Development and Testing of a Framework to Support the Planning of Small-Scale Improvement Projects in Surgery: A Multistage Process Including a Modified Delphi Exercise.

Abstract

Frontline quality improvement (QI) projects are important, but they are not always done well. One reason lies in the weaknesses in the early planning stages, known as the "front-end" of projects. We aimed to develop a framework to guide the very early planning of small-scale, frontline surgical QI efforts. We used a participatory, iterative design over 5 phases. We first identified content items relevant to QI from existing frameworks. Next, based on this content, sorting exercise was applied to generate thematic categories. A 4-round modified Delphi process involving clinicians and improvement experts was used to prioritize the features of these categories. A 9-step framework diagram and accompanying guidance table were then created. We tested the prototype with frontline clinicians (both attending or consultant surgeons and resident surgeons) using a clinical vignette, comparing the plans prepared by participants with 3 levels of framework exposure: without the framework, with the framework diagram only, and with the framework diagram plus guidance table. A framework to guide early planning of small-scale surgical QI projects was developed and tested. It comprised a 9-step diagram and an accompanying table of guidance. Seven planning steps include assembling an improvement team, problem detailing, defining aims, intervention identification, planning implementation and monitoring, and planning end-of-project decisions. Two further steps focus on proceeding and transitioning to launch. Testing with a clinical vignette indicated that using the full framework (framework diagram plus guidance table) may improve project planning by attending or consultant surgeons and resident surgeons. The Early Planning of Small-Scale Surgical Improvement framework for surgeons and teams may be valuable in supporting QI. It requires further evaluation to assess its role in improving improvement efforts.