The American Journal of Surgery (2015) 210, 219-220

Invited Commentary

Quality and improvement Mark A. Malangoni, M.D., F.A.C.S.* American Board of Surgery, 1617 John F. Kennedy Boulevard, Suite 860, Philadelphia, PA 19103, USA The old saw, ‘‘cut well, sew well, do well,’’ is inherent to the surgical lexicon. More recently, a strong case has been made that the eventual outcomes of surgical care not only depend on the surgeon’s technical skill and avoidance of adverse intraoperative events, and that the prevention of complications and failure to rescue (death after complications) are greatly impacted by attention to the details of perioperative care.1–3 We recognize that proper care of invasive monitors (central lines, urinary catheters) and their removal when no longer necessary, early mobilization after operation, prompt extubation, and numerous other carerelated events are important to optimize patient outcomes. In a previous publication, Pucher et al3 demonstrated broad variability in the conduct of ward rounds and observed that when not enough attention was given to details during rounds, patient care was detrimentally affected. Now these same investigators have conducted a semistructured set of interviews with 20 healthcare providers (interns, nurses, residents, and surgeons) and 5 patients to assess the status quo of ward rounds in 8 hospitals in the United Kingdom.4 Let us examine the details more closely to better understand the implications of this study. There was unanimity of opinion among the healthcare providers interviewed that the conduct of patient rounds was variable. The interviewees also agreed that patient assessment (including history, physical examination, review of vital signs, fluid balance, current medications, and laboratory and pathology results) and formulation of a management plan were essential expectations of rounds. Otherwise, their opinions about which patient management components should be

DOI of original article: http://dx.doi.org/10.1016/j.amjsurg.2014.11.013 There was no financial support for this work. * Corresponding author. Tel.: 11-215-568-4000; fax: 11-215-563-5718. E-mail address: [email protected] Manuscript received January 10, 2015 0002-9610/$ - see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.amjsurg.2015.01.030

included to improve the quality of ward rounds varied considerably. Communication skills were listed by all respondents as the most important attribute for successful conduct of rounds ‘‘with implications for both clinical performance as well as patient experience.’’ Yet fewer than half of respondents expressed that communicating the management plan to the nurse, the care team, and the patient was necessary and only 8% thought that additional training in communication would improve the current situation! The disconnect between the necessity of having good communication skills and their role in performance improvement was surprising. It is possible that the respondents believed that the communication skills of the care team were already optimal and hence there was no need for additional training, but that seems far-fetched. Patients understood the importance of communication but had differing opinions about how much they wanted to know about their care and relied on the expertise of the care team to sort out the relevant details. Although the authors focused on the utility of simulation of ward rounds and the incorporation of checklists as tools to improve the quality of ward rounds, only half of the interviewees actually recommended adopting these techniques. This report is another important contribution from Lord Darzi’s clinical research group which has focused on defining factors that affect the outcome of surgical patient care. They conclude that a more uniform perioperative assessment plan for surgical patients is necessary to improve the quality of care. Their emphasis on the importance of communication skills to optimize the effectiveness of rounds aligns with other reports and clarifies the relevance of this competency.5 What remains unclear is identifying the detailed measures that will result in improved care.

References 1. Mazzocco K, Petitti DB, Fong KT, et al. Surgical team behaviors and patient outcomes. Am J Surg 2009;197:678–85.

220 2. 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. 3. Pucher PH, Aggarwal R, Darzi A. Surgical ward round quality and impact on variable patient outcomes. Ann Surg 2014;259: 222–6.

The American Journal of Surgery, Vol 210, No 2, August 2015 4. Pucher PH, Aggarwal R, Singh P, et al. Identifying quality markers and improvement measures for ward based surgical care: a semi-structured interview study. Am J Surg 2014;219:S115. 5. Van Eaton EG, Horvath KD, Lober WB, et al. A randomized, controlled trial evaluating the impact of a computerized rounding and sign-out system on continuity of care and resident work hours. J Am Coll Surg 2005;200:538–45.

Quality and improvement.

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