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World J Surg. 2014 Jun;38(6):1362-73. doi: 10.1007/s00268-013-2424-8.

Enhancing surgical performance outcomes through process-driven care: a systematic review.

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Division of Surgery, Department of Surgery and Cancer, Imperial College London, 10th floor QEQM Building, St Mary's Hospital, Praed Street, London, W2 1NY, UK.



Recent evidence has demonstrated the variability in quality of postoperative care, as measured by rates of failure to rescue (FTR). The identification of structure- and process-related factors affecting the quality of postoperative care is the first step towards understanding and improving outcomes. The aim of this review is to review current evidence for structure and process factors affecting postoperative care.


A systematic review was conducted. Studies were selected that examined structure or process variables affecting FTR rates and postoperative outcomes. Quality analysis with Jadad and Newcastle-Ottawa scales was conducted and poor-quality studies were excluded.


Thirty-seven studies were included in final analysis. Of these, 23 were related to enhanced recovery protocols in seven surgical specialties. Twenty-one of these 23 studies reported decreases in length of stay. Six studies also reported decreases in morbidity. No studies reported increases in stay duration or morbidity. Of the 16 studies that examined other structural and process factors, the strongest evidence was for the association between nursing ratios and FTR rates. The effects of hospital size, resources, and subspecialist care processes were less clear.


Process-led care represents a clear, evidence-based approach that can be integrated on a local scale, without necessitating major structural or organisational change, to improve outcomes and may also be cost effective. To foster success, process improvement must be driven on a local level and backed up by appropriate understanding, education, and multidisciplinary involvement.

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