title: A dynamic quality assessment tool for laparoscopic hysterectomy to measure surgical outcomes.
abstract: BACKGROUND
  The current health care system has an urgent need for tools to measure quality. A wide range of quality indicators have been developed in an attempt to differentiate between high-quality and low-quality health care processes. However, one of the main issues of currently used indicators is the lack of case-mix correction and improvement possibilities. Case-mix is defined as specific (patient) characteristics that are known to potentially affect (surgical) outcome. If these characteristics are not taken into consideration, comparisons of outcome among health care providers may not be valid.
  
  
  OBJECTIVE
  The objective of the study was to develop and test a quality assessment tool for laparoscopic hysterectomy, which can serve as a new outcome quality indicator.
  
  
  METHODS
  This is a prospective, international, multicenter implementation study. A web-based application was developed with 3 main goals: (1) to measure the surgeon's performance using 3 primary outcomes (blood loss, operative time, and complications); (2) to provide immediate individual feedback using cumulative observed-minus-expected graphs; and (3) to detect consistently suboptimal performance after correcting for case-mix characteristics. All gynecologists who perform laparoscopic hysterectomies were requested to register their procedures in the application. A patient safety risk factor checklist was used by the surgeon for reflection. Thereafter a prospective implementation study was performed, and the application was tested using a survey that included the System Usability Scale.
  
  
  RESULTS
  A total of 2066 laparoscopic hysterectomies were registered by 81 gynecologists. Mean operative time was 100 ± 39 minutes, blood loss 127 ± 163 mL, and the complication rate 6.1%. The overall survey response rate was 75%, and the mean System Usability Scale was 76.5 ± 13.6, which indicates that the application was good to excellent. The majority of surgeons reported that the application made them more aware of their performance, the outcomes, and patient safety, and they noted that the application provided motivation for improving future performance.
  
  
  CONCLUSIONS
  We report the development and test of a real-time, dynamic, quality assessment tool for measuring individual surgical outcome for laparoscopic hysterectomy. Importantly, this tool provides opportunities for improving surgical performance. Our study provides a foundation for helping clinicians develop evidence-based quality indicators for other surgical procedures.
authors.affiliation: Department of Gynaecology, Leiden University Medical Center, Leiden, The Netherlands; Department of Biomechanical Engineering, Delft University of Technology, Delft, The Netherlands.
authors.forename: Sara R C
authors.initials: SR
authors.lastname: Driessen
authors.affiliation: Department of Medical Statistics, Leiden University Medical Center, Leiden, The Netherlands.
authors.forename: Erik W
authors.initials: EW
authors.lastname: Van Zwet
authors.affiliation: Institute of Psychology, Leiden University, Leiden, The Netherlands.
authors.forename: Pascal
authors.initials: P
authors.lastname: Haazebroek
authors.affiliation: Department of Gynaecology, Leiden University Medical Center, Leiden, The Netherlands; Department of Biomechanical Engineering, Delft University of Technology, Delft, The Netherlands.
authors.forename: Evelien M
authors.initials: EM
authors.lastname: Sandberg
authors.affiliation: Department of Gynaecology, Leiden University Medical Center, Leiden, The Netherlands; Department of Biomechanical Engineering, Delft University of Technology, Delft, The Netherlands.
authors.forename: Mathijs D
authors.initials: MD
authors.lastname: Blikkendaal
authors.affiliation: Department of Gynaecology, Leiden University Medical Center, Leiden, The Netherlands; Department of Biomechanical Engineering, Delft University of Technology, Delft, The Netherlands.
authors.forename: Andries R H
authors.initials: AR
authors.lastname: Twijnstra
authors.affiliation: Department of Gynaecology, Leiden University Medical Center, Leiden, The Netherlands; Department of Biomechanical Engineering, Delft University of Technology, Delft, The Netherlands. Electronic address: f.w.jansen@lumc.nl.
authors.forename: Frank Willem
authors.initials: FW
authors.lastname: Jansen
mesh_terms: D000328:Adult; D016063:Blood Loss, Surgical / Q000706:statistics & numerical data; D003953:Diagnosis-Related Groups; D005260:Female; D006176:Gynecology; D006801:Humans; D007044:Hysterectomy / Q000592:standards*; D020407:Internet; D010535:Laparoscopy / Q000592:standards*; D016015:Logistic Models; D008875:Middle Aged; D061646:Operative Time; D017063:Outcome Assessment, Health Care; D011183:Postoperative Complications / Q000453:epidemiology; D011446:Prospective Studies; D011785:Quality Assurance, Health Care; D019984:Quality Indicators, Health Care; D020379:Risk Adjustment; D066231:Surgeons
keywords: case-mix; laparoscopic hysterectomy; measure quality; outcome indicator; quality assessment; quality indicator; surgical performance