title: Enhancing surgical performance outcomes through process-driven care: a systematic review.
abstract: BACKGROUND
  Recent evidence has demonstrated the variability in quality of postoperative care, as measured by rates of failure to rescue (FTR). The identification of structure- and process-related factors affecting the quality of postoperative care is the first step towards understanding and improving outcomes. The aim of this review is to review current evidence for structure and process factors affecting postoperative care.
  
  
  METHODS
  A systematic review was conducted. Studies were selected that examined structure or process variables affecting FTR rates and postoperative outcomes. Quality analysis with Jadad and Newcastle-Ottawa scales was conducted and poor-quality studies were excluded.
  
  
  RESULTS
  Thirty-seven studies were included in final analysis. Of these, 23 were related to enhanced recovery protocols in seven surgical specialties. Twenty-one of these 23 studies reported decreases in length of stay. Six studies also reported decreases in morbidity. No studies reported increases in stay duration or morbidity. Of the 16 studies that examined other structural and process factors, the strongest evidence was for the association between nursing ratios and FTR rates. The effects of hospital size, resources, and subspecialist care processes were less clear.
  
  
  CONCLUSIONS
  Process-led care represents a clear, evidence-based approach that can be integrated on a local scale, without necessitating major structural or organisational change, to improve outcomes and may also be cost effective. To foster success, process improvement must be driven on a local level and backed up by appropriate understanding, education, and multidisciplinary involvement.
authors.affiliation: Division of Surgery, Department of Surgery and Cancer, Imperial College London, 10th floor QEQM Building, St Mary's Hospital, Praed Street, London, W2 1NY, UK.
authors.forename: Philip H
authors.initials: PH
authors.lastname: Pucher
authors.forename: Rajesh
authors.initials: R
authors.lastname: Aggarwal
authors.forename: Pritam
authors.initials: P
authors.lastname: Singh
authors.forename: Ara
authors.initials: A
authors.lastname: Darzi
mesh_terms: D002983:Clinical Competence; D003362:Cost-Benefit Analysis; D019317:Evidence-Based Medicine; D005260:Female; D006801:Humans; D033183:Interdisciplinary Communication; D008297:Male; D020380:Needs Assessment; D009937:Organizational Objectives; D017063:Outcome Assessment, Health Care; D010348:Patient Care Team / Q000458:organization & administration; D011182:Postoperative Care / Q000191:economics / Q000379:methods*; D011183:Postoperative Complications / Q000175:diagnosis / Q000191:economics / Q000628:therapy*; D013514:Surgical Procedures, Operative / Q000009:adverse effects* / Q000191:economics / Q000379:methods; D016896:Treatment Outcome