Quality in Surgical Practice presentation

PRESENTED BY: Vivian Akwuaka
DATE: 1st April, 2023
For Surgery Interest Group of Africa (SIGAF)

OUTLINE
Overview of
Quality and
Patient Safety
Surgical Safety
Measuring and
Sustaining
Improvement
Conclusion
P r e s e n t e d B y : V i v i a n
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OVERVIEW OF
QUALITY AND
PATIENT SAFETY

Quality in Healthcare
•Safe
•Delivering health care that
minimizes risks and harm to service
users, including avoiding preventable
injuries and reducing medical errors.
•Timely
•Reducing delays in providing and
receiving health care.
•Effective
•Providing services based on
scientific knowledge and evidence-
based guidelines.
•Efficient
•Delivering health care in a manner
that maximizes resource use and
avoids waste.
•Equitable
•Delivering health care that does not
differ in quality according to personal
characteristics such as gender, race,
ethnicity, geographical location or
socioeconomic status.
•Patient-centered
•Providing care that takes into
account the preferences and
aspirations of individual service
users and the culture of their
community.
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CLIENT, FAMILY AND PUBLIC INVOLVEMENT
Patient and family involvement includes the feedback and
experiences from patients and their family members and
caregivers.
Why?
• Increasing complexity in patient care and needs
• Increasing risk/potential for errors and patient harm
• They have experience, expertise, insights and valuable
perspectives that are useful in bringing about changes in
health care regardless of whether their own experience
was positive or negative.
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CLIENT, FAMILY AND PUBLIC INVOLVEMENT cont’d
Patient and family involvement in patient care can be achieved
through any/all of the following;
 Information sharing/ Education (individualized)
 Providing the opportunity for patients/family to communicate
their knowledge, fears, anxieties, suggestions, complaints
etc.
 Patient satisfaction surveys
 Interviews and focus group sessions
 Support groups
 Others?
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REMEMBER
The patient is a partnerin
his/her care management.

CLINICAL EFFECTIVENESS
The extent to which specific clinical interventions
do what they are intended to do.
 Are we applying ‘best practice’ based on
evidence of effectiveness?
 Are we moving with the times and adapting to
new ways of doing things?
 Do we and our staff have access to
appropriate knowledge resources?
 Is there a wide understanding of up-to-date
guidelines, policies, SOPs in your
organisation?
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Best practices are sets of tasks and procedures that
are proven to lead to optimal efficiency and results.

CONTINUOUS QUALITY IMPROVEMENT
Continuous Quality Improvement (CQI) is a
quality management process that
encourages all health care team members
to continuously ask the questions, “How are
we doing?” and “Can we do it better?”
(Edwards, 2008)
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Donabedian’s
Triad
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Image by Denadai and Lo, 2021.

SURGICAL SAFETY why?
 Annual volume of major surgery globally was 187 – 281 million in 2004 (Public health concern)
 In industrialized countries, major complications occur in 3 – 22% of inpatient surgical
procedures with a death rate of 0.4 – 0.8%. Nearly half of these adverse events are
preventable
 In developing countries, Death rate after major surgery is as high as 10%
 Published series showing avoidable anaesthesia mortality rates of 1:3000 in Zimbabwe,
1:1900 in Zambia, 1:500 in Malawi and 1:150 in Togo
 A 2019 study conducted in 79 Nigerian hospitals showed an 18.5% postoperative
complications rate.
 Mortality from general anaesthesia alone is reported to be as high as one in 150 in some parts
of sub-Saharan Africa.
 According to the Guardian Newspaper UK (2013), three of the 5 worst medical nightmares
patients face are; wrong site surgery, wrong patient surgery and retained instruments/swabs
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SURGICAL SAFETY IN PRACTICE
Doing no harm
through all the
phases of
surgical care.
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Doing no harm
through all the
phases of
surgical care.

WHO PATIENT SAFETY SAFE SURGERY SAVES LIVES
CHALLENGE
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 Focused on identifying the basic components of surgical care to be provided
and by standardizing routines with tools to ensure consistency – WHO
Surgical Safety Checklist, published in 2008
 Pre/post checklist implementation study
 Reduced mortality by nearly half – 1.5% to 0.8%
 Reduced complications by a third – 11% to 7%

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 Responsible Person: Usually
the circulating nurse but can be
done by any other member of
the surgical team.
 Nearly all the steps will be
checked verbally with the
appropriate personnel to ensure
that the key actions have been
performed
 The checklist is broken down
into three phases:
Sign In
Time Out
Sign Out

SIGN IN Before Induction Of Anaesthesia
 Confirm patient identity, site, procedure and consent
 Confirm surgical site marking
 Anaesthesia safety check – machines working, medicines, anaesthetic risks if any?
 A – Airway equipment
 B – Breathing system (oxygen, inhalational agents, suction etc.)
 C – Circulation (monitoring devices)
 D – Drugs and devices
 E – Emergency medications, equipment and assistance
 Allergy check
 Airway and pulse oximeter if general anaesthesia
 Assess risk of >500mls of blood loss. If yes, large bore IV lines or central line should be
inserted before skin incision. Fluids and relevant blood products should also be made available.
 Prosthesis and other surgical needs
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TIME OUT Before Skin Incision
 Confirm all team members have introduced themselves by name and role
 Surgeon, Anaesthesia professional and Nurse verbally confirm patient, site and
procedure to be performed
 Anticipated critical events or concerns are raised
 Surgeon’s review – critical/unexpected steps, operative duration and anticipated blood
loss
 Anaesthesia team – any patient specific concerns?
 Nursing team – confirmation of equipment sterility, any equipment issues or any other
concerns?
 Antibiotic prophylaxis administered within the last 60 minutes?
 Is essential imaging displayed where necessary e.g. orthopedics, spinal, tumor
resections
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SIGN OUT Before removing Patient from the OR
 Nurse verbally confirms with the team the name of the procedure recorded
 Instrument, sponge and needle counts are correct or not applicable.
 Specimen labelled including patient’s name
 Equipment problems to be addressed
 Surgeon, Anaesthesia Personnel and Nurse review the key concerns for recovery
and postoperative management of the patient. This ensures transfer of critical
information to the entire team
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IMPORTANT NOTES
 The safety steps should inspire effective change that will foster compliance
 The checklist can be modified to reflect differences among facilities but removing
safety steps because they cannot be accomplished in the existing environment or
circumstance is strongly discouraged
 An open culture that promotes respect for the value that each team member
brings is essential for continuous quality improvement and patient safety in surgical
practice.
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MEASURING
AND SUSTAINING
IMPROVEMENT

CLINICAL AUDITS AND MONITORING
Healthcare organisations must ensure that
clinicians participate in regular clinical audit and
reviews of clinical services
Clinicians are involved in prioritising, conducting,
reporting and acting on clinical audits.
Clinicians participate in reviewing the effectiveness
of clinical services through evaluation, audit or
research.
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Audit is different from Research

PRINCIPLES TO FOLLOW FOR AUDITS
 Objectivity
 Honesty
 Accurate and use of standards forms
 Confodentiality and patient privacy
 Relevance to common clinical problems
 Clear standards set by peer assessment
 Education and learning rather that blame or punishment
 Complete medical records
 All that happened to the patient
 Result of investigations
 Post-Op notes
 Follow-up information
 Autopsy findings if applicable
 Audit should lead to appropriate action
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A good surgeon must never
hide his/her faults, but should
learn from them in order to
better serve the patients and
improve his/her practice
Akinbode, 2015.

SURGICAL AUDIT PARAMETERS
 Time utilization
 Cost effectiveness
 Mortality and morbidity assessment
 Quality of diagnostic services - discrepancies
 Performance monitoring
 Assessment of newer technologies
 Surgical outcomes and complication rates
 Patient satisfaction
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Structure
•Amount and type of
available resources
e.g. beds, staff,
doctor/nures to
patient ratios,
equipment, wards
Process
•Time and flow of
processes carried
out e.g. surgery
times, down times,
knife on skin time
Outcomes
•Mortality
•SSI rates
•Complication rates
•Unplanned Return
to OR or
readmission
•Quality of life
•Long term survival

CONCLUSION
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Surgical care is one of the very essential
aspects of general clinical care.
Prepare and
Prevent
instead of
Repair and Repent

REFERENCES
Denadai, R., & Lo, L. J. (2021). Adapting Donabedian's structure-process-outcome triad for quality improvement activities in surgical cleft-craniofacial care. Journal of Plastic, Reconstructive & Aesthetic
Surgery, 74(1), 223-243.Britain, G. (2007). Available at: https://www.jprasurg.com/article/S1748-6815(20)30251-5/fulltext
Benjamin Schwartz (2017) Do No Harm Image. Available at: https://kenan.ethics.duke.edu/doing-no-harm/.
Lowery, J. (2013). Patient-Centered Care Methods and Practices Leading to Health Outcomes and Financial Benefits in Hospital Care. Available at: https://www.semanticscholar.org/paper/Patient-
Centered-Care-Methods-and-Practices-Leading-Lowery/284be4c937e59824f8adcbd5e040e9d43850eb24
WHO Guidelines for Safe Surgery 2009: Safe Surgery Saves Lives. Geneva: World Health Organization; 2009. Section I, Introduction. Available from: https://www.ncbi.nlm.nih.gov/books/NBK143229/
Edwards PJ, et al. Maximizing your investment in EHR: Utilizing EHRs to inform continuous quality improvement. JHIM 2008;22(1):32-7.
Osinaike, B., Ayandipo, O., Onyeka, T., Alagbe-Briggs, O., Mohammed, A., Oyedepo, O., Nuhu, A., Asudo, F., Akanmu, O., Nwokorie, C., Mohammed, A., Edubio,
M., Izuora, K., Mohammed, R., Nweze, O., Efu, M., Eguma, S., Jasper, A., Ewah, R., Akhideno, I., … Nigerian Surgical Outcomes Study Investigators (2019).
Nigerian surgical outcomes - Report of a 7-day prospective cohort study and external validation of the African surgical outcomes study surgical risk
calculator. International journal of surgery (London, England), 68, 148–156. https://doi.org/10.1016/j.ijsu.2019.06.003
Meara, J. G., Leather, A. J., Hagander, L., Alkire, B. C., Alonso, N., Ameh, E. A., ... & Yip, W. (2015). Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development.
The lancet, 386(9993), 569-624. Available at: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)60160-X/fulltext?dgcid=recommender_referral_trendmd
Akinbode, O. (2015) Surgical Audit. Available at: https://www.slideshare.net/akinbodeog/surgical-audit-55109683
Wikipedia contributors. (2022, September 11). Clinical governance. In Wikipedia, The Free Encyclopedia. Retrieved 06:28, December 4, 2022, from
https://en.wikipedia.org/w/index.php?title=Clinical_governance&oldid=1109684353
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