Control Charts Usage for Monitoring Performance in Surgery: A Systematic Review

Abstract

Objectives:The control chart is a graphical tool for data interpretation that detects aberrant variations in specific metrics, ideally leading to the identification of special causes that can be resolved. A clear assessment of control chart utilization and its potential impact in surgery is required to justify recommendations for its dissemination. This review aims to describe how performance monitoring using control charts was used over time in surgery.Methods: A systematic search of PubMed regarding statistical process control in surgery from its inception until December 2019 was performed using Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Information extracted from selected publications included study aim and population setting, monitored indicators, control charts methodological parameters, and implementation strategy. Results:One hundred thirteen studies met the selection criteria with a median of 1916 monitored patients. Overall, 57.5% of studies focused on control chart methodology, 24.8% aimed at evaluating performance changes using control charts retrospectively, and 17.7% implemented control charts for continuous quality improvement prospectively. Although there was a great diversity of used indicators and charting tools, the evaluation of patient safety (72.6%) or efficiency (15.9%) metrics based on Shewhart control chart (33.6%) or cumulative sum chart (54.9%) were common. To foster control charts implementation, 14 studies promoted their periodic review, but only three assessed their impact on patient outcomes. Conclusions:The scientific literature supports the feasibility and utility of control chart to improve patient safety in multiple surgical settings. Additional studies are necessary to reveal the optimal manner in which to implement this affordable tool in surgical practice.

A time-adjusted control chart for monitoring surgical outcome variations

“…Numerous studies have shown clear advantages in adjusting models comparatively to non-risk-adjusted tools [ 28 ] using validation methodologies similar to ours [ 25 , 26 ]. A systematic review found that half of studies using control charts in surgery considered outcomes adjustment [ 6 ]. However, adjustment is complex and requires caution with the employed methodology and data [ 29 – 31 ].…”

“…To deal with these methodological challenges, considering time-related proxies such as secular and seasonal trends could be of particular interest when tracking surgical safety. In past control chart literature, these variables were not identified as critical for surgical outcomes adjustment [ 6 ]. Secular trends reflect enhancing or deteriorating outcomes over years nationwide under the influence of a myriad of drivers [ 7 ].…”

Economic analysis of surgical outcome monitoring using control charts: the SHEWHART cluster randomised trial

“…A recent systematic review reported that the number of studies using control charts to monitor performance in the context of surgery has steadily grown over the last two decades. 18 Although some of these studies have focused on economic indicators, including length of stay and costs, none evaluated the economic effects of implementing a control chart-based programme for surgeon performance monitoring. In fact, the majority either aimed to adapt control chart methodology and test the utility or feasibility of their application in surgical departments, or used control charts to 6.5) Data are presented as numbers (percentage) of patients unless otherwise indicated.…”

“…Original research measure the impact of quality improvement efforts in surgical departments. 18 Past research has suggested that reducing hospital bed-days after surgery could benefit healthcare systems by increasing hospital bed turnover. This can alleviate pressure on hospital staff and liberate beds to match demand with capacity for interhospital transfers, intensive care unit care and emergency admissions.…”

“…In fact, the majority either aimed to adapt control chart methodology and test the utility or feasibility of their application in surgical departments, or used control charts to measure the impact of quality improvement efforts in surgical departments. 18 …”