How Well Is Surgical Improvement Being Conducted? Evaluation of 50 Local Surgery-Related Improvement Efforts.

BACKGROUND: Delivering high-quality care is paramount; however, evaluations show mixed results. Studies assessing improvement efforts in nonsurgical disciplines show suboptimal conduct, yet little is known about how well improvement efforts in surgery are conducted. This study evaluates local surgical improvement efforts to determine whether opportunities exist to improve their conduct. STUDY DESIGN: Fifty consecutive improvement efforts were collected from hospitals participating in 1 of 5 American College of Surgeons Quality Accreditation/Verification Programs. Conduct of these efforts was evaluated using a quality framework (with 39 criteria grouped into 8 components). Descriptive, paired, and 1-way ANOVA analyses were undertaken. RESULTS: The mean percentage of 39 criteria fulfilled for the 50 improvement efforts was 36% (range 0% to 72%). Individual criterion scores ranged from 0% to 82%. The 2 highest scoring criteria were improvement planning and problem documentation; the 2 lowest scoring were value assessments and stakeholder value perspective. The highest scoring framework component addressed End-of-Project Decision-Making (47%); the lowest was Cost Evaluation (3%). Twenty-four percent of 50 improvement efforts reported full achievement of project goals, 32% reported partial achievement, and 44% reported no achievement. Higher scores were associated with projects having full/partial achievement of stated project goals vs projects not achieving project goals (p < 0.05). Higher scores were not associated with hospital characteristics (eg bed size, teaching status) or improvement characteristics (eg improvement strategy). CONCLUSIONS: Evaluation of local surgical improvement efforts shows opportunities for improvement. Better-conducted improvement efforts were associated with more effective improvement. To support better surgical quality of care, improvement efforts need to improve.

The immune system provides a strong response to even a low exposure to virus.

How influenza virus dose affects the size of the immune response has not been clearly documented. Mice were challenged with three doses of influenza virus spanning a 100-fold range. Increasing the viral input dose increased the degree of weight loss observed, the clinical score and eventual mortality. Maximum viral loads increased with viral input and lower doses peaked and declined earlier. The level of the immune response only varied 2-fold and was independent of viral dose with near maximal responses elicited by the lowest dose, as measured by influx of antigen-specific and non-specific leukocytes into the lungs and by influenza antibody titers. We conclude that a strong immune response is mounted to a small dose of virus and curbs the spread of virus early and prevents weight loss whereas larger doses of virus elicit a slightly greater response but the associated disease can overwhelm the host.