Surgical Quality Improvement: Working Toward Value or a Work in Progress?

Background: Despite numerous national programs intended to ensure patients receive high-quality surgical care, contemporaneous quality improvement initiatives (QIIs) are limited by the challenges associated with developing universal consensus about how best to define "quality" and the identification of appropriate and actionable quality measures.

Materials and methods: Using the Donabedian conceptual model for the evaluation of health care quality, representative examples of existing surgical QIIs at each level of health care (i.e., structure, process, and outcome) were identified, and the effectiveness of these programs was discussed.

Results: Surgical volume-based measures are a common structural quality indicator. It remains unclear whether volume-based QIIs, such as "Take the Volume Pledge" and the Leapfrog Group's Evidence-Based Hospital Referral initiative, would improve surgical outcomes or potentially exacerbate existing health care disparities. QIIs focused on processes of care, such as the Surgical Care Improvement Project, are frequently effective at improving measure compliance without clearly improving care quality. Risk-adjusted outcome measures remain common quality indicators. But, relevant procedure-specific outcomes are lacking, and continuing to rely on perioperative morbidity and mortality may not provide the most robust picture of surgical quality.

Conclusions: Data regarding the effectiveness of existing QIIs suggest there may be important opportunities to either select measures that more accurately reflect quality surgical care or enhance the manner in which current quality indicators are measured and reported to better capture the complex dynamics of surgical services at the point of care.