Developing and testing a practical framework to help plan small-scale improvement projects in surgery

Why it matters

Surgery is a significant part of healthcare. The quality of surgical care varies though, and this can lead to preventable deaths, complications, and poorer outcomes.

It’s important that frontline, small-scale improvement projects are carried out, but they don’t always work well in practice.

One common problem they encounter is weaknesses in planning at the very start of the projects (the “front-end”) where better support may offer significant opportunity for creating value. We wanted to address this problem by creating a framework that would help guide their early planning.

THIS Institute and the American College of Surgeons worked with the Royal College of Surgeons of England, Royal College of Surgeons of Edinburgh, and Royal College of Surgeons of Ireland  to develop a framework that was simple to understand and use, feasible to use in frontline settings, and helpful for surgeons and their teams.

We developed our framework in five stages, using a highly collaborative approach. First, we gathered key content from existing frameworks. Then, we sorted this content into themes. To decide which features mattered most, we ran four rounds of modified Delphi review with clinicians and improvement experts.

From this, we created a framework made up of a nine-step diagram and a supporting guidance table. We tested the prototype with frontline surgeons – both consultants and resident doctors – using a clinical case scenario. Participants planned improvements under three conditions: first without the framework, then with just the diagram, and finally with both the diagram and the guidance table.

What we found

We wanted the framework to be used by local improvement leaders to guide early planning of small-scale quality improvement efforts in surgery. We wanted it to support clinicians and others with effective planning, conducting, evaluating and reporting in a way that ensures consistent quality, but is achievable within the limited resources usually available to those leading the efforts.

The Early Planning of Small-scale Surgical Improvement projects (EPoSSI) framework includes a step-by-step diagram and a table with detailed guidance. The final EPoSSI framework consists of seven planning steps:

• Choosing the improvement team
• Detailing the problem
• Developing project aims
• Choosing an intervention
• Planning implementation of the intervention
• Planning project monitoring
• Plan end-of-project decision making

There are also two further steps which focus on decisions about whether to proceed.

• Decide whether to move forward with the project
• Launch, monitor, and complete the project

The EPoSSI framework is the first framework that focuses specifically on the early planning stage of small-scale improvement projects in surgery, one of the most important factors in their success. It gives step-by-step advice on what to do, what to avoid, and how to decide, and ultimately, whether to proceed.

Our initial tests using a clinical case scenario indicated that using the framework diagram and the guidance table together may result in more comprehensive project planning, which will be important in helping people working in surgery and potentially other fields to get the most out of their efforts to improve healthcare quality.

Because the EPoSSI framework targets the front-end of a project, it may help to create a better trajectory for success. Further testing will be needed to confirm its impact.