title: Results of a surgeon-directed quality improvement project on breast cancer surgery outcomes in South-Central Ontario.
abstract: BACKGROUND
  Gaps in breast cancer (BC) surgical care have been identified. We have completed a surgeon-directed, iterative project to improve the quality of BC surgery in South-Central Ontario.
  
  
  METHODS
  Surgeons performing BC surgery in a single Ontario health region were invited to participate. Interventions included: audit and feedback (A&F) of surgeon-selected quality indicators (QIs), workshops, and tailoring interviews. Workshops and A&F occurred yearly from 2005-2012. QIs included: preoperative imaging; preoperative core biopsy; positive margin rates; specimen orientation labeling; intraoperative specimen radiography of nonpalpable lesions; T1/T2 mastectomy rates; reoperation for positive margins; sentinel lymph node biopsy (SLNB) rates, number of sentinel lymph nodes; and days to receive pathology report. Semistructured tailoring interviews were conducted to identify facilitators and barriers to improved quality. All results were disseminated to all surgeons performing breast surgery in the study region.
  
  
  RESULTS
  Over 6 time periods, 1,828 BC charts were reviewed from 12 hospitals (8 community and 4 academic). Twenty-two to 40 participants attended each workshop. Sustained improvement in rates of positive margins, preoperative core biopsies, specimen orientation labeling, and SLNB were seen. Mastectomy rates and overall axillary staging rates did not change, whereas time to receive pathology report increased. The tailoring interviews concerning positive margins, SLNB, and reoperation for positive margins identified facilitators and barriers relevant to surgeons.
  
  
  CONCLUSIONS
  This surgeon-directed, regional project resulted in meaningful improvement in numerous QIs. There was consistent and sustained participation by surgeons, highlighting the importance of integrating the clinicians in a long-term, iterative quality improvement strategy in BC surgery.
authors.affiliation: Department of Surgery, McMaster University, G802, St. Joseph's Healthcare 50 Charlton Avenue East, Hamilton, ON, L8N 4A6, Canada, lovricsp@mcmaster.ca.
authors.forename: Peter
authors.initials: P
authors.lastname: Lovrics
authors.forename: Nicole
authors.initials: N
authors.lastname: Hodgson
authors.forename: Mary Ann
authors.initials: MA
authors.lastname: O'Brien
authors.forename: Lehana
authors.initials: L
authors.lastname: Thabane
authors.forename: Sylvie
authors.initials: S
authors.lastname: Cornacchi
authors.forename: Angela
authors.initials: A
authors.lastname: Coates
authors.forename: Barbara
authors.initials: B
authors.lastname: Heller
authors.forename: Susan
authors.initials: S
authors.lastname: Reid
authors.forename: Kenneth
authors.initials: K
authors.lastname: Sanders
authors.forename: Marko
authors.initials: M
authors.lastname: Simunovic
mesh_terms: D062005:Biopsy, Large-Core Needle; D001943:Breast Neoplasms / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008408:Mastectomy / Q000592:standards*; D009864:Ontario; D017063:Outcome Assessment, Health Care; D010818:Practice Patterns, Physicians' / Q000592:standards*; D058996:Quality Improvement / Q000458:organization & administration*; D019984:Quality Indicators, Health Care; D021701:Sentinel Lymph Node Biopsy; D066231:Surgeons