Quality and Safety in Health Care Journal

Can virtual reality simulations improve macrocognition?

Simulation studies provide a unique opportunity to develop a deeper understanding of how healthcare workers manage risk in everyday care. In this issue of the journal, Mumma and colleagues1 use a simulation design to analyse how nurses think during infection prevention and control practices and identify the cognitive skills that are associated with high performance.

Most nurse educators are familiar with the low-fidelity glow germ simulation intended to make nursing students and other health care providers aware of cross-contamination and the ubiquitous nature of microorganisms. Mumma et al have taken this exercise to another level by using actual microorganisms, thereby increasing the stakes of the simulated experience. The study has considerable methodological rigour and is an exciting way to highlight a unique use of simulation. Several important ideas and insights stem from reading this article.

The study looked at how 42 nurses provided care for two simulated...

Variation in quality of care between hospitals: how to identify learning opportunities

In healthcare, as in life, the adage ‘variety is the spice of life’ often holds true. Variation can represent individual patient preferences, but when it comes to the quality of healthcare, variation can also be unwanted and harmful. Analysis of variation in a quality-of-care indicator assumes that finding only limited variation is a good thing, suggesting consistently high compliance with evidence-based guidelines and providing evidence of equity. In this editorial, we consider how variation is and should be quantified, comment on the findings of a review1 in this issue of BMJ Quality and Safety, and explore whether measurement at the hospital level is best for learning. We conclude by reflecting on the assumption that only limited variation is good.

How is variation analysed? Take CT scanning for suspected stroke as an example. This should be done soon after the patient arrives in the emergency department. The scan...

Understanding linguistic inequities in healthcare: moving from the technical to the social

When patients and clinicians do not speak the same language, the quality and safety concerns that can arise seem evident. However, the literature on the association between language and a host of health outcomes is vast and varied. In this issue of BMJQS, Chu et al share the results of their well-conducted systematic review and meta-analysis of the relationship between a patient’s spoken language and hospital readmissions and emergency department (ED) revisits.1 They report that adult inpatients who prefer a non-dominant language are more likely to experience an unplanned hospital readmission or ED revisit after discharge. Moreover, they found that children whose parents spoke a non-dominant language had more ED revisits. The authors’ work is a thoughtful synthesis of a somewhat disparate literature and offers a starting point to consider key challenges in the broader area of research on linguistic inequities in healthcare.

Language as a...

Connecting pathogen transmission and healthcare worker cognition: a cognitive task analysis of infection prevention and control practices during simulated patient care


Relatively little is known about the cognitive processes of healthcare workers that mediate between performance-shaping factors (eg, workload, time pressure) and adherence to infection prevention and control (IPC) practices. We taxonomised the cognitive work involved in IPC practices and assessed its role in how pathogens spread.


Forty-two registered nurses performed patient care tasks in a standardised high-fidelity simulation. Afterwards, participants watched a video of their simulation and described what they were thinking, which we analysed to obtain frequencies of macrocognitive functions (MCFs) in the context of different IPC practices. Performance in the simulation was the frequency at which participants spread harmless surrogates for pathogens (bacteriophages). Using a tertiary split, participants were categorised into a performance group: high, medium or low. To identify associations between the three variables—performance groups, MCFs and IPC practices—we used multiblock discriminant correspondence analysis (MUDICA).


MUDICA extracted two factors discriminating between performance groups. Factor 1 captured differences between high and medium performers. High performers monitored the situation for contamination events and mitigated risks by applying formal and informal rules or managing their uncertainty, particularly for sterile technique and cleaning. Medium performers engaged more in future-oriented cognition, anticipating contamination events and planning their workflow, across many IPC practices. Factor 2 distinguished the low performers from the medium and high performers who mitigated risks with informal rules and sacrificed IPC practices when managing tradeoffs, all in the context of minimising cross-contamination from physical touch.


To reduce pathogen transmission, new approaches to training IPC (eg, cognitive skills training) and system design are needed. Interventions should help nurses apply their knowledge of IPC fluidly during patient care, prioritising and monitoring situations for risks and deciding how to mitigate risks. Planning IPC into one’s workflow is beneficial but may not account for the unpredictability of patient care.

"Its probably an STI because youre gay": a qualitative study of diagnostic error experiences in sexual and gender minority individuals


There is a critical need to identify specific causes of and tailored solutions to diagnostic error in sexual and gender minority (SGM) populations.


To identify challenges to diagnosis in SGM adults, understand the impacts of patient-reported diagnostic errors on patients’ lives and elicit solutions.


Qualitative study using in-depth semistructured interviews. Participants were recruited using convenience and snowball sampling. Recruitment efforts targeted 22 SGM-focused organisations, academic centres and clinics across the USA. Participants were encouraged to share study details with personal contacts. Interviews were analysed using codebook thematic analysis.


Interviewees (n=20) ranged from 20 to 60 years of age with diverse mental and physical health symptoms. All participants identified as sexual minorities, gender minorities or both. Thematic analysis revealed challenges to diagnosis. Provider-level challenges included pathologisation of SGM identity; dismissal of symptoms due to anti-SGM bias; communication failures due to providers being distracted by SGM identity and enforcement of cis-heteronormative assumptions. Patient-level challenges included internalised shame and stigma. Intersectional challenges included biases around factors like race and age. Patient-reported diagnostic error led to worsening relationships with providers, worsened mental and physical health and increased self-advocacy and community-activism. Solutions to reduce diagnostic disparities included SGM-specific medical education and provider training, using inclusive language, asking questions, avoiding assumptions, encouraging diagnostic coproduction, upholding high care standards and ethics, involving SGM individuals in healthcare improvement and increasing research on SGM health.


Anti-SGM bias, queerphobia, lack of provider training and heteronormative attitudes hinder diagnostic decision-making and communication. As a result, SGM patients report significant harms. Solutions to mitigate diagnostic disparities require an intersectional approach that considers patients’ gender identity, sexual orientation, race, age, economic status and system-level changes.

Between-hospital variation in indicators of quality of care: a systematic review


Efforts to mitigate unwarranted variation in the quality of care require insight into the ‘level’ (eg, patient, physician, ward, hospital) at which observed variation exists. This systematic literature review aims to synthesise the results of studies that quantify the extent to which hospitals contribute to variation in quality indicator scores.


Embase, Medline, Web of Science, Cochrane and Google Scholar were systematically searched from 2010 to November 2023. We included studies that reported a measure of between-hospital variation in quality indicator scores relative to total variation, typically expressed as a variance partition coefficient (VPC). The results were analysed by disease category and quality indicator type.


In total, 8373 studies were reviewed, of which 44 met the inclusion criteria. Casemix adjusted variation was studied for multiple disease categories using 144 indicators, divided over 5 types: intermediate clinical outcomes (n=81), final clinical outcomes (n=35), processes (n=10), patient-reported experiences (n=15) and patient-reported outcomes (n=3). In addition to an analysis of between-hospital variation, eight studies also reported physician-level variation (n=54 estimates). In general, variation that could be attributed to hospitals was limited (median VPC=3%, IQR=1%–9%). Between-hospital variation was highest for process indicators (17.4%, 10.8%–33.5%) and lowest for final clinical outcomes (1.4%, 0.6%–4.2%) and patient-reported outcomes (1.0%, 0.9%–1.5%). No clear pattern could be identified in the degree of between-hospital variation by disease category. Furthermore, the studies exhibited limited attention to the reliability of observed differences in indicator scores.


Hospital-level variation in quality indicator scores is generally small relative to residual variation. However, meaningful variation between hospitals does exist for multiple indicators, especially for care processes which can be directly influenced by hospital policy. Quality improvement strategies are likely to generate more impact if preceded by level-specific and indicator-specific analyses of variation, and when absolute variation is also considered.

PROSPERO registration number


Association between language discordance and unplanned hospital readmissions or emergency department revisits: a systematic review and meta-analysis

Background and objective

Studies conflict about whether language discordance increases rates of hospital readmissions or emergency department (ED) revisits for adult and paediatric patients. The literature was systematically reviewed to investigate the association between language discordance and hospital readmission and ED revisit rates.

Data sources

Searches were performed in PubMed, Embase and Google Scholar on 21 January 2021, and updated on 27 October 2022. No date or language limits were used.

Study selection

Articles that (1) were peer-reviewed publications; (2) contained data about patient or parental language skills and (3) included either unplanned hospital readmission or ED revisit as one of the outcomes, were screened for inclusion. Articles were excluded if: unavailable in English; contained no primary data or inaccessible in a full-text form (eg, abstract only).

Data extraction and synthesis

Two reviewers independently extracted data using Preferred Reporting Items for Systematic Reviews and Meta-Analyses-extension for scoping reviews guidelines. We used the Newcastle-Ottawa Scale to assess data quality. Data were pooled using DerSimonian and Laird random-effects models. We performed a meta-analysis of 18 adult studies for 28-day or 30-day hospital readmission; 7 adult studies of 30-day ED revisits and 5 paediatric studies of 72-hour or 7-day ED revisits. We also conducted a stratified analysis by whether access to interpretation services was verified/provided for the adult readmission analysis.

Main outcome(s) and measure(s)

Odds of hospital readmissions within a 28-day or 30-day period and ED revisits within a 7-day period.


We generated 4830 citations from all data sources, of which 49 (12 paediatric; 36 adult; 1 with both adult and paediatric) were included. In our meta-analysis, language discordant adult patients had increased odds of hospital readmissions (OR 1.11, 95% CI 1.04 to 1.18). Among the 4 studies that verified interpretation services for language discordant patient-clinician interactions, there was no difference in readmission (OR 0.90, 95% CI 0.77 to 1.05), while studies that did not specify interpretation service access/use found higher odds of readmission (OR 1.14, 95% CI 1.06 to 1.22). Adult patients with a non-dominant language preference had higher odds of ED revisits (OR 1.07, 95% CI 1.004 to 1.152) compared with adults with a dominant language preference. In 5 paediatric studies, children of parents language discordant with providers had higher odds of ED revisits at 72 hours (OR 1.12, 95% CI 1.05 to 1.19) and 7 days (OR 1.02, 95% CI 1.01 to 1.03) compared with patients whose parents had language concordant communications.


Adult patients with a non-dominant language preference have more hospital readmissions and ED revisits, and children with parents who have a non-dominant language preference have more ED revisits. Providing interpretation services may mitigate the impact of language discordance and reduce hospital readmissions among adult patients.

PROSPERO registration number


Grand rounds in methodology: designing for integration in mixed methods research

Mixed methods research is a popular approach used to understand persistent and complex problems related to quality and safety, such as reasons why interventions are not implemented as intended or explaining differential outcomes. However, the quality and rigour of mixed methods research proposals and publications often miss opportunities for integration, which is the core of mixed methods. Achieving integration remains challenging, and failing to integrate reduces the benefits of a mixed methods approach. Therefore, the purpose of this article is to guide quality and safety researchers in planning and designing a mixed methods study that facilitates integration. We highlight how meaningful integration in mixed methods research can be achieved by centring integration at the following levels: research question, design, methods, results and reporting and interpretation levels. A holistic view of integration through all these levels will enable researchers to provide better answers to complex problems and thereby contribute to improvement of safety and quality of care.

Locums: threat or opportunity

The medical workforce is key to service quality. Organisations have a duty to develop their workforce—to ensure professional development, good governance and, from time to time, discipline staff. But what if part of the workforce is contracted from outside to fill gaps in the rota? That is the world of the ‘locum’—a peripatetic medical workforce that is in, but not of, the organisation.

Locum doctors are deployed in many countries of the world. There is a thriving international market across English-speaking countries,1 Western Europe2 3 and in the USA, where the Veterans Administration alone pays about $50 million per annum for temporary medical staff.4 Considering the size and importance of this human resources market, the subject has attracted surprisingly little academic attention.

Ferguson and colleagues peer into the world of the medical locum through an in-depth qualitative study based on interviews...

Pragmatic trials are needed to assess the effectiveness of enhanced recovery after surgery protocols on patient safety

Contemporary healthcare systems comprise a myriad of organisations and professionals committed to patient care. These systems often develop innovations that are not easily transferable from one context to another. Three decades ago, Enhanced Recovery After Surgery (ERAS) protocols originated in Northern Europe, introducing a systematic approach to perioperative care, initially focusing on major colorectal surgeries.1 2 Using a patient-centred and evidence-based approach, their goal was to improve patient's early recovery through enhancing the quality of surgical processes. ERAS protocols were specifically designed to facilitate the dissemination of multimodal perioperative care pathways covering all aspects of the patient’s surgical journey. Addressing key factors traditionally extending post-surgery hospital stays, including the need for analgesia, intravenous fluids due to gut dysfunction and bed rest due to limited mobility, the ERAS protocols offered guidance for well-coordinated perioperative care teams.3 These protocols have since transcended borders, catalysing transformative...

Taking action on inequities: a structural paradigm for quality and safety

As quality improvement and patient safety (QIPS) practitioners, we aspire to improve care for all patients, caregivers and families using improvement methods. While teams are trained to carefully implement the science of improvement, less is known of how to effectively incorporate equity into QIPS work. Should there be more projects focused specifically on equity, or should equity be embedded into all quality improvement? Inattention to the equity domain in improvement efforts ignores systemic biases and can worsen inequities in health outcomes. How to measure inequity, and growing calls to reframe health equity data measurement, presentation and analysis are central to this discourse.

Arrington and colleagues' article offers strategies to collect, share and interpret quality data using a racial equity lens.1 The authors first describe the problems with stratifying quality data by race and ethnicity, which can perpetuate the false notion that race or ethnicity is responsible for...

Locum doctor working and quality and safety: a qualitative study in English primary and secondary care


The use of temporary doctors, known as locums, has been common practice for managing staffing shortages and maintaining service delivery internationally. However, there has been little empirical research on the implications of locum working for quality and safety. This study aimed to investigate the implications of locum working for quality and safety.


Qualitative semi-structured interviews and focus groups were conducted with 130 participants, including locums, patients, permanently employed doctors, nurses and other healthcare professionals with governance and recruitment responsibilities for locums across primary and secondary healthcare organisations in the English NHS. Data were collected between March 2021 and April 2022. Data were analysed using reflexive thematic analysis and abductive analysis.


Participants described the implications of locum working for quality and safety across five themes: (1) ‘familiarity’ with an organisation and its patients and staff was essential to delivering safe care; (2) ‘balance and stability’ of services reliant on locums were seen as at risk of destabilisation and lacking leadership for quality improvement; (3) ‘discrimination and exclusion’ experienced by locums had negative implications for morale, retention and patient outcomes; (4) ‘defensive practice’ by locums as a result of perceptions of increased vulnerability and decreased support; (5) clinical governance arrangements, which often did not adequately cover locum doctors.


Locum working and how locums were integrated into organisations posed some significant challenges and opportunities for patient safety and quality of care. Organisations should take stock of how they work with the locum workforce to improve not only quality and safety but also locum experience and retention.

Implementation of an enhanced recovery after surgery protocol for colorectal cancer in a regional hospital network supported by audit and feedback: a stepped wedge, cluster randomised trial


Enhanced recovery after surgery (ERAS) protocols are known to potentially improve the management and outcomes of patients undergoing colorectal surgery, with limited evidence of their implementation in hospital networks and in a large population. We aimed to assess the impact of the implementation of an ERAS protocol in colorectal cancer surgery in the entire region of Piemonte, Italy, supported by an audit and feedback (A&F) intervention.


A large, stepped wedge, cluster randomised trial enrolled patients scheduled for elective surgery at 29 general surgery units (clusters). At baseline (first 3 months), standard care was continued in all units. Thereafter, four groups of clusters began to adopt the ERAS protocol successively. By the end of the study, each cluster had a period in which standard care was maintained (control) and a period in which the protocol was applied (experimental). ERAS implementation was supported by initial training and A&F initiatives. The primary endpoint was length of stay (LOS) without outliers (>94th percentile), and the secondary endpoints were outliers for LOS, postoperative medical and surgical complications, quality of recovery and compliance with ERAS items.


Of 2626 randomised patients, 2397 were included in the LOS analysis (1060 in the control period and 1337 in the experimental period). The mean LOS without outliers was 8.5 days during the control period (SD 3.9) and 7.5 (SD 3.5) during the experimental one. The adjusted difference between the two periods was a reduction of –0.58 days (95% CI –1.07, –0.09; p=0.021). The compliance with ERAS items increased from 52.4% to 67.3% (estimated absolute difference +13%; 95% CI 11.4%, 14.7%). No difference in the occurrence of complications was evidenced (OR 1.22; 95% CI 0.89, 1.68).


Implementation of the ERAS protocol for colorectal cancer, supported by A&F approach, led to a substantial improvement in compliance and a reduction in LOS, without meaningful effects on complications.

Trial registration number NCT04037787.

Accuracy of telephone triage for predicting adverse outcomes in suspected COVID-19: an observational cohort study


To assess accuracy of telephone triage in identifying need for emergency care among those with suspected COVID-19 infection and identify factors which affect triage accuracy.


Observational cohort study.


Community telephone triage provided in the UK by Yorkshire Ambulance Service NHS Trust (YAS).


40 261 adults who contacted National Health Service (NHS) 111 telephone triage services provided by YAS between 18 March 2020 and 29 June 2020 with symptoms indicating COVID-19 infection were linked to Office for National Statistics death registrations and healthcare data collected by NHS Digital.


Accuracy of triage disposition was assessed in terms of death or need for organ support up to 30 days from first contact.


Callers had a 3% (1200/40 261) risk of serious adverse outcomes (death or organ support). Telephone triage recommended self-care or non-urgent assessment for 60% (24 335/40 261), with a 1.3% (310/24 335) risk of adverse outcomes. Telephone triage had 74.2% sensitivity (95% CI: 71.6 to 76.6%) and 61.5% specificity (95% CI: 61% to 62%) for the primary outcome. Multivariable analysis suggested respiratory comorbidities may be overappreciated, and diabetes underappreciated as predictors of deterioration. Repeat contact with triage service appears to be an important under-recognised predictor of deterioration with 2 contacts (OR 1.77, 95% CI: 1.14 to 2.75) and 3 or more contacts (OR 4.02, 95% CI: 1.68 to 9.65) associated with false negative triage.


Patients advised to self-care or receive non-urgent clinical assessment had a small but non-negligible risk of serious clinical deterioration. Repeat contact with telephone services needs recognition as an important predictor of subsequent adverse outcomes.

Effect of contextual factors on the prevalence of diagnostic errors among patients managed by physicians of the same specialty: a single-centre retrospective observational study


There has been growing recognition that contextual factors influence the physician’s cognitive processes. However, given that cognitive processes may depend on the physicians’ specialties, the effects of contextual factors on diagnostic errors reported in previous studies could be confounded by difference in physicians.


This study aimed to clarify whether contextual factors such as location and consultation type affect diagnostic accuracy.


We reviewed the medical records of 1992 consecutive outpatients consulted by physicians from the Department of Diagnostic and Generalist Medicine in a university hospital between 1 January and 31 December 2019. Diagnostic processes were assessed using the Revised Safer Dx Instrument. Patients were categorised into three groups according to contextual factors (location and consultation type): (1) referred patients with scheduled visit to the outpatient department; (2) patients with urgent visit to the outpatient department; and (3) patients with emergency visit to the emergency room. The effect of the contextual factors on the prevalence of diagnostic errors was investigated using logistic regression analysis.


Diagnostic errors were observed in 12 of 534 referred patients with scheduled visit to the outpatient department (2.2%), 3 of 599 patients with urgent visit to the outpatient department (0.5%) and 13 of 859 patients with emergency visit to the emergency room (1.5%). Multivariable logistic regression analysis showed a significantly higher prevalence of diagnostic errors in referred patients with scheduled visit to the outpatient department than in patients with urgent visit to the outpatient department (OR 4.08, p=0.03), but no difference between patients with emergency and urgent visit to the emergency room and outpatient department, respectively.


Contextual factors such as consultation type may affect diagnostic errors; however, since the differences in the prevalence of diagnostic errors were small, the effect of contextual factors on diagnostic accuracy may be small in physicians working in different care settings.

Ensuring safe and equitable discharge: a quality improvement initiative for individuals with hypertensive disorders of pregnancy


To improve timely and equitable access to postpartum blood pressure (BP) monitoring in individuals with hypertensive disorders of pregnancy (HDP).


A quality improvement initiative was implemented at a large academic medical centre in the USA for postpartum individuals with HDP. The primary aim was to increase completed BP checks within 7 days of hospital discharge from 40% to 70% in people with HDP in 6 months. Secondary aims included improving rates of scheduled visits, completed visits within 3 days for severe HDP and unattended visits. The balancing measure was readmission rate. Statistical process control charts were used, and data were stratified by race and ethnicity. Direct feedback from birthing individuals was obtained through phone interviews with a focus on black birthing people after a racial disparity was noted in unattended visits.


Statistically significant improvements were noted across all measures. Completed and scheduled visits within 7 days of discharge improved from 40% to 76% and 61% to 90%, respectively. Completed visits within 3 days for individuals with severe HDP improved from 9% to 49%. The unattended visit rate was 26% at baseline with non-Hispanic black individuals 2.3 times more likely to experience an unattended visit than non-Hispanic white counterparts. The unattended visit rate decreased to 15% overall with an elimination of disparity. A need for BP devices at discharge and enhanced education for black individuals was identified through patient feedback.


Timely follow-up of postpartum individuals with HDP is challenging and requires modification to our care delivery. A hospital-level quality improvement initiative using birthing individual and frontline feedback is illustrated to improve equitable, person-centred care.

Quality, safety and artificial intelligence

Healthcare quality and safety span multiple topics across the spectrum of academic and clinical disciplines. Keeping abreast of the rapidly growing body of work can be challenging. In this series, we provide succinct summaries of selected relevant studies published in the last several months. Some articles will focus on a particular theme, whereas others will highlight unique publications from high-impact medical journals.

Key points

  • Global perspectives from 881 artificial intelligence (AI) and cancer researchers into the future impact of AI on cancer care highlight AI’s potential to improve cancer grading, classification, diagnostic accuracy and follow-up, while also identifying significant barriers to its integration into clinical practice and the need for standardisation in cancer health data. Current Oncology, 16 March 2023.

  • Additional information (from human peers or AI) can have a strong influence on prescribing decisions made by intensive care doctors, particularly for AI...

  • It is up to healthcare professionals to talk to us in a way that we can understand: informed consent processes in people with an intellectual disability

    People with an intellectual disability form a sizeable minority group. Estimates of prevalence vary, depending on criteria used, but it is thought that intellectual disability affects around 1%–2% of the world population.1 2 Intellectual disability is present when the following three criteria are met: a significantly reduced ability to understand new or complex information, or to learn and apply new skills (impaired intelligence); a reduced ability to cope independently (impaired social functioning); and beginning before adulthood, with a lasting effect on development.3 4

    Health inequities

    People with an intellectual disability experience stark health inequities. Understanding the causes of these inequities is important in making steps towards addressing them. The ‘Learning from Lives and Deaths’ (LeDeR) programme, which has investigated deaths of people with an intellectual disability and autistic people in England since 2016,5 contributes towards achieving such understanding....

    Routine versus prompted clinical debriefing: aligning aims, mechanisms and implementation

    The great art of learning is to understand but little at a time. —John Locke

    Clinical debriefing (CD) is rapidly gaining traction as a valuable activity. CD is usually conducted as a guided exploration and reflection of clinical events in an attempt to bridge the gap between experience and understanding, with the ultimate aim of influencing future practice.1 CD has the potential to improve outcomes for staff, teams, patients and systems.2 3 The evidence for CD exists and continues to grow; benefits range from changes in staff attitudes4 to favourable outcomes following cardiac arrest.5 Despite this, some clinicians have been sceptical about the impact of CD, and there are various barriers which may limit implementation. These include lack of clear purpose, actual or perceived lack of time, lack of experienced debriefers and cultural resistance to change.6 Our...

    Economic analysis of surgical outcome monitoring using control charts: the SHEWHART cluster randomised trial


    Surgical complications represent a considerable proportion of hospital expenses. Therefore, interventions that improve surgical outcomes could reduce healthcare costs.


    Evaluate the effects of implementing surgical outcome monitoring using control charts to reduce hospital bed-days within 30 days following surgery, and hospital costs reimbursed for this care by the insurer.


    National, parallel, cluster-randomised SHEWHART trial using a difference-in-difference approach.


    40 surgical departments from distinct hospitals across France.


    155 362 patients over the age of 18 years, who underwent hernia repair, cholecystectomy, appendectomy, bariatric, colorectal, hepatopancreatic or oesophageal and gastric surgery were included in analyses.


    After the baseline assessment period (2014–2015), hospitals were randomly allocated to the intervention or control groups. In 2017–2018, the 20 hospitals assigned to the intervention were provided quarterly with control charts for monitoring their surgical outcomes (inpatient death, intensive care stay, reoperation and severe complications). At each site, pairs, consisting of one surgeon and a collaborator (surgeon, anaesthesiologist or nurse), were trained to conduct control chart team meetings, display posters in operating rooms, maintain logbooks and design improvement plans.

    Main outcomes

    Number of hospital bed-days per patient within 30 days following surgery, including the index stay and any acute care readmissions related to the occurrence of major adverse events, and hospital costs reimbursed for this care per patient by the insurer.


    Postintervention, hospital bed-days per patient within 30 days following surgery decreased at an adjusted ratio of rate ratio (RRR) of 0.97 (95% CI 0.95 to 0.98; p<0.001), corresponding to a 3.3% reduction (95% CI 2.1% to 4.6%) for intervention hospitals versus control hospitals. Hospital costs reimbursed for this care per patient by the insurer significantly decreased at an adjusted ratio of cost ratio (RCR) of 0.99 (95% CI 0.98 to 1.00; p=0.01), corresponding to a 1.3% decrease (95% CI 0.0% to 2.6%). The consumption of a total of 8910 hospital bed-days (95% CI 5611 to 12 634 bed-days) and 2 615 524 (95% CI 32 366 to 5 405 528) was avoided in the intervention hospitals postintervention.


    Using control charts paired with indicator feedback to surgical teams was associated with significant reductions in hospital bed-days within 30 days following surgery, and hospital costs reimbursed for this care by the insurer.

    Trial registration number