Describing methods and interventions: a protocol for the systematic analysis of the perioperative quality improvement literature
© Jones et al.; licensee BioMed Central Ltd. 2014
Received: 23 July 2014
Accepted: 13 August 2014
Published: 5 September 2014
Quality improvement (QI) methods are widely used in surgery in an effort to improve care, often using techniques such as Plan-Do-Study-Act cycles to implement specific interventions. Explicit definition of both the QI method and quality intervention is necessary to enable the accurate replication of effective interventions in practice, facilitate cumulative learning, reduce research waste and optimise benefits to patients. This systematic review aims to assess quality of reporting of QI methods and quality interventions in perioperative care.
Studies reporting on quality interventions implemented in perioperative care settings will be identified. Searches will be conducted in the Ovid SP version of Medline, Scopus, the Cochrane Central Register of Controlled Trials, the Cochrane Effective Practice and Organisation of Care database and the related articles function of PubMed. The journal BMJ Quality will be searched separately. Search strategy terms will relate to (i) surgery, (ii) QI and (iii) evaluation methods. Explicit exclusion and inclusion criteria will be applied. Data from studies will be extracted using a data extraction form. The Template for Intervention Description and Replication (TIDieR) checklist will be used to evaluate quality of reporting, together with additional items aimed at assessing QI methods specifically.
Systematic review registration
KeywordsQuality improvement Perioperative care Surgery Interventions Reporting Quality of care Description
Quality Improvement (QI) methods are specially designed efforts and processes aimed at generating improvements in patient care . Such methods include those based on Lean, Six Sigma, Plan-Do-Study-Act (PDSA) cycles, Total Quality Management and Continuous Quality Management, audit and feedback, and many others . Guidance on reporting of QI studies  and of intervention delivery in evaluative studies [4–7] has been published. Surgery is an especially important area for quality improvement: an estimated 234 million surgical interventions are performed every year worldwide , yet it remains hazardous and prone to error and complication. An international drive to improve quality of care in surgery is now supported by initiatives such as the Centre for Global Surgery  and the Lancet Commission for Global Surgery . Yet the quality of reporting of interventions in QI studies in surgery is unknown. This is an important problem, as it is increasingly recognised that explicit descriptions of interventions are necessary to ensure that successful interventions can be replicated in practice, to avoid research waste, to facilitate cumulate learning and to ensure that patients gain the best possible benefits from any learning from QI studies [11, 12]. We seek to adopt and adapt the Template for Intervention Description and Replication (TIDieR) checklist  to evaluate the quality and completeness of reporting of studies of quality improvement interventions in perioperative care.
Perioperative care is a process encompassing care received before, during and after a surgical procedure . The translation of successful QI strategies into surgical practice has the potential to contribute towards ensuring the delivery of safe, high-quality, accessible and affordable surgery [2, 14–18]. Systematic review has evaluated data generated by QI methods across cardiothoracic, colorectal , vascular, hepatobiliary and upper gastrointestinal specialties [2, 15, 16] and has reported measureable improvements across the whole perioperative journey including the preoperative period (reduction in time to surgery ), intraoperative period (reduction of sepsis ) and postoperative period (reduction of surgical site infection [14, 16], central venous catheter infection  and venous thromboembolism ) Yet the QI literature in surgery has also been found to suffer from a range of problems including lack of explicit rationale, poor detail and overlapping components in the published descriptions of QI methods [2, 19] and quality interventions . The extent and quality of patient and public involvement (PPI) in surgical research are also unclear, despite recommendations that the Guidance for Reporting Involvement of Patients and Public (GRIPP) checklist be used in order to provide a quality assurance on the level of PPI reporting .
One problem in assessing the literature on quality improvement is a degree of conceptual and terminological confusion over the term ‘intervention’. The methods of improvement are sometimes referred to as interventions, yet so too are the quality interventions that such methods seek to implement. Thus, for example, the literature may use the term ‘intervention’ interchangeably to describe both application of the PDSA method and a quality intervention such as a checklist or ‘bundle’.
For purposes of this review, QI methods will be defined as the processes (such as PDSA cycles) which are typically intended to support the implementation of a quality intervention. Quality interventions will be defined as the individual components of care delivery which are implemented in order to achieve an improvement in the delivery of patient care. Quality interventions need to be described explicitly and precisely if it is to be possible to implement them. The parameters that might be used in describing such interventions include
What (which materials, and activities should be used)
Who (qualification type and competency)
How (face-to-face, in a group, via the internet)
Where (setting, infrastructure)
When and how much (dose, timing, frequency, duration)
Modifications (changes during the course of the study)
How well (what challenges were identified, e.g. dropouts or missing data)
This systematic review aims to assess the completeness of reporting within the perioperative literature on QI methods and quality interventions and to identify which elements are most frequently missing.
We will undertake a review of the published qualitative and quantitative surgical literature on QI. We will define QI methods as the processes which are usually intended to support implementation of the quality intervention such as PDSA cycles. We will define quality interventions as the individual components of care delivery which are selected in order to make an improvement (such as issuing checklists or care bundles).
This review will include
All studies published between 1 January 2000 and 28 May 2014 to capture all papers indexed since the publication of the Institute of Medicine's ‘To Err is Human: Building a Safer Health System’ report , which highlighted the importance of systems-based interventions to address quality and safety problems
All surgical specialities
Adult surgical services
Elective and emergency (trauma) surgery
Primary and secondary care, because hospital stay is just one aspect of the surgical patient's whole pathway 
Studies using both validated and unvalidated measures
Quality improvement taxonomy
1. Provider education
Dissemination of information
Educational outreach visits
Component separation training and recurrence rates
Distribution of educational material
Cadaveric training and surgeon confidence
2. Provider reminder systems
Any ‘clinical encounter-specific’ information intended to prompt a clinician to recall information or consider a specific process of care
The WHO surgical safety checklist
3. Patient reminders
Any methods of encouraging patient compliance to self-management
SMS exercise reminders before bariatric surgery
4. Promotion of self-management
Access to a resource that enhances the patients' ability to manage their condition
Follow up phone calls with recommended adjustments to care
5. Audit and feedback
Any feedback of clinical performance
Percentage of patients achieving target LOS
Morbidity and mortality
6. Patient education
Dissemination of information
Distribution of educational material
Tri-modal pre-habilitation programme compliance and effect on LOS
Individual or group sessions
7. Organizational change
Any change in organizational structure
Changes to staff rota to facilitate early patient mobilization after elective arthroplasty
8. Financial, regulatory, or legislative incentives
Any financial bonus, reimbursement or provider licensure scheme
Positive or negative incentives for providers or patients
18-week wait target for elective orthopaedic surgery
9. Facilitated relay of clinical data to providers
Transfer of clinical information from patients to the provider when data was not collected during a patient visit
Relay of BP measurements to the pre-assessment team
Collection of postoperative complication data through postal survey
All epubs ahead of print which are indexed in one of the selected databases by the end date specified for the review
QI papers reporting upon a deliberate effort to produce change in perioperative care. This may be in the form of a QI report, or a study of a QI method or quality intervention
This review will exclude
Audits, unless they explicitly report on the implementation of a QI method which is designed to produce and evaluate a change
Qualitative papers reporting exclusively on staff or patient experience of using QI methods
Papers reporting on screening programmes and diagnostic interventions such as endoscopy and end-of-life care
Papers reporting on secondary analyses where the main results have been published elsewhere
Editorials and articles not published in the English language
Abstracts and conference proceedings
Disagreements about eligibility will be resolved by discussion within the team.
Databases will be selected for their ability to represent surgical and improvement method literature. Searches will be performed in the Ovid SP version of Medline, Scopus, the Cochrane Central Register of Controlled Trials, the Cochrane Effective Practice and Organisation of Care (EPOC) database (which indexes interventional studies focused on improvement in healthcare delivery) and the related articles function of PubMed. The journal BMJ Quality will be searched online using the find function for perioperative and surgical terms. MeSH terms, search terms, thesaurus mapping and Boolean operators will be used.
A training exercise was undertaken with a sample of search results where two authors (ELJ and MDW) considered selected full-text articles and discrepancies were resolved with a third reviewer (GPM). This enabled the authors to refine inclusion and exclusion criteria, ensuring consensus and reliable article selection.
A further training exercise will be undertaken whereby two authors (ELJ and NJL) will independently rate a sample of full-text articles against the TIDieR checklist until a high agreement is reached. TIDieR  is recommended by the Enhancing the Quality and Transparency of Health Research (EQUATOR) Network as an extension of the Consolidated Standards of Reporting Trials (CONSORT)  and SPIRIT  statements to improve reporting across all ‘evaluative’ study designs. Each item in the checklist will have an explanatory statement to guide the rater on how it should be interpreted. In accordance with previous work conducted by Hoffman and colleagues , the 12 items on the TIDieR checklist will be rated as ‘Yes’ (indicating that the description of that element of the intervention had been explicit) or ‘No’ (not reported or not clearly described).
Two reviewers (ELJ and NJL) will independently assess titles and abstracts of all abstracts to select and obtain full-text articles. The search results will be supplemented with hand searching of the reference lists of the full-text articles and of one recently published systematic review on improvement science  (ELJ).
This review defines a quality intervention as a change to process directed at securing improvement, for example, introducing joint working patterns at weekends for assistant practitioners and foundation year 1 doctors to improve the rate of peripheral cannula insertion to reduce missed antibiotics. A QI method is defined as the process by which the change is supported and facilitated, for example, PDSA cycles. Patient and public involvement will be defined as the incorporation of the knowledge, skills and experience of patients, carers and the public into a study [27, 28].
Data extraction template items
Quality intervention (TIDieR parameters)
Author, year, country, surgical speciality
1. Brief name
1. Sample size
2. Why (rationale for intervention)
2. Baseline measurement
3. What (materials used to apply the intervention)
3. Data collection schedule
4. Procedures (processes used in the intervention)
4. Data analysis (e.g. driver diagrams)
5. Who (who delivered the intervention, including level of training)
5. Data volume/duration (e.g. length of PDSA cycle)
6. How (mode of delivery: face to face, internet)
6. Explicit description of prediction of change
7. Where (location: emergency or elective, and primary or secondary care)
7. Missing data (and reasons given)
8. When and how much (duration, dose, intensity)
8. Description of generalizability
9. Tailoring (was the intervention planned to be personalised)
9. Adverse effects (on health care providers and resource utilisation)
10. Modifications (describe what, why, when and how modifications were made)
10. Presence and type of patient or stakeholder involvement (collaborative or consultative)
11. How well (strategies to improve or maintain compliance)
12. How well (outcome of compliance assessment)
Data will be analysed descriptively using an Excel data extraction sheet. Nominal data will be used to present the proportion of complete and incomplete TIDieR checklist items. The potential transferability of findings between contexts will be considered. This is a descriptive review, and meta-analysis will not be undertaken.
Consistent with the principle that reviews may engage an iterative process , the review may evolve iteratively to include additional analysis such as bibliometric measures and descriptions of the fidelity of the interventions.
This review has a number of strengths and limitations. It will be the first review assessing how well QI methods and quality interventions are described across diverse settings (emergency and elective, and primary and secondary care) in perioperative care. This will advance understanding on what is required to improve reporting on QI methods and quality interventions. The review will extend beyond a presentation of raw outcome data, also considering the following: What rationales are provided for the application of specific QI strategies? How is QI defined? To what extent are patients involved? The findings of this review will be used to generate a research protocol to identify and resolve the challenges associated with defining and providing accounts of all of the elements of QI methods and interventions in surgery. This knowledge will generate a practical framework to facilitate the replication of effective QI strategies in practice. This framework will be pilot tested to confirm that it is a reliable method of specifying and describing the elements of QI methods and quality interventions. We anticipate that this work will be relevant to a wide multi-disciplinary community of clinicians and researchers who wish to reliably accelerate positive changes to practice to improve quality of care for patients and to improve the quality of the reporting of QI methods and interventions in perioperative literature.
Our study may have limitations. Papers not published in English will be excluded due to resource limitations, which may introduce bias. However, research has suggested that such exclusions tend to have a limited effect overall on systematic review conclusions . Steps have been taken to limit potential subjectivity in data analysis by including standardised data extraction tools and checklists and by achieving consensus with a third reviewer. A team of social scientists and clinicians will ensure that key messages most appropriate to a surgical audience will be disseminated, addressing gaps in the current reporting of QI methods and interventions.
Cochrane Effective Practice and Organisation of Care
Guidance for Reporting Involvement of Patients and Public checklist
Patient and public involvement
Template for Intervention Description and Replication
This work was conducted as part of a Doctoral Research Fellowship funded by The Health Foundation. Mary Dixon-Woods' work is supported by a Wellcome Trust Senior Investigator award ref WT097899.
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