Evaluation of Wales Postgraduate Medical and Dental Education Deanery outcomes at core and higher general surgery before and after national reconfiguration, enhanced selection, and Joint Committee on Surgical Training defined curricular standards

This thesis examines contemporary outcomes of surgical training in Wales and the UK. The hypotheses tested were: Core Surgical Training (CST) outcome is related to specific curricular defined goals, and themed focused CST rotations improve success at National Training Number (NTN)appointment; CST rotations including rural placements provide training comparable with non-rural placements; General Surgery (GS) Certificate of Completion of Training (CCT) curricular guidelines require focused appraisal and rotation planning; GS Higher Surgical Trainee (HST) indicative procedure targets are not in keeping with competence achievement determined by Procedural Based Assessment (PBA); Dedicated Emergency General Surgery (EGS) modules enhance HST training experience; H-Indices are a valid measure of GS consultant academic productivity and identify training research opportunity. Successful ST3 NTN appointment improved from 5.3 to 33.3% (p=0.005) following CST [OR 4.789 (1.666 - 13.763), p=0.004] and is independently associated with success. ST3 appointment was similar irrespective of rural or non-rural CST rotational placement (18.1 vs. 22.1%, p=0.695). Of the 155 UK GS HST CCTs awarded in 2013, global operative log book and academic achievements varied widely, with two-thirds of trainees achieving elective operative targets, but only half the requisite experience in EGS, and 5% nonoperative targets. Wales’ HSTs level 4 GS operative competencies varied 4- fold, ranging from 0.76 to 3.4 times national targets. EGS modular training introduction delivered a high volume of index EGS procedures and higher rates of PBA completion when compared with controls. H-indices were a robust measure of surgeons’ academic activity (p<0.001)

The validity, reliability and responsiveness of procedure based assessment in simulated vascular procedures

IntroductionProcedure based assessment (PBA) has been shown to be valid and reliable in the workplace however whether this translates to the simulation setting has not yet been demonstrated. Therefore the aim of this thesis is to demonstrate that PBA is a valid, reliable and responsive assessment tool in simulated vascular procedures.MethodsThree experiments based on simulated vascular operations were designed to explore the validity, reliability and responsiveness of PBA utilising 3 commonly performed vascular procedures. The global and task specific checklist (GTSC) and global summary score (GSS) of a modified PBA were analysed separately. Validity was determined by correlating performance with prior operative experience (number of operations previously observed and performed) and stage in surgical training. Reliability and responsiveness was determined by use of multiple raters and assessingchange in performance over time.ResultsThe modified PBA was found to be a valid assessment method based on number of operations previously performed (r=0.446 p=0.029 for the GTSC and r=0.553 p= 0.005 for the GSS) but not for operations previously observed. Only the PBA GTSC was valid for stage of surgical training (r= 0.588 p=0.002). The modified PBA demonstrated good inter-rater reliability (r= 0.665 p= 0.005 for the GTSC and r= 0.843 p> 0.001 for the GSS) during simulated vascular procedures. Intra-rater reliability was not demonstrated. The PBA GSS was found to be responsive to improved performance (WSR p< 0.001) but the PBA GTSC was not (WSR p = 0.104).ConclusionThe modified PBA is a valid assessment of surgical skill when correlated with previous operative performance. Observation alone appears to contribute little to assessment outcomes. Performance is index specific and not fully dependant on training level. PBA has only partial reliability in simulated vascular procedure due to the lack of intra-rater reliability. PBA was responsive to practice effect suggesting it could be useful to monitor trainee performance in simulation. PBA potentially has a role in simulation assessment but did not demonstrate sufficient reliability for high stakes examination

A Virtual University Infrastructure For Orthopaedic Surgical Training With Integrated Simulation

This thesis pivots around the fulcrum of surgical, educational and technological factors. Whilst there is no single conclusion drawn, it is a multidisciplinary thesis exploring the juxtaposition of different academic domains that have a significant influence upon each other. The relationship centres on the engineering and computer science factors in learning technologies for surgery. Following a brief introduction to previous efforts developing surgical simulation, this thesis considers education and learning in orthopaedics, the design and building of a simulator for shoulder surgery. The thesis considers the assessment of such tools and embedding into a virtual learning environment. It explains how the performed experiments clarified issues and their actual significance. This leads to discussion of the work and conclusions are drawn regarding the progress of integration of distributed simulation within the healthcare environment, suggesting how future work can proceed

A virtual university infrastructure for orthopaedic surgical training with integrated simulation

This thesis pivots around the fulcrum of surgical, educational and technological factors. Whilst there is no single conclusion drawn, it is a multidisciplinary thesis exploring the juxtaposition of different academic domains that have a significant influence upon each other. The relationship centres on the engineering and computer science factors in learning technologies for surgery. Following a brief introduction to previous efforts developing surgical simulation, this thesis considers education and learning in orthopaedics, the design and building of a simulator for shoulder surgery. The thesis considers the assessment of such tools and embedding into a virtual learning environment. It explains how the performed experiments clarified issues and their actual significance. This leads to discussion of the work and conclusions are drawn regarding the progress of integration of distributed simulation within the healthcare environment, suggesting how future work can proceed.EThOS - Electronic Theses Online ServiceGBUnited Kingdo

Application of intraoperative quality assurance to laparoscopic total mesorectal excision surgery

Introduction: The role of laparoscopy in the surgical management of rectal cancer is debated. Randomised trials have reported contrasting results with inadequate specimens obtained in a minority of patients. The reasons behind these findings are unclear. Complex surgical interventions and human performance are prone to variation, which may account for outcome differences, but neither are robustly measured. Application of quality assurance (QA) to the intraoperative period could explore surgical performance and any relationship with subsequent outcomes. The overarching aim of this thesis is the promotion of oncological and patient safety through application of QA to laparoscopic TME surgery. Methods: Evidence synthesis of QA tools was obtained through a systematic review to identify reported objective laparoscopic total mesorectal excision (TME) assessment tools. Development of novel QA tools for laparoscopic TME was performed and applied and validated using case video from two multicentre randomised trials with reliability and validity of the laparoscopic TME performance tool (L-TMEpt) assessed. A multicentre randomised trial comparing 3D vs. 2D laparoscopic TME was performed incorporating objective performance analyses. Scores divided surgeons into quartiles and compared with histopathological and clinical endpoints. A novel intraoperative adverse event classification was developed and piloted. Results: 176 cases from 48 credentialed surgeons were analysed. L-TMEpt inter-rater, test-retest and internal consistency reliabilities were established. Substantial variation in surgical performance were seen. Scores were strongly associated with the number of intraoperative errors, plane of mesorectal dissection and short-term patient morbidity. Upper quartile surgeons obtained excellent results compared with the lower quartile (mesorectal fascia 93% vs. 59%, NNT 2.9, p=0.002; 30-day morbidity 23% vs. 48%, NNT 4, p=0.043). Conclusions: Intraoperative QA using assessment tools can objectively and reliably measure complex cancer interventions. Laparoscopic TME surgical performance assessment showed substantial variation which is strongly associated with clinical outcomes holding implications for surgical trial design and interpretation.Open Acces

Towards high performing hospital enterprise architectures : elevating hospitals to lean enterprise thinking

Thesis (Ph. D.)--Massachusetts Institute of Technology, Engineering Systems Division, 2011.Cataloged from PDF version of thesis.Includes bibliographical references (p. 608-630).This research is motivated by the National Academy of Engineering and the Institute of Medicine's joint call for research in healthcare, promoting the application of principles, tools, and research from engineering disciplines, and complex systems in particular. In 2005, the US healthcare expenditure represented 16% of its GDP, with hospitals representing the largest source of expenditure, as is the case in the United Kingdom. Consequently, the strategies and operations developed and implemented by hospitals have a significant impact on healthcare. Today, it would be hard to find a hospital that is not implementing a Lean initiative or who isn't familiar with its concepts. However, more often than not, their approach has narrowly focused at a process level and inside individual service units like an emergency department. This research seeks to elevate traditionally narrow hospital definitions of lean and explore the broader concepts of lean enterprise principles and Enterprise Architecture (EA) while enhancing our knowledge of hospitals' socio-technical complexity and enriching an emerging EA Framework (EAF) developed at the Massachusetts Institute of Technology (MIT). Following an extensive longitudinal multidisciplinary literature review, a number of expert interviews, and preliminary empirical findings, an exploratory inductive and deductive hybrid study was designed to collect and concurrently analyze both qualitative and quantitative empirical data from multiple hospital settings over two main phases: * The first phase consisted of recorded interviews with the Chief Executive Officers of seven leading Massachusetts hospitals, who also provided sensitive internal strategy and operations documents. We explored how hospitals currently measure their hospital performance and how their explicit and implicit practices may be improved using lean enterprise principles. e The second phase comprised two in-depth case studies of large leading multidisciplinary hospitals, one located in the US and other in the United Kingdom, and included a total of 13 embedded units of analysis. Multiple sources of evidence were collected including electronic medical records, 54 interviews, observation, and internal documents. Findings were categorized and sorted, as phenomena of interest consistently emerged from the data, and enriched both the EAF, and our understanding of hospitals' EA in particular. In both in-depth hospital cases we found that their EA consisted of multiple internal architectural configurations, and in particular, those with an enriched understanding of EA had made decisions which had improved not only their local performance, but also enhanced their interactions with other service units upstream and downstream. Conversely, worse performing configurations demonstrated a limited understanding of their hospital's EA. We conclude that hospital performance can be improved through an enriched understanding of hospital EA. Furthermore, whilst considering all hospitals included in this study, we propose general and specific recommendations, as well as diagnostic questions, performance dimensions, and metrics, to assist senior hospital leaders in architecting and managing their enterprise.by Jorge Miguel dos Santos Fradinho.Ph.D

Functional Outcomes of Anterior Cruciate Ligament Reconstruction Surgery

Anterior cruciate ligament (ACL) is one of the most common sports injuries with a reported yearly incidence rate of over two million injuries worldwide. The main aim of this thesis is to investigate various aspects related to the functional outcomes of ACLR through a series of clinical studies. Ethical approval was sought and granted by the North of Scotland Research Ethics Service. A systematic review was conducted to investigate the outcome measures used in Level I and II clinical ACLR studies. The review showed wide variability in the outcome measures utilised with no consensus on the ideal outcome instrument or combination of instruments to report the outcome of ACLR. Five-year results from the UK National Ligament Registry (NLR) were analysed with review for limitations of registry data and future recommendations. The data analysed provided a comprehensive review for the demographics, surgical techniques and functional outcomes of ACLR surgery across the UK. NLR data is limited by multiple factors including high rate of incomplete data, duplication of data, poor patient compliance and lack of validation of the data. A study was conducted to examine the hypothesis that patients with ACLR do not return to their pre-injury functional status at two years postoperatively. The study showed significant improvement in patient symptoms postoperatively compare to their post-injury scores, but the majority of patients failed to achieve their pre-injury functional outcome scores at 2 years postoperatively. In a comparative study, the anteromedial portal (AM) technique in femoral tunnel drilling was compared with the trans-tibial (TT) technique with respect to radiological and functional outcomes. The hypothesis was that AM portal produces better functional outcomes compared with TT technique. We found that the AM portal achieved a more anatomical position of the graft but there was no difference between the two techniques in functional outcome at 2 years postoperatively. However, ACLR with the AM portal technique had higher graft failure rate compared with the TT technique. The medium- term outcome of all-inside meniscal repairs was investigated in a longitudinal study. Meniscal repairs with concomitant ACLR had a lower failure rate compared with isolated meniscal repairs. This indicates that surgeons should have a low threshold for repairing meniscal tear during ACLR surgery. The healing response technique was studied in a selected group of patients with complete proximal ACL tears. This technique yielded good functional outcome for most of the patients at 2 years postoperative follow up. The studies included in this thesis provides substantial information for surgeons treating patients with ACL injuries. It provides a platform for further research studies investigating the outcomes of ACLR surgery