Prioritisation of quality indicators for elective perioperative care: a Delphi consensus.

BACKGROUND: A systematic review of the peer-reviewed and grey literature previously identified over 1200 perioperative structure and process quality indicators. We undertook a Delphi consensus process with the aim of creating a concise list of indicators that experts deemed most important for assessing quality in perioperative care. METHODS: A basic Delphi consensus was completed using an online survey which was distributed to surgeons, anaesthetists, nurses, physicians and lay representatives. Participants were asked to prioritise the indicators in order of importance (high, medium or low) to be included for collection in a national perioperative quality improvement programme. RESULTS: One hundred and thirty-seven indicators were included in the first iteration of the Delphi consensus (91 structure and 48 process indicators). Sixty-three experts agreed to participate and the consensus was completed in five rounds. Ninety-five indicators were agreed as high priority: 65 structural and 30 process indicators. CONCLUSION: The Delphi consensus process was able to reduce the number of recommended indicators to only a modest extent. Further work to evaluate the practicalities of routinely collecting such a comprehensive list of quality indicators is now required.

Development and evaluation of an obstetric quality-of-recovery score (ObsQoR-11) after elective Caesarean delivery.

BACKGROUND: Whilst validated quality-of-recovery (QoR) tools exist for general surgery, there is no specific obstetric equivalent. We aimed to develop and evaluate a modified QoR score after elective Caesarean delivery. METHODS: Twenty-two obstetric specific items were selected following review and modification of the QoR-40 survey by 16 experts and interviews with 50 stakeholders. Item selection was based on relevance to Caesarean delivery and endorsement by >66% of stakeholders. Items were tested on women pre-delivery, at 24 h, and 25 h post-delivery. An 11-item obstetric-specific QoR score (ObsQoR-11) was created based on correlation with a numerical rating scale (NRS) of global health status (r>0.20) at all time points. Reliability, responsiveness, acceptability, and feasibility were tested. RESULTS: One hundred and fifty-two women responded to the 22-item questionnaire pre-delivery (complete in 146), 100 at 24 h, and 10 at 25 h. The ObsQoR-11 correlated with the global health status NRS (r=0.53; 95% confidence interval: 0.43-0.62; P<0.0001) and discriminated good vs poor recovery (NRS score ≥70 vs <70 mm) at 24 h. There was a negative correlation between the ObsQoR-11 score at 24 h and hospital length of stay (r=-0.39; P=0.003). ObsQoR-11 was reliable (internal consistency: 0.85; split-half 0.76; test-retest intra-class correlation coefficient ri>0.6 in 82% of items) and responsive (Cohen effect size: 1.36; standardised response mean: 0.85). A longer 22-item ObsQoR had high (97%) completion rates and short (median: 2 min) completion times. CONCLUSIONS: The ObsQoR-11 provides a valid, reliable, and responsive global assessment of recovery after elective Caesarean delivery.

Perioperative structure and process quality and safety indicators: a systematic review.

BACKGROUND: Clinical indicators assess healthcare structures, processes, and outcomes. While used widely, the exact number and level of scientific evidence of these indicators remains unclear. The aim of this study was to evaluate the number, type, and evidence base of clinical process and structure indicators currently available for quality and safety measurement in perioperative care. METHODS: We performed a systematic review searching Medline, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane, Google Scholar, and System for Information in Grey Literature in Europe databases for English language human studies in adults (age >18) published in the past 10 years (January 2005-January 2016). We also included professional and governmental body publications and guidelines describing the development, validation, and use of structure and process indicators in perioperative care. RESULTS: We identified 43 860 journal articles and 43 relevant indicator program publications. From these, we identified a total of 1282 clinical indicators, split into structure (36%, n=463) and process indicators (64%, n=819). The dimensions of quality most frequently addressed were effectiveness (38%, n=475) and patient safety (29%, n=363). The majority of indicators (53%, n=675) did not have a level of evidence ascribed in their literature. Patient-centred metrics accounted for the fewest published clinical indicators. CONCLUSIONS: Despite widespread use, the majority of clinical indicators are not based on a strong level of scientific evidence. There may be scope in setting standards for the development and validation process of clinical indicators. Most indicators focus on the effectiveness, safety, and efficiency of care. PROSPERO DATABASE: CRD4201501277.

Measuring quality of recovery-15 after day case surgery.

BACKGROUND: 'Quality of recovery' scores are patient-reported outcome measures evaluating recovery after surgery and anaesthesia. However, they are not widely used in the clinical or research setting. The Quality of Recovery-15 (QoR-15) is a recently developed, psychometrically tested and validated questionnaire. METHODS: We conducted a prospective study of all adult patients undergoing orthopaedic day case surgery over a period of six months (June 2013-November 2013). Patients completed the QoR-15 score preoperatively, and then were asked to repeat the score by telephone at 24 h, 48 h and seven days after surgery. RESULTS: 633 patients from a possible 714 (89%) completed the preoperative questionnaire and data from 437 patients who completed scores at all four time points were analysed. Most patients returned to their preoperative score by 48 h, and had exceeded it by seven days. Construct validity was supported by a negative correlation with duration of surgery and total inpatient opioid use. There was also excellent internal consistency (Cronbach's alpha 0.80-0.83). CONCLUSION: The QoR-15 is a clinically acceptable and feasible patient-centred outcome measure after day case surgery. The score demonstrated good validity, reliability and responsiveness. However, measurement of the QoR-15 score on the day of surgery may not provide a true baseline value. We suggest one follow-up call at 48 h would enable an adequate patient-centred assessment of postoperative recovery after day case orthopaedic surgery.