Open Access Open Badges Research article

Improving quality through process change: a scoping review of process improvement tools in cancer surgery

Alice C Wei12*, David R Urbach12, Katharine S Devitt1, Meagan Wiebe1, Oliver F Bathe3, Robin S McLeod24, Erin D Kennedy24 and Nancy N Baxter25

Author Affiliations

1 Princess Margaret Cancer Centre, University Health Network, Department of Surgery, University of Toronto, Toronto, ON, Canada

2 Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada

3 Department of Surgery and Oncology, University of Calgary, Calgary, AB, Canada

4 Division of General Surgery, Mount Sinai Hospital, Toronto, ON, Canada

5 Division of General Surgery, St. Michael’s Hospital, Toronto, ON, Canada

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BMC Surgery 2014, 14:45  doi:10.1186/1471-2482-14-45

Published: 19 July 2014



Surgery is a cornerstone of treatment for malignancy. However, significant variation has been reported in patterns and quality of cancer care for important health outcomes, including perioperative mortality. Surgical process improvement tools (SPITs) have been developed that focus on enhancing the processes of care at the point of care, as a means of quality improvement. This study describes SPITs and develops a conceptual framework by synthesizing the available literature on these novel quality improvement tools.


A scoping review was conducted based on instruments developed for quality improvement in surgery. The search was executed on electronically indexed sources (MEDLINE, EMBASE, and the Cochrane library) from January 1990 to March 2011. Data were extracted, tabulated and reported thematically using a narrative synthesis approach. These results were used to develop a conceptual framework that describes and classifies SPITs.


232 articles were reviewed for data extraction and analysis. SPITs identified were classified into 3 groups: clinical mapping tools, structure communication tools and error reduction instruments. The dominant instrument reported were clinical mapping tools, including: clinical pathways (113, 48%), fast track (46, 20%) and enhanced recovery after surgery protocols (36, 15%). Outcomes reported included: length of stay (174, 75%), readmission rates (116, 50%), morbidity (116, 50%), mortality (104, 45%), and economic (60, 26%). Many gaps in the literature were recognized.


We have developed a conceptual framework of SPITs and identified gaps in current knowledge. These results will guide the design and development of new quality instruments in surgery.

Surgical procedures; Operative; Quality; Safety; Neoplasms; Scoping review