What is the purpose and process of a surgical audit in evaluating and improving the quality of surgical care?

Surgical Audit: Purpose and Process

Surgical audit is a systematic, critical analysis of surgical care quality reviewed against explicit standards to reduce variability, improve outcomes, and ultimately enhance patient care through continuous feedback and quality improvement cycles. 1

Core Purpose

Surgical audit serves as an essential quality assurance mechanism that:

• Monitors compliance to best practice standards and benchmarks patient outcomes to inform policy and drive quality improvement 1
• Identifies variations in care between countries, regions, hospitals, and individual surgeons that impact mortality and morbidity 1
• Reduces failure-to-rescue rates by enabling early identification and escalation of complications 1
• Provides continuous feedback to healthcare professionals on performance against selected quality standards and outcomes 1

The fundamental principle, dating back to Ernest Amory Codman's "End Result" concept, is that every hospital should follow every patient long enough to determine treatment success and inquire "If not, why not?" to prevent similar failures 1

The Audit Cycle Process

1. Data Collection and Recording

Establish systematic data collection at all stages of the surgical process using electronic systems rather than paper-based methods, as questionnaires have notoriously low response rates. 1

Key parameters to capture include:

• Demographic data, mode of admission, diagnosis, and outcomes 2
• Complications recorded using standardized classifications (Clavien-Dindo classification and Comprehensive Complication Index) 1, 3
• Patient-reported outcome measures (PROMs) and patient-reported experience measures (PREMs) to capture the patient perspective 1, 3
• Key performance indicators: major complications, readmissions, reoperations, transfers, incident reports, complaints, and mortalities 4
• Process measures: booking failures, day-of-surgery cancellations, theatre start times, discharge times, unplanned admissions, and unplanned contact with primary care 1

2. Comparison Against Standards

Compare collected data against selected quality standards and benchmark values across surgeons and institutions. 1, 3

The audit should:

• Measure outcomes at standardized time points to enable accurate assessment 3
• Grade illness severity (e.g., using Glasgow Coma Scale for head injuries) to ensure reliable comparisons 5
• Classify cases appropriately (e.g., viable vs. nonviable patients, emergency vs. elective procedures) to provide meaningful comparative results 6

3. Peer Review and Analysis

Conduct regular interdisciplinary mortality and morbidity conferences that specifically address cognitive biases and systematically review cases against explicit criteria. 1, 3, 6

The peer review process should:

• Document issues raised by audit together with recommendations for improvement 4
• Analyze factors responsible for adverse outcomes to identify preventable causes 6, 5
• Avoid a culture of blame, instead fostering collaboration and collective learning, as most errors result from multiple systemic factors rather than single causes 1
• Follow the TRACK principle (Transparency, Respect, Accountability, Continuity, and Kindness) when unwarranted outcomes occur 3

4. Feedback and Dissemination

The most reliable way of improving service is continuous audit and review of outcomes rather than one-off snapshots. 1

Effective feedback requires:

• Wide distribution of audit information to all team members, particularly key individuals empowered to influence change 1
• Monthly graphs and figures detailing all outcomes and trends, clearly displayed and freely disseminated 1
• Specific targets identified with a clear plan of action, as audit is more efficient when baseline performance is low 1
• Cyclical feedback process where every missing link that stops the cycle causes loss of effect 1

5. Implementation of Change

Undertake actions over just measurement—effective audit requires implementing solutions to identified problems. 1

Implementation strategies include:

• Appoint a "data quality guarantor" at every institution to ensure accurate tracking of outcomes and complications 3
• Develop institution-specific guidelines for postoperative monitoring, evaluation, and escalation of care 1
• Provide professional safety tools, training, and support to clinicians to improve the overall process of care delivery 1
• Centralize care when appropriate based on volume-outcome relationships and comprehensive audit data 1

Evidence of Impact

National audit programs have demonstrated remarkable improvements in surgical outcomes:

• Norwegian Rectal Cancer Project: Local recurrence rate decreased from 28% to 6%, and 4-year survival increased from 55% to 73% after implementing systematic audit with feedback and training 1
• Danish Colorectal Cancer Database: 5-year survival increased from 37-42% (1987-1989) to 55-63% (1994-1999) 1
• Improved ERAS compliance: Associated with decreased length of stay and complications 1

Critical Success Factors

Audit effectiveness depends on:

• Continuous rather than episodic review of outcomes 1
• Electronic data collection systems that facilitate comparison and sharing between units 4
• Mandatory participation in quality assurance programs for all centers providing surgical care 1
• Strong recommendation for regular audits of compliance to guidelines and reporting of outcomes (Evidence: high, Recommendation: strong) 1

Common Pitfalls to Avoid

• Relying on paper-based questionnaires with low response rates instead of electronic systems 1
• Conducting one-off snapshots rather than continuous monitoring 1
• Failing to disseminate results to those who can implement change 1
• Measuring without acting on the findings 1
• Comparing outcomes without adjusting for case mix, illness severity, or patient characteristics 1, 5
• Creating a culture of blame rather than focusing on systemic improvement 1