When the first try fails: re-implementation of SIMPL in a general surgery residency.

BACKGROUND: Workplace-based assessment (WBA) can facilitate evaluation of operative performance; however, implementation of WBA is sometimes unsuccessful. The American Board of Surgery Entrustable Professional Activities WBA project was launched in July 2023. Some programs will face the challenge of re-implementation of a WBA following previous failures. It is unknown what interventions are most effective for WBA re-implementation. Our goal is to identify barriers and facilitators to re-implementing SIMPL, an operative performance WBA. METHODS: The System for Improving and Measuring Procedural Learning (SIMPL) was implemented at our residency in 2018, but usage rates were low. We interviewed residents and faculty to identify barriers to usage and opportunities for improvement. Residents reported that SIMPL usage declined because of several factors, including a low faculty response rate, while some faculty reported not responding because they were unable to login to the app and because usage was not mandated. We then re-implemented SIMPL using a plan based on Kotter's Model of Change. To evaluate impact, we analyzed rates of SIMPL usage when it was first implemented, as well as before and after the date of re-implementation. RESULTS: In September 2022, we re-implemented SIMPL at our program with measures addressing the identified barriers. We found that, in the six months after re-implementation, an average of 145.8 evaluations were submitted by residents per month, compared with 47 evaluations per month at the start of the original implementation and 5.8 evaluations per month just prior to re-implementation. Faculty completed 60.6% of evaluations and dictated feedback for 59.1% of these evaluations, compared with 69.1% at implementation (44% dictated) and 43% prior to re-implementation (53% dictated). CONCLUSIONS: After identifying barriers to implementation of a WBA, we re-implemented it with significantly higher usage by faculty and residents. Future opportunities exist to implement or re-implement assessment tools within general surgery programs. These opportunities may have a significant impact in the setting of national standardization of workplace-based assessment among general surgery residencies.

The Quality of Operative Performance Narrative Feedback: A Retrospective Data Comparison Between End of Rotation Evaluations and Workplace-based Assessments.

OBJECTIVE: To describe the quality of operative performance feedback using evaluation tools commonly used by general surgery residency training programs. SUMMARY OF BACKGROUND DATA: The majority of surgical training programs administer an evaluation through which faculty members may rate and comment on trainee operative performance at the end of the rotation (EOR). Many programs have also implemented the system for improving and measuring procedural learning (SIMPL), a workplace-based assessment tool with which faculty can rate and comment on a trainee's operative performance immediately after a case. It is unknown how the quality of narrative operative performance feedback delivered with these tools compares. METHODS: The authors collected EOR evaluations and SIMPL narrative comments on trainees' operative performance from 3 university-based surgery training programs during the 2016-2017 academic year. Two surgeon raters categorized comments relating to operative skills as being specific or general and as encouraging and/or corrective. Comments were then classified as effective, mediocre, ineffective, or irrelevant. The frequencies with which comments were rated as effective were compared using Chi-square analysis. RESULTS: The authors analyzed a total of 600 comments. 10.7% of EOR and 58.3% of SIMPL operative performance evaluation comments were deemed effective (P < 0.0001). CONCLUSIONS: Evaluators give significantly higher quality operative performance feedback when using workplace-based assessment tools rather than EOR evaluations.

Crowd-Sourced and Attending Assessment of General Surgery Resident Operative Performance Using Global Ratings Scales.

OBJECTIVE: We sought to assess the extent to which both crowd and intraoperative attending ratings using objective structured assessment of technical skill (OSATS) or global objective assessment of laparoscopic skills (GOALS) would correlate with the system for improving procedural learning (SIMPL) Zwisch and Performance scales. DESIGN: Comparison of directly observed versus crowd sourced review of operative video. SETTING: Operative video captured at 2 institutions. PARTICIPANTS: Six (6) core general surgery procedures, 3 open and 3 laparoscopic, were selected from the American Board of Surgery's Resident Assessments list. Thirty-two cases performed by General Surgery residents across all training levels at 2 institutions were filmed. Videos were condensed using a standardized protocol to include the critical portion of the procedure.  Condensed videos were then submitted to crowd-sourced assessment of technical skills (C-SATS), an online crowd source-driven assessment service, for assessment using the appropriate resident assessment form (GOALS or OSATS) as well as with the SIMPL Zwisch and Performance scales. Crowd workers watched an educational tutorial on how to use the Zwisch and SIMPL Performance rating scales prior to participating. Attendings scored residents using the same tools immediately after the shared operative experience. Statistical analysis was performed using Pearson's correlation coefficient. RESULTS: Crowd raters evaluated 32 procedures using GOALS/OSATS, Zwisch and Performance (35-50 ratings per video). Attendings also evaluated all 32 procedures using GOALS/OSATS and 26 of the procedures using SIMPL Zwisch and Performance. Pearson correlation coefficients with 95% confidence intervals for crowd ratings were: GOALS and Zwisch -0.40 [-0.73 to 0.10], OSATS and Zwisch 0.11 [-0.41 to 0.57], GOALS and Performance -0.06 [-0.44 to 0.35], and OSATS and Performance 0.22 [-0.46 to 0.20]. Pearson correlation coefficients for attendings were: GOALS and Zwisch (0.77), OSATS and Zwisch (0.65), GOALS and Performance (0.93), and OSATS and Performance (0.59). CONCLUSIONS: Overall, correlations between crowd-sourced ratings using GOALS/OSATS and SIMPL global operative performance ratings tools were weak, yet for attendings, they were strong. Direct attending assessment may be required for evaluation of global performance while crowd sourcing may be more suitable for technical assessment.  Further studies are needed to see if more extensive crowd training would result in improved ability for global performance evaluation.

Do End-of-Rotation Evaluations Adequately Assess Readiness to Operate?

PURPOSE: Medical educators have developed no standard way to assess the operative performance of surgical residents. Most residency programs use end-of-rotation (EOR) evaluations for this purpose. Recently, some programs have implemented workplace-based "microassessment" tools that faculty use to immediately rate observed operative performance. The authors sought to determine (1) the degree to which EOR evaluations correspond to workplace-based microassessments and (2) which factors most influence EOR evaluations and directly observed workplace-based performance ratings and how the influence of those factors differs for each assessment method. METHOD: In 2017, the authors retrospectively analyzed EOR evaluations and immediate postoperative assessment ratings of surgical trainees from a university-based training program from the 2015-2016 academic year. A Bayesian multivariate mixed model was constructed to predict operative performance ratings for each type of assessment. RESULTS: Ratings of operative performance from EOR evaluations vs workplace-based microassessment ratings had a Pearson correlation of 0.55. Postgraduate year (PGY) of training was the most important predictor of operative performance ratings on EOR evaluations: Model estimates ranged from 0.62 to 1.75 and increased with PGY. For workplace-based assessment, operative autonomy rating was the most important predictor of operative performance (coefficient = 0.74). CONCLUSIONS: EOR evaluations are perhaps most useful in assessing the ability of a resident to become a surgeon compared with other trainees in the same PGY of training. Workplace-based microassessments may be better for assessing a trainee's ability to perform specific procedures autonomously, thus perhaps providing more insight into a trainee's true readiness for operative independence.