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ObjectivesHospitals introducing the National Surgical Quality Improvement Program (NSQIP) face implementation challenges. To understand the work of embedding NSQIP into routine practice, we explored interactions between contextual factors and the work among implementation teams at the individual, team and organisational level to illuminate how to support and sustain NSQIP implementation.DesignQualitative interpretative study using thematic analysis.SettingFive contextually diverse hospital sites in Alberta, Canada, for in-depth interviewing and four additional hospitals for observation of NSQIP meetings.Participants9 Surgeon and Anaesthesiologist Champions; 6 Surgical Clinical Reviewers; 4 Directors and 1 Surgical Site Manager; 3 Operating Room Managers; 3 Quality Improvement Consultants; 1 Surgeon and 1 Provincial NSQIP Lead.MethodsTo capture context, process and the dynamic interplay between the two, we integrated the Consolidated Framework for Implementation Research (CFIR) and Normalisation Process Theory (NPT) to guide data collection and analysis. 28 individual semi-structured interviews with key informants and observations with field notes of 10 NSQIP meetings were conducted. Data were coded deductively and inductively and analysed thematically.ResultsKey findings informed by CFIR describe the impact of Provincial Collaboratives, leadership support and resources to support NSQIP work. Key findings illuminated by NPT highlight how teams overcame mistrust in NSQIP through relationship building, creating formative spaces to inform collective understandings of NSQIP and inviting feedback from professional groups to cocreate quality improvement solutions. This approach led to increased engagement with NSQIP data and encouraged shifts in conversations within and between nursing and physician groups from problems to solutions based.ConclusionsThe work the teams did to implement and sustain NSQIP highlights the need for time and resources to develop shared understandings of work processes, reorganise themselves to work together and understand how to help others in the surgical community interpret and value using NSQIP to improve care.

Introduction The wait times crisis for hip and knee total joint replacement surgery has been a significant health care issue in Alberta and across Canada. Significant resource and financial efforts have been put forward to reduce wait times for surgery as a means of treating patients with osteoarthritis (OA), but the gains achieved were not sustained. Objective To effectively address wait time issues, an alternative perspective on this problem is presented – that the wait times are an immediate problem for those needing surgery, but are also a symptom of the bigger issue of an inability of health care systems in Canada to address the needs of individuals with early OA with first-line treatment protocols. Discussion In considering this more comprehensive understanding of the overall OA management problem, encapsulated by the concept of an “osteoarthritis funnel”, we outline potential approaches for a solution on a systemic level that integrates services delivery, health care resource allocation and conceptualization of OA in research activities. It also emphasizes the need for a more effective and relevant program of research to address this complex problem that requires unique solutions. Conclusions New approaches and understanding are needed to address integrated implementation of effective first-line treatments for newly diagnosed osteoarthritis to prevent the expanding demand for joint replacement surgery. While the focus here is on the Canadian perspective, the need to develop and implement better first-line treatments for those with early OA and those at risk for development of OA is not unique to Canada.

ObjectivesTo understand how surgical services have been reorganised during and following public health emergencies, particularly the first wave of the COVID-19 pandemic, and the consequences for patients, healthcare providers and healthcare systems.DesignA rapid scoping review.SettingWe searched the MEDLINE, Embase and grey literature sources for documents and press releases from governments and surgical organisations or associations.ParticipantsStudies examining surgical service delivery during public health emergencies including COVID-19, and the impact on patients, providers and healthcare systems were included.Primary and secondary outcome measuresPrimary outcomes were strategies implemented for the reorganisation of surgical services. Secondary were the impacts of reorganisation and resuming surgical services, such as: adverse events (including morbidity and mortality), primary care and emergency department visits, length of hospital and ICU stay, and changes to surgical waitlists.ResultsOne hundred and thirty-two studies were included in this review; 111 described reorganisation of surgical services, 55 described the consequences of reorganising surgical services; and 6 reported actions taken to rebuild surgical capacity in public health emergencies. Reorganisations of surgical services were grouped under six domains: case selection/triage, personal protective equipment (PPE) regulations and practice, workforce composition and deployment, outpatient and inpatient patient care, resident and fellow education, and the hospital or clinical environment. Service reorganisations led to large reductions in non-urgent surgical volumes, increases in surgical wait times and impacted medical training (ie, reduced case involvement) and patient outcomes (eg, increases in pain). Strategies for rebuilding surgical capacity were scarce but focused on the availability of staff, PPE and patient readiness for surgery as key factors to consider before resuming services.ConclusionsReorganisation of surgical services in response to public health emergencies appears to be context dependent and has far-reaching consequences that must be better understood in order to optimise future health system responses to public health emergencies.

BackgroundHealthcare systems globally have been challenged by the COVID-19 pandemic, necessitating the reorganization of surgical services to free capacity within healthcare systems.ObjectivesTo understand how surgical services have been reorganized during and following public health emergencies, and the consequences of these changes for patients, healthcare providers and healthcare systems.MethodsThis rapid scoping review searched academic databases and grey literature sources to identify studies examining surgical service delivery during public health emergencies including COVID-19, and the impact on patients, providers and healthcare systems. Recommendations and guidelines were excluded. Screening was completed in partial (title, abstract) or complete (full text) duplicate following pilot reviews of 50 articles to ensure reliable application of eligibility criteria.ResultsOne hundred and thirty-two studies were included in this review; 111 described reorganization of surgical services, 55 described the consequences of reorganizing surgical services and six reported actions taken to rebuild surgical capacity in public health emergencies. Reorganizations of surgical services were grouped under six domains: case selection/triage, PPE regulations and practice, workforce composition and deployment, outpatient and inpatient patient care, resident and fellow education, and the hospital or clinical environment. Service reorganizations led to large reductions in non-urgent surgical volumes, increases in surgical wait times, and impacted medical training (i.e., reduced case involvement) and patient outcomes (e.g., increases in pain). Strategies for rebuilding surgical capacity were scarce, but focused on the availability of staff, PPE, and patient readiness for surgery as key factors to consider before resuming services.ConclusionsReorganization of surgical services in response to public health emergencies appears to be context-dependent and has far-reaching consequences that must be better understood in order to optimize future health system responses to public health emergencies.ARTICLE SUMMARYStrengths and limitations of the studyThis rapid scoping review provides an exhaustive and rigorous summary of the academic and grey literature regarding modifications to surgical services in response to public health emergencies, especially COVID-19.This study did not limit studies based on location or language of publication to ensure a worldwide pandemic had contributions from worldwide voices.Both quantitative and qualitative outcomes were included, with a mix of inductive and deductive data abstraction approaches to provide a comprehensive understanding of surgical services during public health emergencies.Studies with potential relevance to this question are emerging at an unprecedented rate in response to the COVID-19 pandemic and as such, some may not be included in the current review.Original protocol for the studyAs requested, the original unpublished protocol for this study is included as a supplementary file.Funding statementThis study did not receive grant from any funding agency in the public, commercial or not-for-profit sectors.Competing interest statementAll authors declare that they have no competing interests in accordance with the International Committee of Medical Journal Editors uniform declaration of competing interests.

Short summary Health systems are under contant pressure to improve the quality and safety of the care they provide. ACS-NSQIP was developed and refined over the past two decades to provide surgical programs with high quality, risk-adjusted, benchmarked data which they can use to monitor their progress and identify areas for improvement. While ACS-NSQIP has been integrated into surgical systems across the United States and internationally, there remains an incomplete understanding of whether the implementation of ACS-NSQIP is independently sufficient to drive surgical quality improvement. This systematic review examines this important knowledge gap.