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What good looks like in small-scale surgical improvement efforts – developing a quality framework


Surgery makes up a significant, and growing, part of healthcare. However, variations and challenges in the quality of surgical care persist, including preventable mortality and harm to patients, perioperative complications, and inefficiencies.

To address this, improvement efforts are needed. These range from large-scale, well-resourced and funded efforts across many organisations, to small-scale, less well-funded, local efforts, often in a single hospital, department or ward.

Publications in the peer-reviewed literature tend to focus on large-scale improvement efforts. However, small-scale efforts are important as they are widespread and typically look to address important clinical issues that frontline surgical teams face.

An evaluation of these small-scale improvement efforts has found that they are often poorly designed and executed. Common problems include a lack of strategic planning, insufficient consideration of contextual or cultural issues, a lack of involvement of stakeholders, poorly articulated project goals, and insufficient reporting on why and how the effort was undertaken, and what the impact was.

This study aims to develop a framework that will help clinicians and others effectively plan, conduct, evaluate and report on small-scale surgical improvement efforts in a way that ensures consistent quality, but is achievable within the limited resources usually available to those leading these efforts. THIS Institute at the University of Cambridge, the American College of Surgeons, Royal College of Surgeons of England, and the Q community (led by the Health Foundation) are working together on this project.


The development and evaluation of the quality framework for small-scale surgical improvement efforts will be conducted in a series of phases. A literature review will be carried out to generate a list of candidate framework components. Workshops will be held with an expert panel, with members identified through networks of surgeons, healthcare practitioners, patients and others with an interest in healthcare improvement.

A consensus-building exercise will then be carried out to rate the candidate framework components, using insight from a broad range of experienced stakeholders, including patients, improvement experts and clinicians. This will involve rating and re-rating the possible items for their importance and feasibility for small-scale improvement efforts, with a view to ensuring that the most appropriate items are included in the framework.

The quality framework will then be developed, based on the results of the surveys. It will be evaluated with multiple stakeholders using small-scale improvement vignettes, whereby participants will be asked to evaluate the acceptability of the framework on a nine-point scale.

The study is expected to report in late 2023.

  • THIS Institute | American College of Surgeons | Royal College of Surgeons of England | Q is led by the Health Foundation and supported by partners across the UK and Ireland

Funding and ethics

This study is funded by The Healthcare Improvement Studies Institute (THIS Institute), an independent research institute co-created by the University of Cambridge and The Health Foundation (an independent charity committed to bringing about better health and health care for people in the UK).

The project investigator (Clifford Ko) is funded by the American College of Surgeons, an organisation in the United States committed to high-quality surgical care. The American College of Surgeons has more than 84,000 members, with fellows from the US and Canada, international fellows, and affiliate members representing clinical staff and allied health professionals.

This study has been reviewed by the University of Cambridge Psychology Research Ethics Committee.

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