of course plays a very important role in this area of patient care. The goal of this is to interview study is - first, to define the WR and general skills trainees need for this - second, to come up with ways in which we might measure the quality of ward rounds - finally, moving on from that, to think of ways to improve them.’’ Confirm subject identity and personal details Background Years of experience/training level Confirm permission to record ‘‘Can I just start by confirming that you are a patient/what your role is? (How long have you been a consultant/trainee?) (How long have you been in hospital for?) And can I just confirm that you are aware that we are being recorded and that you are happy for this?’’ Opening statement: ‘‘I would like to start by asking about surgical ward rounds, in general. In your experience, do you think there is variability in way in which different clinicians conduct a ward round, and do you think this impacts patient care? How do you think that variability manifests itself/can you give specific examples? Do you think this impacts patient care?’’ ‘‘What is your personal definition, if I were to ask you what a ward round is as what processes take place during the ward round?’’ ‘‘In order to do all this, what do you think are some of the skills a clinician needs to have to be able to do all this?’’ Prompt ‘‘I’m thinking here specifically of both clinical or technical skills, but also non-technical qualities, can you name any which you think are relevant?’’ ‘‘As I mentioned at the start, part of the aim of this interview is to try and identify quality markers for WRs.’’ If prompt required – ‘‘Imagine it’s Saturday morning and you meeting a patient on HDU for the first time, he was operated on yesterday, and he looks a bit unwell. What are you going to do?’’ If only patient assessment discussed – We’ve talked about assessing the patient. What about the management aspect of things? What does the team need to know about how to manage the patient for the rest of the day as a result of the WR? ‘‘As we said at the beginning, there is a great amount of variability which occurs. How do you think we might address this to improve individual clinicians’ practice?’’ ‘‘Implementing any kind of change can be difficult without first appropriately training staff. How would you go about assessing and training clinicians for this kind of thing?’’ ‘‘Thank you for your time. Just before we finish, do you think there is anything else you would like to add on the topic?’’
Clinical Science
Identifying quality markers and improvement measures for ward-based surgical care: a semistructured interview study Philip H. Pucher, M.D., Ph.D., M.R.C.S.a,*, Rajesh Aggarwal, M.B.B.S., M.A., Ph.D.b,c, Pritam Singh, M.B.B.S., M.A., M.R.C.S.a, Muaaz Tahir, B.Sc.a, Ara Darzi, M.D., K.B.E.a a
Department of Surgery and Cancer, St. Mary’s Hospital, Imperial College London, London, UK; Department of Surgery and cArnold & Blema Steinberg Medical Simulation Centre, Faculty of Medicine, McGill University, Montreal, Canada
b
KEYWORDS: Surgery; Ward round; Postoperative care; Quality improvement; Patient round
Abstract BACKGROUND: The surgical ward round (WR) represents the primary interface between the clinical team and the patient and is integral to the quality of postoperative care and subsequent patient outcomes. This study aims to explore key issues pertaining to the surgical WR, defining challenges in current practice, and identifying potential means of quality assessment and improvement. METHODS: A qualitative, semistructured interview-based approach was adopted, including patients, nurses, interns, residents, and attendings. RESULTS: Twenty-five interview subjects were recruited across 8 hospitals. Twenty-three of the 25 (92%) subjects believed that there was significant variation in the quality of WRs and that this affected patient care. Lack of thoroughness (18/25, 72%) and poor communication (12/25, 48%) were the most commonly identified causes. Nontechnical skills such as communication (25/25, 100%) were seen as crucial to WR quality. Quality markers for surgical WRs were identified. Simulation-based training was recommended (13/25, 52%) to improve performance. CONCLUSIONS: Clinical staff and patients alike perceive there to be significant variability in current surgical WR practice. Further development of interventions to assess and improve surgeons’ performance is necessary to standardize and improve WRs and patient care. Ó 2015 Elsevier Inc. All rights reserved.
There were no relevant financial relationships or any sources of support in the form of grants, equipment, or drugs. Rajesh Aggarwal receives consulting fees from Applied Medical. The authors declare no conflicts of interest. Presented at the International Conference on Residency Education, October 2014, Toronto, Ontario. * Corresponding author. Tel.: 144-203-312-6666; fax: 144-203-312-6309. E-mail address: [email protected] Manuscript received July 25, 2014; revised manuscript October 18, 2014 0002-9610/$ - see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.amjsurg.2014.11.013
212 Modern surgical expertise demands more than technical ability. Variations in hospital mortality rates have been shown to be reflective of differences in the quality of postoperative patient care, rather than solely quality of surgery itself.1,2 This variability, and its effect on surgical outcomes,3,4 continues to drive research seeking to identify and improve underlying causative factors.3,5–7 In part because of the nature of the recorded data available for retrospective analysis, much of the current body of research in this domain has focused on structural variables such as nurse staffing levels5 or operative volume7; much less is known about the role of care processes taking place at the bedside. The surgical ward round (WR) represents the primary interface between the clinical team and the patient, typically involving a daily review of patient progress and prescription of the management plan for continued patient care. The WR is therefore integral to the quality of postoperative care and the determination of patient outcomes. Despite such a critical role, however, little scientific knowledge on this topic currently exists. Previous research relating to surgical WRs has considered staff and patient viewpoints on the subject,8–10 or assessed individual aspects of the WR such as documentation11 or patient timing.12 These largely anecdotal and subjective data have suggested the existence of significant variability underlying the quality of care provided during the surgical WR. A recent single-center observational study of surgical WRs demonstrated significant variation in WR conduct, wherein less thorough patient assessment was found to be significantly associated with a higher incidence of preventable complications.13 Such findings highlight the need to improve WR quality, and postoperative care in general. Increasingly, there has been recognition of the importance of WRs and nontechnical skills for surgical training. Team-based skills have recently been introduced as part of the American College of Surgeons Surgery Resident Skills Curriculum in the United States.14 Meanwhile, several studies have reported the effectiveness of nontechnical skills training programs in improving surgical outcomes.15–17 These have focused primarily on the operating room environment, rather than the postoperative phase of care. In the UK, the Royal College of Physicians and the Royal College of Nursing recently joint issued a white paper calling specifically for a refocusing of priorities on WRs as a key point of care for quality improvement.18 Crucially, however, this lacked specific guidance on how to address this training gap, reflecting the current dearth of knowledge in this area. Research to explore, assess, and improve surgical WRs must consider the large number of stakeholder groups involveddto address all sides of this multifaceted process, as well as to ensure consideration of potential confounders. Although the primary surgeon will determine the course of patient care during the WR, they are not alone in determining outcomes. Management decisions are made with input from junior clinicians, care delivered by nursing staff, and experienced by patients, all of whom contribute significantly to the quality of patient care.
The American Journal of Surgery, Vol 210, No 2, August 2015 The aim of this study was to explore key issues pertaining to the surgical WR. Semistructured interviews were conducted, with interviewees asked to identify perceived causes of problems in current WR practice, suggest markers by which WR quality might be quantified, and how practice in future might be improved.
Methods A qualitative, semistructured interview-based approach was adopted to explore issues around surgical WRs and postoperative care. An institutional research ethics committee approved the study.
Subjects Interviewees were selected to represent the multidisciplinary roles involved in a general surgical ward round, and to give voice to all major stakeholders in postoperative care: patients, nurses, interns, residents, and attendings. A sample size of 25 interviewees was selected, based on the methods of a previous interview study which sought to explore the related field of surgical handover and information transfer, in which Nagpal et al19,20 achieved thematic saturation with 18 multidisciplinary participants. Interviewees were purposively sampled for a broad range of backgrounds and experience levels, with patients identified from the inpatient register of a single tertiary academic surgical center and considered for inclusion in the study if they had undergone a general surgical procedure during their current admission.
Setting To ensure patients would be well enough to participate in an interview, and to minimize any concerns that the interview might affect their care, subject interviews were limited to the day of, or day before, planned discharge. Interviews took place in a private office in the general surgical ward, with an independent interviewer who was identified as a researcher, and not a member of the surgical care team.
Interview process Subjects were interviewed using a predetermined, semistructured interview protocol which was developed and piloted before use in the final subject interviews. The interview protocol covered the following topics with reference to ward-based care in general surgery, with a focus on clinician-led processes: Introduction and demographic details Identifying current problems in ward-based surgical care (ie, variability) Defining the surgical WR Required skill set Identifying quality markers for WRs Improving surgical WR quality
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Data analysis
staff, some are bad with both. So we see huge variation, yes.’’ (subject 24, attending)
Recorded interviews were anonymized and transcribed by a third party not familiar with the participants. Identifying phrases and names were removed. Anonymized transcripts were then analyzed by a member of the research team, with emerging themes recorded until thematic saturation was reached. A second blinded researcher also analyzed 20% of transcripts, selected using a computergenerated randomization sequence, to ensure reliability of theme extraction. Themes mentioned by each subject were coded by both researchers independently, overarching theme content unified between reviewers via consensus discussion within the research team, and reliability of thematic extraction compared using Cohen’s kappa. Statistical analysis was performed using IBM SPSS 21 (IBM Corp, Armonk, NY). A P value of less than .05 was considered statistically significant.
The most common cause identified was the degree of thoroughness with which the WR was conducted (18/25, 72%), followed by poor communication (12/25, 48%) and the lack of a structured approach (9/25, 36%): ‘‘If you’re not thorough, then you can miss things that are easy to sort out in the beginning, but if you let them drag on then it can be much harder to sort them out or the patient can get sicker before you really realize that there’s a problem.’’ (subject 10, intern)
Defining the surgical ward round In response to being asked to define their expectations of the surgical WR, generally similar themes were identified by the majority of subjects interviewed. The WR was defined as a process of patient assessment (25/25, 100%), during which patient progress was reviewed (18/25, 72%) and a management plan defined (23/25, 92%). It was felt to represent a forum for communication with the patient (16/ 25, 64%) and for communication within the multidisciplinary clinical team (13/25, 52%):
Results Twenty-five interview subjects were recruited from 8 hospitals across southern England, UKd2 tertiary academic centers (16/25 subjects, 64%) and 6 community hospitals (9/25 subjects, 36%)dwith varying levels of experience (Table 1). Response rate was 100%, with all approached interviewees agreeing to participate in the study. Median interview duration was 21 (interquartile range 17 to 27) minutes (range 11 to 55 minutes). A total of 562 minutes were transcribed and coded by independent raters as described above. Inter-rater reliability of coding was very good, as measured by Cohen’s kappa (.724, P , .001). Themes for each interview subheading were summarized and are presented below.
‘‘[The purpose of the WR] is to assess the progress of the patient in regard to their treatment. That means picking up problems which may or may not be anticipated, the patient’s concerns, their worries. And all that information should be passed across . through the other members of the team.’’ (subject 24, attending)
Required skill set Interviewees identified clinicians’ skills which they deemed critical to the conduct of high-quality WRs. Above all, communication was identified as the most important (25/25, 100%), with implications for both clinical performance as well as patient experience:
Current problems in ward-based care Almost all subjects (23/25, 92%), including all clinical staff (20/20, 100%), believed that there was significant variation in the quality of surgical WRs, and that this had the potential to affect patient care (Table 2):
‘‘Communication is essential . professionalism generally follows’’ (subject 2, attending) ‘‘Some people, you really feel like you’re working as a team . sometimes you feel that you’re completely not, which is not very nice because you’re the [nurse] who’s there the whole time. And you pick up on the way the patients feel because they notice straight away . it’s
‘‘. There are differences in quality and activity. Some [clinicians] are good with the complex amount of information which needs to be processed, some are not. Some are good with patients, some are good with
Table 1
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Participant demographics
Attendings Residents Interns Nurses Patients
n
Male:Female
Academic:Community
Experience in role (median, range)
5 5 5 5 5
4:1 3:2 2:3 2:3 3:2
4:1 2:3 1:4 5:0 4:1
9 (1 to 22) years PGY 7 (5 to 10) PGY 1 (1 to 1) 9 (2 to 20) years 21 (3 to 35) inpatient days
PGY 5 postgraduate year.
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Table 2
Interviewees’ opinions on current WR practice
Variation exists and affects care Causes of variation in WR quality Thoroughness of round Communication quality Structured approach Team approach Expectations of the WR Patient assessment Define management plan Review progress Communication with patient Communication with team Required skill set Communication skills Patient assessment/history taking Diagnostic ability/knowledge Teamwork/multidisciplinary cooperation Leadership and management skills
n (%)
Attending
Resident
Intern
Nurse
Patient
23 (92%)
5
5
5
5
3
18 12 9 9
(72%) (48%) (36%) (36%)
4 3 2 2
5 1 2 1
5 2 1 3
3 3 3 3
1 3 1 0
25 23 18 16 13
(100%) (92%) (72%) (64%) (52%)
5 5 4 4 4
5 5 5 4 4
5 5 3 2 2
5 5 4 2 3
5 3 2 4 0
25 18 17 11 10
(100%) (72%) (68%) (44%) (40%)
5 5 4 3 2
5 5 4 2 5
5 5 3 2 2
5 3 4 2 0
5 4 2 2 1
WR 5 ward round.
not very nice to hear ‘oh they weren’t very nice were they?’’’ (subject 4, nurse)
Related skills such as history taking and patient assessment (18/25, 72%) were also cited, as well as teamwork (11/ 25, 44%), leadership, and management skills (10/25, 40%).
Identifying quality markers for ward rounds Subjects identified a number of processes which would be expected to be included in the ideal WR, in the context of an unwell postoperative patient. These were felt to potentially be used as markers of WR quality (Table 3). Processes were divided into processes of patient assessment and management. Assessment tasks included physical examination (21/25, 84%), taking a recent history from the patient (21/25, 84%), and checking of vital sign charts (21/25, 84%). Management tasks included defining further investigations or interventions necessary (19/25, 76%), dietary status (14/25, 56%), and ensuring appropriate documentation (13/25, 52%). In reference to processes determining patient management during the WR, there was a marked divide between clinical staff and patients. Although there was broad agreement between clinical staff, which named a median of 6 themes (range 2 to 9), patients named far fewer tasks, 2 (1 to 4), possibly reflecting a lack of clinical knowledge by lay patients in this domain. Most frequently named by patients was the expectation that the management plan be communicated to the patient (3/5, 60%). This varied between patients, however, with some patients less interested in the details of their ongoing care, whereas others wished to have full and active involvement:
‘‘I’m not too bothered [about knowing what’s going on with me in hospital]’’ (subject 19, patient) ‘‘I want to know everything. Partly because if I know everything, I can push to keep the plan. Like I knew about [my prescribed diet], so I had to call the junior doctor because the caterer didn’t know anything about it. Every time it turns out they need to take blood, I say ‘what for?’’’ (subject 21, patient)
None of the patient interviewees expressed a desire to explicitly not be told of their ongoing management.
Improving surgical ward round quality All subjects agreed that measures to improve surgical WR quality were needed, with a number of potential interventions identified (Table 4). The most commonly mentioned intervention was to implement scenario- or simulation-based training (13/25, 52%): ‘‘You could simulate a ward round . the benefit is that you could reproduce the same patients so you could create the complex patients that you wouldn’t otherwise have, necessarily, when someone is watching you [during routine clinical practice]. And you’ve got to remember [during a clinical teaching WR] you’ve got a patient here, do you want to start scaring them . going through the vast array of complications you can get? It’s not really appropriate to do that in front of the patient.’’ (subject 8, resident)
Checklists and proformas for WRs were also named as a potential intervention (12/25, 48%). Some interviewees strongly advocated this approach, citing the empowering nature of checklists and the potential for these to ensure basic essential tasks are reliably completed (subject 3,
P.H. Pucher et al. Table 3
Quality improvement for surgical ward care
215
Identified markers for ward round quality
Patient assessment Physical examination History from patient Status charts (ie, vitals, fluid balance) Prescription chart Pathology and laboratory results Review medical notes Radiology results History from nurse VTE prophylaxis Assess analgesia Patient management Investigations or interventions Dietary status Appropriate documentation Communicate plan to nursing staff Appropriate prescribing Blood tests if required Discharge planning Communicate plan to team Communicate plan to patient
n (%)
Attending
Resident
Intern
Nurse
Patient
21 21 21 19 18 17 17 12 9 6
(84%) (84%) (84%) (76%) (72%) (68%) (68%) (48%) (36%) (24%)
4 4 5 5 4 3 4 3 2 0
5 5 5 4 5 4 5 4 4 1
5 5 4 4 5 4 5 0 3 3
4 3 5 5 3 3 3 3 0 0
3 4 2 1 1 3 0 2 0 2
19 14 13 12 12 11 10 9 8
(76%) (56%) (52%) (48%) (48%) (44%) (40%) (36%) (32%)
5 2 4 1 3 2 1 1 1
5 4 4 4 2 3 3 3 2
5 3 2 2 4 4 1 2 1
4 3 3 4 3 1 3 2 1
0 2 0 1 0 1 2 1 3
VTE 5 venous thromboembolism prophylaxis.
attending). However, others argued that checklists did not allow the necessary flexibility for different WRs between, for example, unwell postoperative patients or fully recovered patients about to be discharged (subject 7, resident). Another concern raised was that checklists might limit clinicians’ own free interpretation of the patient by enforcing narrow prompts (subject 24, attending). In addition to training interventions, the need for a formalized system of trainee WR assessment was specifically mentioned by 7 of the 25 (28%) subjects. Others mentioned the need for top-down cultural change to improve the quality of WRs and training overall (7/25, 28%). Modifications to structural factors were also identified, such as staffing levels to increase the amount of clinician time available for WRs (2/25, 8%).
Comments This study presents an exploration of the current problems, and solutions, pertaining to the practice of surgical Table 4
WRs. It identifies potential quality markers which might be used to measure, and interventions with which to improve, this critical process of postoperative care. Additionally, this study offers a novel perspective, with all stakeholder groups involved in the surgical WRdattendings, residents, interns, nurses, and patientsdincluded in such a study for the first time. The results of this study indicate clear agreement across all interviewees, from diverse backgrounds and 8 different hospitals, that current WR practice contains levels of variability which potentially place patients at risk. This finding is in agreement with the previously described observational study of surgical WRs,13 and places further emphasis on the need for assessment and improvement of WRs. To address these issues, this study first sought to define various parties’ expectations of the WR, as well as the skill set required to meet these. These expectations included patient assessment, management, progress review, and communication with both patient and clinical team, broadly in agreement with the definition of WRs set out by the
Recommendations for quality improvement and training
Simulation- or scenario-based training Checklist or proforma Definition of standardized approach Regular formalized trainee assessment Top-down cultural change Communication training Increase staffing and time available
n (%)
Attending
Resident
Intern
Nurse
Patient
13 12 8 7 7 2 2
3 2 3 2 1 1 0
3 3 1 2 1 0 1
3 4 2 2 2 0 0
2 1 2 1 1 1 1
2 2 0 0 1 0 0
(52%) (48%) (32%) (28%) (28%) (8%) (8%)
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Royal College of Physicians/Royal College of Nursing joint statement.18 The skill set identified by interviewees, which emphasizes nontechnical skills such as communication, teamwork, and leadership skills, is reflective of the growing perceptual shift of surgical training in general, to expand the focus of training beyond operative skill alone. A number of potential subprocesses, which might be used to assess WR quality, were identified in this study, with broad agreement among interviewees. Although not all processes may apply to all patients (ie, not all patients might have radiological investigations, or require specific dietary plans), it is intuitive that patients will always benefit from a comparatively more thorough assessment. Indeed, a ‘‘lack of thoroughness’’ was identified in interviews as a major perceived source of variability in WR quality: ‘‘More senior [clinicians], these ones tend to take a little more time looking at all the information. They do actually come up with more jobs for us to do as juniors . They can trouble-shoot problems before they really start and I think that’s what keeps [patients] safe.’’ (subject 14, intern)
Such statements suggest the use of thoroughness of assessment as a marker of WR quality. A similar conclusion has been inferred by Silber etal21 in their cohort study analysis of over 4.5 million patients, linking more aggressive postoperative treatment strategies to a reduction in failure to rescue metrics. The processes identified in this study may act as a guide in defining thoroughness. This approach has been initially validated by the Surgical Ward Care Assessment Tool,13,22 an assessment tool which assesses completion of generic care processes such as evaluation of charts, prescriptions, and venous thromboembolism prophylaxis, to measure surgical WR performance. One area in which a lack of agreement was seen among interviewees was the discussion of the agreed management plan with the patient. Sixty percent of the patients (3/5) expressed a strong wish to be told of their management plan, contrasting with only 25% (5/20) of clinical interviewees who named this as a necessary part of WRs. In the modern era of patient choice and patient-related outcome measures, such a disconnect serves only to further highlight the need for increased awareness and training in this area of care. The importance of patient involvement in their own care cannot be understated. As illustrated by the quote from subject 21 (in the Results section), patient understanding of their care may contribute substantially to their clinical progress, and play a role in reducing medical error and improving outcomes. Although some patients may not desire the same level of detailed information, it is important that all be given the options to receive it. Finally, this study identified a number of potential interventions for WR improvement, including simulationbased training. The benefits of simulation, allowing trainees to train in a high-fidelity, controlled environment, with the elimination of risk of patient harm, has resulted in the wide uptake of simulation-based training for technical skills in
surgery, with an established body of evidence demonstrating its efficacy.23–25 The results of this interview study suggest that there is a perceived need for the application of simulation specifically for WR training. A recent survey of North American program directors has supported the increased adoption of simulation generally to train surgeons’ nontechnical skills.26 Although ward simulation is a relatively recent concept,22 initial studies have demonstrated its validity for use in both assessment,27 as well as improvement,28 of trainee WR performance. Other recommendations identified by interviewees in this study, such as regular trainee assessment and communication training, would be well suited for incorporation into a simulation-based training scheme or curriculum in future. Checklists or proformas were named as a further potential intervention to improve care. However, despite support from 12 of the 25 (48%) interviewees, several subjects also stated their objection to the use of checklists in this area of care. These cited the perceived necessary variation and flexibility of WRs between patients, according to their physiological status and level of clinical concern, which could not be accommodated by uniform checklists. Checklists, in the form of daily goals sheets, have been effectively used to improve communication quality in the context of intensive care units (ICUs).29,30 However, the ICU environment represents a highly standardized level of patient care; it is possible, therefore, that principles which work in the ICU setting may be inappropriate to transfer to the context of surgical ward care. Despite this, the standardization and improvement of patient assessment in the acutely unwell is clearly desirable. While controlled exposure to such a patient cohort for training purposes would be impossible in vivo, this would be well suited to a simulated environment. The breadth of stakeholder groups interviewed in this study, while a methodological strength, has resulted in a relatively small number of interviewees per group. Despite this limitation, thematic saturation was reached, with broadly similar recommendations from all groups. Although a larger sample size might have allowed greater differentiation between groups, this was not the primary aim of this study, which was to explore ideas and perceptions across groups on the topic of surgical WR practice. Despite a study population based within the UK, the findings here relate to the generic care process of the WR which may be assumed to be conducted in a similar fashion in other medical systems; the findings of this study suggest topics for future development applicable to modern healthcare systems in general. In conclusion, this study suggests that clinical staff and patients alike perceive there to be significant variability in current surgical WR practice, which places patients at risk and affects care. It highlights nontechnical skills, rather than medical knowledge, as a target for improvement of care. Interviewees identified perceived quality markers which may be used for assessment of WR quality. Further
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development of interventions, such as ward simulation, to assess and improve surgeons’ and surgical trainees’ performance is needed to standardize and improve both WRs patient care.
References 1. Hull L, Arora S, Aggarwal R, et al. The impact of nontechnical skills on technical performance in surgery: a systematic review. J Am Coll Surg 2012;214:214–30. 2. Sharma B, Mishra A, Aggarwal R, et al. Non-technical skills assessment in surgery. Surg Oncol 2011;20:169–77. 3. Ghaferi AA, Osborne NH, Birkmeyer JD, et al. Hospital characteristics associated with failure to rescue from complications after pancreatectomy. J Am Coll Surg 2010;211:325–30. 4. Silber JH, Williams SV, Krakauer H, et al. Hospital and patient characteristics associated with death after surgery. A study of adverse occurrence and failure to rescue. Med Care 1992;30:615–29. 5. Aiken LH, Cimiotti JP, Sloane DM, et al. Effects of nurse staffing and nurse education on patient deaths in hospitals with different nurse work environments. Med Care 2011;49:1047–53. 6. Friese CR, Earle CC, Silber JH, et al. Hospital characteristics, clinical severity, and outcomes for surgical oncology patients. Surgery 2010; 147:602–9. 7. Ghaferi AA, Birkmeyer JD, Dimick JB. Hospital volume and failure to rescue with high-risk surgery. Med Care 2011;49:1076–81. 8. Mahar P, Lake H, Waxman BP. Patient perceptions of the surgical ward round. ANZ J Surg 2009;79:584–5. 9. Montague ML, Hussain SS. Patient perceptions of the otolaryngology ward round in a teaching hospital. J Laryngol Otol 2006;120:314–8. 10. Birtwistle L, Houghton JM, Rostill H. A review of a surgical ward round in a large paediatric hospital: does it achieve its aims? Med Educ 2000;34:398–403. 11. Fernando KJ, Siriwardena AK. Standards of documentation of the surgeon-patient consultation in current surgical practice. Br J Surg 2001;88:309–12. 12. Creamer GL, Dahl A, Perumal D, et al. Anatomy of the ward round: the time spent in different activities. ANZ J Surg 2010; 80:930–2. 13. Pucher PH, Aggarwal R, Darzi A. Surgical ward round quality and impact on variable patient outcomes. Ann Surg 2014;259:222–6. 14. American College of Surgeons. ACS/APDS Surgery Resident Skills Curriculum. Available at: http://www.facs.org/education/surgicalskills. html. Accessed November 1, 2013.
217 15. Ortiz H, Wibe A, Ciga MA, et al. Impact of a multidisciplinary team training programme on rectal cancer outcomes in Spain. Colorectal Dis 2013;15:544–51. 16. Armour Forse R, Bramble JD, McQuillan R. Team training can improve operating room performance. Surgery 2011;150:771–8. 17. McCulloch P, Mishra A, Handa A, et al. The effects of aviationstyle non-technical skills training on technical performance and outcome in the operating theatre. Qual Saf Health Care 2009;18: 109–15. 18. Royal College of Physicians, Royal College of Nursing. Ward Rounds in Medicine: Principles for Best Practice. London: Royal College of Physicians; 2012. 19. Nagpal K, Arora S, Abboudi M, et al. Postoperative handover: problems, pitfalls, and prevention of error. Ann Surg 2010;252: 171–6. 20. Nagpal K, Arora S, Vats A, et al. Failures in communication and information transfer across the surgical care pathway: interview study. BMJ Qual Saf 2012;21:843–9. 21. Silber JH, Kaestner R, Even-Shoshan O, et al. Aggressive treatment style and surgical outcomes. Health Serv Res 2010;45:1872–92. 22. Pucher PH, Darzi A, Aggarwal R. Simulation for ward processes of surgical care. Am J Surg 2013;206:96–102. 23. Orzech N, Palter VN, Reznick RK, et al. A comparison of 2 ex vivo training curricula for advanced laparoscopic skills: a randomized controlled trial. Ann Surg 2012;255:833–9. 24. Palter VN, Orzech N, Reznick RK, et al. Validation of a structured training and assessment curriculum for technical skill acquisition in minimally invasive surgery: a randomized controlled trial. Ann Surg 2013;257:224–30. 25. Crochet P, Aggarwal R, Dubb SS, et al. Deliberate practice on a virtual reality laparoscopic simulator enhances the quality of surgical technical skills. Ann Surg 2011;253:1216–22. 26. Dedy NJ, Zevin B, Bonrath EM, et al. Current concepts of team training in surgical residency: a survey of North American program directors. J Surg Educ 2013;70:578–84. 27. Pucher PH, Aggarwal R, Srisatkunam T, et al. Validation of the simulated ward environment for assessment of ward-based surgical care. Ann Surg 2014;259:215–21. 28. Pucher PH, Aggarwal R, Singh P, et al. Ward simulation to improve surgical ward round performance: a randomised controlled trial of a simulation-based curriculum. Ann Surg 2014;260:236–43. 29. Pronovost P, Berenholtz S, Dorman T, et al. Improving communication in the ICU using daily goals. J Crit Care 2003;18:71–5. 30. Agarwal S, Frankel L, Tourner S, et al. Improving communication in a pediatric intensive care unit using daily patient goal sheets. J Crit Care 2008;23:227–35.
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Appendix Semistructured interview template Identification of quality markers for ward rounds and postoperative care
Semistructured interview framework 1. Demographics, introduction
2. Identifying the problem
3. Define WR process and sub-processes 4. Define required skill set
5. Identify quality markers
6. How to improve practice
7. Final points?
‘‘We are conducting research looking at measuring and improving surgical care outside of the operating room. The daily ward round of course plays a very important role in this area of patient care. The goal of this is to interview study is - first, to define the WR and general skills trainees need for this - second, to come up with ways in which we might measure the quality of ward rounds - finally, moving on from that, to think of ways to improve them.’’ Confirm subject identity and personal details Background Years of experience/training level Confirm permission to record ‘‘Can I just start by confirming that you are a patient/what your role is? (How long have you been a consultant/trainee?) (How long have you been in hospital for?) And can I just confirm that you are aware that we are being recorded and that you are happy for this?’’ Opening statement: ‘‘I would like to start by asking about surgical ward rounds, in general. In your experience, do you think there is variability in way in which different clinicians conduct a ward round, and do you think this impacts patient care? How do you think that variability manifests itself/can you give specific examples? Do you think this impacts patient care?’’ ‘‘What is your personal definition, if I were to ask you what a ward round is as what processes take place during the ward round?’’ ‘‘In order to do all this, what do you think are some of the skills a clinician needs to have to be able to do all this?’’ Prompt ‘‘I’m thinking here specifically of both clinical or technical skills, but also non-technical qualities, can you name any which you think are relevant?’’ ‘‘As I mentioned at the start, part of the aim of this interview is to try and identify quality markers for WRs.’’ If prompt required – ‘‘Imagine it’s Saturday morning and you meeting a patient on HDU for the first time, he was operated on yesterday, and he looks a bit unwell. What are you going to do?’’ If only patient assessment discussed – We’ve talked about assessing the patient. What about the management aspect of things? What does the team need to know about how to manage the patient for the rest of the day as a result of the WR? ‘‘As we said at the beginning, there is a great amount of variability which occurs. How do you think we might address this to improve individual clinicians’ practice?’’ ‘‘Implementing any kind of change can be difficult without first appropriately training staff. How would you go about assessing and training clinicians for this kind of thing?’’ ‘‘Thank you for your time. Just before we finish, do you think there is anything else you would like to add on the topic?’’
