title: Debate: what is the best method to monitor surgical performance?
abstract: BACKGROUND
  There is considerable recent interest in the monitoring of individual surgeon or hospital surgical outcomes. If one aggregates data over time and assesses performance with a funnel plot, then the detection of any process deterioration or improvement could be delayed. The variable life adjusted display (VLAD) is widely used for monitoring on a case-by-case basis, but we show that use of the risk-adjusted Bernoulli cumulative sum (RA-CUSUM) chart leads to much better performance.
  
  
  CONCLUSIONS
  We use simulation to illustrate that the RA-CUSUM chart has better performance than the VLAD in detecting changes in the rates of adverse events. We recommend the RA-CUSUM approach over the VLAD approach for monitoring surgical performance. If the VLAD is used, we recommend running the RA-CUSUM chart in the background to generate signals that the process performance has changed.
authors.affiliation: Department of Statistic and Actuarial Science, University of Waterloo, Waterloo, ON, N2L 3G1, Canada. shsteine@uwaterloo.ca.
authors.forename: Stefan H
authors.initials: SH
authors.lastname: Steiner
authors.affiliation: Department of Statistics, Virginia Tech, Blacksburg, VA, 24061-0439, USA.
authors.forename: William H
authors.initials: WH
authors.lastname: Woodall
mesh_terms: D002983:Clinical Competence; D013502:General Surgery; D006801:Humans; D017063:Outcome Assessment, Health Care / Q000379:methods*