Systematic Review Assessing Quality of the Survey Literature in Surgery.

INTRODUCTION: The use of survey methodology in surgical research has proliferated in recent years, but the quality of these surveys and of their reporting is understudied. METHODS: We conducted a comprehensive review of surgical survey literature (January 2022-July 2023) via PubMed in July 2023. Articles which (1) reported data gleaned from a survey, (2) were published in an English language journal, (3) targeted survey respondents in the United States or Canada, and (4) pertained to general surgery specialties were included. We assessed quality of survey reports using the Checklist for Reporting Of Survey Studies (CROSS) guidelines. Articles were evaluated for concordance with CROSS using a dichotomous (yes or no) scale. RESULTS: Initial literature search yielded 481 articles; 57 articles were included in analysis based on the inclusion criteria. The mean response rate was 37% (range 0.62%-98%). The majority of surveys were administered electronically (n = 50, 87.8%). No publications adhered to all 40 CROSS items; on average, publications met 61.2% of items applicable to that study. Articles were most likely to adhere to reporting criteria for title and abstract (mean adherence 99.1%), introduction (99.1%), and discussion (92.4%). Articles were least adherent to items related to methodology (42.6%) and moderately adherent to items related to results (76.6%). Only five articles cited CROSS guidelines or another standardized survey reporting tool (10.5%). CONCLUSIONS: Our analysis demonstrates that CROSS reporting guidelines for survey research have not been adopted widely. Surveys reported in surgical literature may be of variable quality. Increased adherence to guidelines could improve development and dissemination of surveys done by surgeons.

Validity Evidence for Procedure-specific Competence Assessment Tools in General Surgery: A Scoping Review.

OBJECTIVE: This study aims to provide a focused and detailed assessment of the validity evidence supporting procedure-specific operative assessment tools in general surgery. SUMMARY OF BACKGROUND DATA: Competency-based assessment tools should be supported by robust validity evidence to be used reliably for evaluation of operative skills. The contemporary framework of validity relies on five sources of evidence: content, response process, internal structure, relation to other variables, and consequences. METHODS: A systematic search of 8 databases was conducted for studies containing procedure-specific operative assessment tools in general surgery. The validity evidence supporting each tool was assessed and scored in alignment with the contemporary framework of validity. Methodological rigour of studies was assessed with the Medical Education Research Study Quality Instrument. The educational utility of each tool was assessed with the Accreditation Council for Graduate Medical Education framework. RESULTS: There were 28 studies meeting inclusion criteria and 23 unique tools were assessed. Scores for validity evidence varied widely between tools, ranging from 3 - 14 (maximum 15). Medical Education Research Study Quality Instrument scores assessing the quality of study methodology were also variable (8.5-15.5, maximum 16.5). Direct reporting of educational utility criteria was limited. CONCLUSIONS: This study has identified a small group of procedure-specific operative assessment tools in general surgery. Many of these tools have limited validity evidence and have not been studied sufficiently to be used reliably in high-stakes summative assessments. As general surgery transitions to competency-based training, a more robust library of operative assessment tools will be required to support resident education and evaluation.

Technical Standards for Cancer Surgery: Commission on Cancer Standards 5.3-5.8.

Clinical practice guidelines in oncology have typically focused on workup, disease staging, and medical management. Although recommendations for surgical care have been included in these guidelines, those recommendations have primarily addressed issues such as the role of surgery or the incorporation of surgery into multidisciplinary treatment strategies, not the technical performance of the operative procedures themselves. Therefore, the quality of surgery, the only component of multidisciplinary cancer care proven to be potentially curative, has been poorly controlled. During the past decade, the American College of Surgeons (ACS) cancer programs have attempted to fill this gap by developing "operative standards" for cancer surgery. This report discusses the history of the operative standards, highlights evidence to demonstrate their efficacy, and describes the activities of the ACS Commission on Cancer and Cancer Surgery Standards Program toward disseminating and implementing them.

Implementation and Evaluation of Quality Improvement Training in Surgery: A Systematic Review.

OBJECTIVE: The aim of this study was to review and appraise how quality improvement (QI) skills are taught to surgeons and surgical residents. BACKGROUND: There is a global drive to deliver capacity in undertaking QI within surgical services. However, there are currently no specifications regarding optimal QI content or delivery. METHODS: We reviewed QI educational intervention studies targeting surgeons or surgical trainees/residents published until 2017. Primary outcomes included teaching methods and training materials. Secondary outcomes were implementation frameworks and strategies used to deliver QI training successfully. RESULTS: There were 20,590 hits across 10 databases, of which 11,563 were screened following de-duplication. Seventeen studies were included in the final synthesis. Variable QI techniques (eg, combined QI models, process mapping, and "lean" principles) and assessment methods were found. Delivery was more consistent, typically combining didactic teaching blended with QI project delivery. Implementation of QI training was poorly reported and appears supported by collaborative approaches (including building learning collaboratives, and coalitions). Study designs were typically pre-/post-training without controls. Studies generally lacked clarity on the underpinning framework (59%), setting description (59%), content (47%), and conclusions (47%), whereas 88% scored low on psychometrics reporting. CONCLUSIONS: The evidence suggests that surgical QI training can focus on any well-established QI technique, provided it is done through a combination of didactic teaching and practical application. True effectiveness and extent of impact of QI training remain unclear, due to methodological weaknesses and inconsistent reporting. Conduct of larger-scale educational QI studies across multiple institutions can advance the field.

The IDEAL Reporting Guidelines: A Delphi Consensus Statement Stage Specific Recommendations for Reporting the Evaluation of Surgical Innovation.

OBJECTIVE: The aim of this study was to define reporting standards for IDEAL format studies. BACKGROUND: The IDEAL Framework and Recommendations establish an integrated pathway for evaluation of new surgical techniques and complex therapeutic technologies. However guidance on implementation has been incomplete, and incorrect use is commonly seen. We describe the consensus development of reporting guidelines for the IDEAL stages, and plans for their dissemination and evaluation. METHODS: Using the EQUATOR Network recommendations, participants with knowledge of IDEAL were surveyed to determine which IDEAL stages needed reporting guidelines. Draft checklists for stages 1, 2a, 2b, and 4 were subsequently developed by 3 researchers (N.B., A.H., P.M.), and revised through a 2-round Delphi consensus process. A final consensus teleconference resolved outstanding disagreements and clarified wording for checklist items. RESULTS: Sixty-one participants completed the initial survey, a clear majority indicating that new reporting guidelines were needed for IDEAL Stage 1 (69.5%), Stage 2a (78%), Stage 2b (74.6%), and Stage 4 (66%). A proposed set of checklists was modified by survey participants in 2 online Delphi rounds (n = 54 and n = 47, respectively), resulting in a penultimate checklist for each stage. Fourteen expert working group members finalized the checklist items and successfully resolved any outstanding areas without agreement on a consensus call. CONCLUSIONS: Participants familiar with IDEAL called for reporting guidelines for studies in all IDEAL stages except stage 3. The checklists developed have the potential to improve standards of reporting and thereby advance the quality of research on surgery and complex interventions and technologies, but require further evaluation in use.

Is Initial Board Certification Associated With Better Early Career Surgical Outcomes?

OBJECTIVE: To determine if initial American Board of Surgery certification in general surgery is associated with better risk-adjusted patient outcomes for Medicare patients undergoing partial colectomy by an early career surgeon. BACKGROUND: Board certification is a voluntary commitment to professionalism, continued learning, and delivery of high-quality patient care. Not all surgeons are certified, and some have questioned the value of certification due to limited evidence that board-certified surgeons have better patient outcomes. In response, we examined the outcomes of certified versus noncertified early career general surgeons. METHODS: We identified Medicare patients who underwent a partial colectomy between 2008 and 2016 and were operated on by a non-subspecialty trained surgeon within their first 5 years of practice. Surgeon certification status was determined using the American Board of Surgery data. Generalized linear mixed models were used to control for patient-, procedure-, and hospital-level effects. Primary outcomes were the occurrence of severe complications and occurrence of death within 30 days. RESULTS: We identified 69,325 patients who underwent a partial colectomy by an early career general surgeon. The adjusted rate of severe complications after partial colectomy by certified (n = 4239) versus noncertified (n = 191) early-career general surgeons was 9.1% versus 10.7% (odds ratio 0.83, P = 0.03). Adjusted mortality rate for certified versus noncertified early-career general surgeons was 4.9% versus 6.1% (odds ratio 0.79, P = 0.01). CONCLUSION: Patients undergoing partial colectomy by an early career general surgeon have decreased odds of severe complications and death when their surgeon is board certified.

Structured Feedback Enhances Compliance with Operating Room Debriefs.

BACKGROUND: Surgical debriefs help reduce preventable errors in the operating room (OR) leading to patient injury. However, compliance with debriefs remains poor. The objective of this study was to evaluate the role of structured feedback to surgeons in improving compliance with and quality of surgical debriefs. MATERIALS AND METHODS: Surgical cases at an 875-bed urban teaching hospital from January-June 2019 were audited via audio/video recording to evaluate debrief performance. Debriefs were evaluated for clinical completeness and teamwork quality via two structured forms. Surgeons received an evaluation of their debrief performance at two time points during the study period (February and April). Univariate and mixed-effects regression analyses were used to assess changes in debrief compliance and quality over time. RESULTS: A total of 878 surgical cases performed by 61 surgeons were reviewed: 198 (22.6%) cases during Period 1 (P1), 371 (42.3%) P2, and 309 (35.1%) P3. The rate at which a debrief occurred was 62.1% in P1, 73.0% in P2, and 82.2% in P3 (P < 0.001). Debriefs were 1.96 (95% CI 1.31-2.95, P = 0.001) times more likely to be completed during P2 and 3.21 (95% CI 2.07-5.04, P < 0.001) times more likely during P3 compared to P1. The percent of debriefs initiated by the lead surgeon increased from 59.8% in P1, to 80.0% in P2, to 81.5% in P3 (P < 0.001). CONCLUSIONS: Providing structured feedback to surgeons on their debrief performance was associated with improvements in compliance and completeness with debriefing protocols, OR teamwork and communication, and leadership and accountability from the lead surgeons.

Implementation of a Parent-centered Approach to the Preinduction Checklist in Pediatric Surgery.

BACKGROUND: The preinduction checklist, part of the three-phase surgical safety checklist, is performed before induction of anesthesia. Our previous research demonstrated higher checklist adherence by perioperative staff when parents were engaged in the preinduction checklist. We hypothesized that use of a parent-centered script (PCS) during the preinduction checklist would increase parent engagement and checklist adherence. METHODS: A single-center, prospective, observational study was conducted in which parents of children (<18 y) undergoing nonemergent surgeries (June 2018-July 2019) were observed before and after PCS implementation. The PCS, developed by the health care team, engaged parents by directly asking them to contribute information relevant to parent knowledge. Parent engagement was rated using a five-point Likert scale, and adherence was scored for each relevant checkpoint completed. RESULTS: Of 270 checklists, 154 (57%) occurred before and 116 (43%) after PCS implementation. Groups were similar by primary language, patient age, and type of surgery, but more postimplementation children had a prior surgery. The overall parent engagement score did not improve with the PCS (P = 0.8); however, there was an improvement in eye contact by parents. After introduction of the PCS, checklist adherence decreased from a median score of 6 (interquartile range 5-6) to 4 (interquartile range 4-5) (P < 0.001). CONCLUSIONS: Use of a PCS did not improve parent engagement during the preinduction checklist and an unexpected decline in checklist adherence was observed. Further research, with parent and staff input, is necessary to determine how best to engage parents while ensuring high checklist adherence.

Cognitive Bias Impact on Management of Postoperative Complications, Medical Error, and Standard of Care.

BACKGROUND: Cognitive bias (CB) is increasingly recognized as an important source of medical error and up to 75% of errors in internal medicine are thought to be cognitive in origin (O'Sullivan ED, Schofield SJ. Cognitive bias in clinical medicine. J R Coll Physicans Edinb. 2018;48;225-232). However, primary data regarding the true incidence of bias is lacking. A prospective evaluation of CB in the management of surgical cases with complications has not been reported. This study reports the incidence and distribution of various types of CBs, and evaluates their impact on management errors and standard of care (SOC). METHODS: A prospectively collected series of 736 general surgical cases with complications from three university hospitals was analyzed. Surgical residents evaluated cases for 22 types of CBs (Croskerry P. The importance of cognitive errors in diagnosis and strategies to minimize them. Acad Med. 2003;78:775-780). Supervising quality officers validated all quality assessments. Data were assessed for the incidence of CBs, error assessments (diagnostic, technical, judgment, system, communication, therapeutic, and professionalism), and SOC. RESULTS: CB was attributed in 32.7% (241/736) of all cases with complications. The most common CBs identified, both singly and in groups, were anchoring, confirmation, omission, commission, overconfidence, premature closure, hindsight, diagnosis momentum, outcome, and ascertainment bias. The attribution of CB was correlated to a statistically significant increase in the incidence of management errors by the surgical team and lower SOC assessments. CONCLUSIONS: CBs are identified in the management of cases with complications and are associated with an increase in management errors and a degradation in SOC. Insight into the types of CBs and their association with the type and severity of management errors may prove useful in improving quality care.

Readmission After Emergency General Surgery: NSQIP Review of Risk, Cause and Ideal Follow-Up.

BACKGROUND: The Emergency General Surgery (EGS) population is particularly at high risk for readmission. Currently, no system exists to predict which EGS patients are most at risk. We hypothesized that a subset of EGS patients could be identified with increased 30-day unplanned readmission. We also hypothesized that a majority of readmissions occur sooner than the conventional 2-week follow-up period. METHODS: National Surgical Quality Improvement Program (NSQIP) nonelective general surgery patients were analyzed. Multivariable logistic regression identified factors with increased odds of unplanned readmission. AAST EGS Diagnosis Categories were used to categorize postop ICD-9 codes, and the top 10 CPT codes in each group were analyzed. Readmission rate, the reason for unplanned readmission, and time to readmission were analyzed. RESULTS: A total of 383,726 patients were identified with a readmission rate of 8.1% within 30 d of their primary procedure. The top 50 CPT codes accounted for 84% of EGS readmissions. Increased readmission risk was demonstrated for underweight patients (OR = 1.15, P < 0.05). High-risk hospital characteristics were LOS >2 d, any inpatient pulmonary complications, and discharge to any facility or rehab (all P < 0.05). Surgical site infections cause nearly 25% of readmissions. Intestinal procedures are most frequently readmitted (22% of EGS readmissions), with colorectal procedures having the higher odds of readmission. Most readmissions occur <10 d after discharge. CONCLUSIONS: A high-risk subpopulation exists within EGS, and most readmissions occur sooner than a typical 2-week follow-up. Early interventions for high-risk EGS subpopulations may allow for early intervention and reduction of unnecessary healthcare utilization.

Surgical Residents' Perspective on Informed Consent-How Does It Compare With Attending Surgeons?

BACKGROUND: The informed consent discussion (ICD) is a compulsory element of clinical practice. Surgical residents are often tasked with obtaining informed consent, but formal instruction is not included in standard curricula. This study aims to examine attitudes of surgeons and residents concerning ICD. MATERIALS AND METHODS: A survey regarding ICD was administered to residents and attending surgeons at an academic medical center with an Accreditation Council for Graduate Medical Education-accredited general surgery residency. RESULTS: In total, 44 of 64 (68.75%) residents and 37 of 50 (72%) attending surgeons participated. Most residents felt comfortable consenting for elective (93%) and emergent (82%) cases, but attending surgeons were less comfortable with resident-led ICD (51% elective, 73% emergent). Resident comfort increased with postgraduate year (PGY) (PGY1 = 39%, PGY5 = 85%). A majority of participants (80% attending surgeons, 73% residents) believed resident ICD skills should be formally evaluated, and most residents in PGY1 (61%) requested formal instruction. High percentages of residents (86%) and attendings (100%) believed that ICD skills were best learned from direct observation of attending surgeons. CONCLUSIONS: Resident comfort with ICD increases as residents advance through training. Residents acknowledge the importance of their participation in this process, and in particular, junior residents believe formal instruction is important. Attending surgeons are not universally comfortable with resident-led ICDs, particularly for elective surgeries. Efforts for improving ICD education including direct observation between attending surgeons and residents and formal evaluation may benefit the residency curriculum.

Performance assessment using sensor technology.

Over the past 30 years, there have been numerous, noteworthy successes in the development, validation, and implementation of clinical skills assessments. Despite this progress, the medical profession has barely scratched the surface towards developing assessments that capture the true complexity of hands-on skills in procedural medicine. This paper highlights the development implementation and new discoveries in performance metrics when using sensor technology to assess cognitive and technical aspects of hands-on skills.

Speech-Based Surgical Phase Recognition for Non-Intrusive Surgical Skills' Assessment in Educational Contexts.

Surgeons' procedural skills and intraoperative decision making are key elements of clinical practice. However, the objective assessment of these skills remains a challenge to this day. Surgical workflow analysis (SWA) is emerging as a powerful tool to solve this issue in surgical educational environments in real time. Typically, SWA makes use of video signals to automatically identify the surgical phase. We hypothesize that the analysis of surgeons' speech using natural language processing (NLP) can provide deeper insight into the surgical decision-making processes. As a preliminary step, this study proposes to use audio signals registered in the educational operating room (OR) to classify the phases of a laparoscopic cholecystectomy (LC). To do this, we firstly created a database with the transcriptions of audio recorded in surgical educational environments and their corresponding phase. Secondly, we compared the performance of four feature extraction techniques and four machine learning models to find the most appropriate model for phase recognition. The best resulting model was a support vector machine (SVM) coupled to a hidden-Markov model (HMM), trained with features obtained with Word2Vec (82.95% average accuracy). The analysis of this model's confusion matrix shows that some phrases are misplaced due to the similarity in the words used. The study of the model's temporal component suggests that further attention should be paid to accurately detect surgeons' normal conversation. This study proves that speech-based classification of LC phases can be effectively achieved. This lays the foundation for the use of audio signals for SWA, to create a framework of LC to be used in surgical training, especially for the training and assessment of procedural and decision-making skills (e.g., to assess residents' procedural knowledge and their ability to react to adverse situations).

Colonoscopy Direct Observation of Procedural Skills Assessment Tool for Evaluating Competency Development During Training.

INTRODUCTION: Formative colonoscopy direct observation of procedural skills (DOPS) assessments were updated in 2016 and incorporated into UK training but lack validity evidence. We aimed to appraise the validity of DOPS assessments, benchmark performance, and evaluate competency development during training in diagnostic colonoscopy. METHODS: This prospective national study identified colonoscopy DOPS submitted over an 18-month period to the UK training e-portfolio. Generalizability analyses were conducted to evaluate internal structure validity and reliability. Benchmarking was performed using receiver operator characteristic analyses. Learning curves for DOPS items and domains were studied, and multivariable analyses were performed to identify predictors of DOPS competency. RESULTS: Across 279 training units, 10,749 DOPS submitted for 1,199 trainees were analyzed. The acceptable reliability threshold (G > 0.70) was achieved with 3 assessors performing 2 DOPS each. DOPS competency rates correlated with the unassisted caecal intubation rate (rho 0.404, P < 0.001). Demonstrating competency in 90% of assessed items provided optimal sensitivity (90.2%) and specificity (87.2%) for benchmarking overall DOPS competence. This threshold was attained in the following order: "preprocedure" (50-99 procedures), "endoscopic nontechnical skills" and "postprocedure" (150-199), "management" (200-249), and "procedure" (250-299) domain. At item level, competency in "proactive problem solving" (rho 0.787) and "loop management" (rho 0.780) correlated strongest with the overall DOPS rating (P < 0.001) and was the last to develop. Lifetime procedure count, DOPS count, trainer specialty, easier case difficulty, and higher cecal intubation rate were significant multivariable predictors of DOPS competence. DISCUSSION: This study establishes milestones for competency acquisition during colonoscopy training and provides novel validity and reliability evidence to support colonoscopy DOPS as a competency assessment tool.

Variation in global uptake of the Surgical Safety Checklist.

BACKGROUND: The Surgical Safety Checklist (SSC) is a patient safety tool shown to reduce mortality and to improve teamwork and adherence with perioperative safety practices. The results of the original pilot work were published 10 years ago. This study aimed to determine the contemporary prevalence and predictors of SSC use globally. METHODS: Pooled data from the GlobalSurg and Surgical Outcomes studies were analysed to describe SSC use in 2014-2016. The primary exposure was the Human Development Index (HDI) of the reporting country, and the primary outcome was reported SSC use. A generalized estimating equation, clustering by facility, was used to determine differences in SSC use by patient, facility and national characteristics. RESULTS: A total of 85 957 patients from 1464 facilities in 94 countries were included. On average, facilities used the SSC in 75·4 per cent of operations. Compared with very high HDI, SSC use was less in low HDI countries (odds ratio (OR) 0·08, 95 per cent c.i. 0·05 to 0·12). The SSC was used less in urgent compared with elective operations in low HDI countries (OR 0·68, 0·53 to 0·86), but used equally for urgent and elective operations in very high HDI countries (OR 0·96, 0·87 to 1·06). SSC use was lower for obstetrics and gynaecology versus abdominal surgery (OR 0·91, 0·85 to 0·98) and where the common or official language was not one of the WHO official languages (OR 0·30, 0·23 to 0·39). CONCLUSION: Worldwide, SSC use is generally high, but significant variability exists. Implementation and dissemination strategies must be developed to address this variability.

ANTECEDENTES: Se ha demostrado que la utilización de la lista de verificación de seguridad quirúrgica (Surgical Safety Checklist, SSC) reduce la mortalidad y mejora el trabajo en equipo, así como el cumplimiento de las prácticas de seguridad perioperatorias. Los resultados de un trabajo piloto original se publicaron hace 10 años. El objetivo de este estudio fue determinar la prevalencia actual y los predictores de uso de la SSC a nivel mundial. MÉTODOS: Se analizaron los datos agrupados de los estudios GlobalSurg y Surgical Outcomes para describir la utilización de la SSC entre 2014-2016. La principal variable de exposición fue el índice de desarrollo humano (Human Development Index, HDI) del país informante y la principal variable de resultado, la tasa de utilización de la SCC. Para determinar las diferencias en la utilización de la SSC por paciente, centro y características nacionales se utilizó una ecuación de estimación generalizada con conglomerados por centros. RESULTADOS: Se incluyeron 85.957 pacientes de 1.464 centros en 94 países. La tasa media de utilización de la SSC fue del 75,4% de las operaciones. Al compararlos con países de HDI muy alto, la utilización de la SCC fue menor en los países con HDI bajo (razón de oportunidades, odds ratio, OR 0,08, i.c. del 95% 0,05-0,12). En países con HDI bajo, la SSC se utilizó menos en operaciones urgentes en comparación con operaciones electivas (OR 0,68, i.c. del 95% 0,53- 0,86) a diferencia de los países con HDI elevado, en los que se utilizó por igual en ambas situaciones (OR 0,96, i.c. del 95% 0,87-1,06). La utilización de la SSC fue menor en operaciones de obstetricia y ginecología que en cirugía abdominal (OR 0,91, i.c. del 95% 0,85 a 0,98) y en aquellos países en los que el idioma habitual u oficial era diferente a los idiomas oficiales de la OMS (OR 0,30, i.c. del 95% 0,23 a 0,39). CONCLUSIÓN: A nivel mundial, el uso de SSC en general es alto, pero existe una variabilidad significativa. Se deben desarrollar estrategias de implementación y difusión para resolver esta variabilidad.

Emotional Intelligence Predicts Accurate Self-Assessment of Surgical Quality: A Pilot Study.

BACKGROUND: Self-assessment is fundamental in surgical training. Accuracy of self-assessment is superior with greater age, experience, and the use of video playback. Presently, there is scarce evidence in the literature regarding predictors for a surgical trainee's aptitude for self-assessment. The objective of this study was to investigate whether emotional intelligence or visual-spatial aptitude can predict effective self-assessment among novice surgeons performing laparoscopic appendectomy (LA). MATERIALS AND METHODS: Eighteen novice trainees performed a simulated LA, and two aptitude measures were evaluated: (1) emotional intelligence questionnaire and (2) visual spatial ability test. Self-assessment of their performance was conducted using the Objective Assessment of Surgical and Technical Skills global rating scale and ranking five subtasks of the procedure in order of quality of performance after watching a playback of their LA. Two blinded experts (senior consultant surgeons, performed >100 LAs) assessed surgical quality using the same scoring system. Candidates were ranked into higher and lower aptitude groups for the two aptitude measures. Spearman's rank correlation coefficient was calculated to identify if either of the two groups demonstrated greater agreement between self and expert assessment in relation to the two aptitude measures. RESULTS: Participants with a higher degree of emotional intelligence demonstrated significant agreement with expert assessment (r = 0.73, P = 0.031). CONCLUSIONS: Emotional intelligence can predict better self-assessment of surgical quality after performing a simulated LA. This may facilitate early identification of individuals who might require mentoring or guidance with self-assessment as well as contribute to selection criteria.

Are you better off than you were 4 years ago? Measuring the impact of the ABS flexible endoscopy curriculum.

INTRODUCTION: In 2014, the ABS introduced the Flexible Endoscopy Curriculum (FEC). The FEC did not alter the minimum defined category case volumes for endoscopy; however, it did introduce specific cognitive and technical milestones for endoscopy training. It also mandated that residents pass the Fundamentals of Endoscopic Skills (FES) exam to qualify for board certification. Although significant research has been published regarding residents' success on the FES exam, very little is known regarding how the FEC has changed the way general surgery programs train their residents in surgical endoscopy. The aim of this study was to quantify changes in flexible endoscopy education at a large academic program in the 4 years since the FEC was published. METHODS: We classified the impact of FEC into four categories: (a) case volume or distribution, (b) clinical rotations, (c) required didactics or simulation exercises, and (d) FES pass rates. For category (a), we reviewed current and historical case logs for all categorical residents from 2013 to 2018. Mann-Whitney U tests were used to compare endoscopy volumes for each PGY level in 2013-2014 to the respective PGY level in 2017-2018 with p < 0.05 considered significant. For categories (b)-(d), we gathered historical records from the residency coordinator and endoscopy rotation director. RESULTS: Complete data were available for 57 residents in the 2013-2014 academic year and 56 residents in the 2017-2018 academic year. Median total endoscopies performed by PGY2, PGY3, and PGY5 residents all significantly increased during the FEC rollout. Our program's focus on endoscopy also expanded with absolute increases in endoscopy rotations, didactics, and simulation exercises. These changes translated into significantly increased pass rates on the FES exam from 40 to 100%. CONCLUSIONS: Implementation of the FEC at a large academic program led to measurable improvements in clinical experience, program structure, educational programing, and performance on high-stakes assessments.

Improving attainment of the critical view of safety during laparoscopic cholecystectomy.

INTRODUCTION: We hypothesized that practicing surgeons would successfully achieve a better and more frequent Critical View of Safety (CVS) during laparoscopic cholecystectomy (LC) after participation in a structured Safe CVS Curriculum. METHODS: All surgeons performing LC at a regional health system had four LC cases recorded: twice before and twice after a curriculum focused on the CVS, which was led by a member of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Safe LC Task Force. Videos were then de-identified and randomly ordered for grading on a 6-point CVS assessment tool by two expert surgeons, who were blinded to the operator and whether the surgeries were performed before or after the curriculum. Confidence surveys and performance on a CVS identification video quiz were also compared pre- and post-curriculum. RESULTS: Twelve surgeons (five general, four acute care, and three minimally invasive) with an average experience of 17.9 ± 6.3 years participated in the study. After the curriculum, surgeons achieved all three CVS criteria in more cases (1/24 (4%) versus 10/24 (42%), p < 0.004). There was also significant improvement in correctly identifying whether the CVS was achieved in 10 video clips from the Internet (7.9 ± 1.5 vs. 9.3 ± 0.8, p = 0.006) and increased confidence on a 5-point Likert scale in accurately identifying the CVS (4.5 ± 0.5 vs. 4.9 ± 0.3, p = 0.017). CONCLUSION: A structured curriculum on achieving a quality CVS for practicing, experienced surgeons improved their confidence and frequency of obtaining the Critical View of Safety during LC. We recommend that the Safe CVS Curriculum be considered for widespread use in order to increase the quality and frequency of attaining the Critical View of Safety.

Objective assessment of surgical operative performance by observational clinical human reliability analysis (OCHRA): a systematic review.

BACKGROUND: Both morbidity and mortality data (MMD) and learning curves (LCs) do not provide information on the nature of intraoperative errors and their mechanisms when these adversely impact on patient outcome. OCHRA was developed specifically to address the unmet surgical need for an objective assessment technique of the quality of technical execution of operations at individual operator level. The aim of this systematic review was to review of OCHRA as a method of objective assessment of surgical operative performance. METHODS: Systematic review based on searching 4 databases for articles published from January 1998 to January 2019. The review complies with Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines and includes original publications on surgical task performance based on technical errors during operations across several surgical specialties. RESULTS: Only 26 published studies met the search criteria, indicating that the uptake of OCHRA during the study period has been low. In 31% of reported studies, the operations were performed by fully qualified consultant/attending surgeons and by surgical trainees in 69% in approved training programs. OCHRA identified 7869 consequential errors (CE) during the conduct of 719 clinical operations (mean = 11 CEs). It also identified 'hazard zones' of operations and proficiency-gain curves (P-GCs) that confirm attainment of persistent competent execution of specific operations by individual trainee surgeons. P-GCs are both surgeon and operation specific. CONCLUSIONS: Increased OCHRA use has the potential to improve patient outcome after surgery, but this is a contingent progress towards automatic assessment of unedited videos of operations. The low uptake of OCHRA is attributed to its labor-intensive nature involving human factors (cognitive engineering) expertise. Aside from faster and more objective peer-based assessment, this development should accelerate increased clinical uptake and use of the technique in both routine surgical practice and surgical training.