Checklist-Based Intervention to Improve Outcomes

safety in four UK hospitals: mixed method evaluation. BMJ. 2011;342:d195. 38. Michigan Surgical Quality Collaborative. Member hospitals. /membership_hospitals.php. Accessed December 1, 2013. 39. Pastor C, Artinyan A, Varma MG, Kim E, Gibbs L, Garcia-Aguilar J. An increase in compliance with the Surgical Care Improvement Project measures does not prevent surgical site infection in colorectal surgery. Dis Colon Rectum. 2010;53(1): 24-30.

Original Investigation Research

40. Helfrich CD, Damschroder LJ, Hagedorn HJ, et al. A critical synthesis of literature on the Promoting Action on Research Implementation in Health Services (PARIHS) framework. Implement Sci. 2010;5:82. 41. Share DA, Campbell DA, Birkmeyer N, et al. How a regional collaborative of hospitals and physicians in Michigan cut costs and improved the quality of care. Health Aff (Millwood). 2011;30(4): 636-645.

unit-based safety program to reduce surgical site infections. J Am Coll Surg. 2012;215(2):193-200. 43. Curran GM, Bauer M, Mittman B, Pyne JM, Stetler C. Effectiveness-implementation hybrid designs: combining elements of clinical effectiveness and implementation research to enhance public health impact. Med Care. 2012;50 (3):217-226.

42. Wick EC, Hobson DB, Bennett JL, et al. Implementation of a surgical comprehensive

Invited Commentary

The Challenge of Quality Improvement in Surgical Care David R. Urbach, MD, MSc

The story of surgical quality improvement has become a saga of high hopes followed by dashed expectations. Eminently sensible quality and safety interventions—promoted by opinion leaders, endorsed by health quality organizations, and supported by impressive results in promising Related article page 208 early studies—too frequently fail to perform as expected when they are introduced into routine care. Reames and colleagues1 appear to have added one more disappointment to this boulevard of broken dreams. Keystone Surgery—a checklist-based quality improvement program modeled after the successful Keystone ICU (intensive care unit) program,2,3 consisting of a tool to enhance compliance with the Surgical Care Improvement Program process of care measures and a Comprehensive Unit-based Safety Program intended to improve teamwork and a culture of safety—did not improve the rates of adverse surgical outcomes as hoped when it was implemented in Michigan hospitals. ARTICLE INFORMATION Author Affiliations: Department of Surgery, University Health Network, Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; Department of Surgery and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada. Corresponding Author: David R. Urbach, MD, MSc, University Health Network, 200 Elizabeth St, Room 10-214, Toronto, ON M5G 2C4, Canada ([email protected]).

Why do quality improvement programs fail in practice when they appear so promising in the research setting? Here, Reames and colleagues offer 2 possible explanations: (1) that adherence to the Surgical Care Improvement Program process measures is not strongly associated with improved outcomes, or (2) that the Surgical Care Improvement Program measures are effective, but implementation of the Keystone Surgery program was not effective in increasing compliance. Information on whether implementation of the program affected the use of process-of-care measures could help distinguish between these 2 possibilities. Further improvements in the quality of surgical care in typical practice settings will happen only if we know how to ensure that efficacious processes are actually used during routine care. To make matters more complex, Reames and colleagues remind us that programs that work in one clinical setting, such as intensive care units, do not work in other settings, such as operating rooms.

Published Online: January 14, 2015. doi:10.1001/jamasurg.2014.2908. Conflict of Interest Disclosures: None reported. REFERENCES 1. Reames BN, Krell RW, Campbell DA Jr, Dimick JB. A checklist-based intervention to improve surgical outcomes in Michigan: evaluation of the Keystone Surgery program [published online January 14, 2015]. JAMA Surg. doi:10.1001/jamasurg.2014.2873.

2. Sexton JB, Berenholtz SM, Goeschel CA, et al. Assessing and improving safety climate in a large cohort of intensive care units. Crit Care Med. 2011; 39(5):934-939. 3. Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006;355(26):2725-2732.

(Reprinted) JAMA Surgery March 2015 Volume 150, Number 3

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