Quality Assurance and Quality Control in Plastic Surgery

Introduction 

Plastic surgery is a surgical field which specializes in the restoration of function and form to missing or damaged skin and tissues due to aspects such as congenital abnormality, illnesses, injury, and surgery (Henderson, 2012). Reconstructive surgery incorporates various procedures; these procedures include treatment of burns, microsurgery, hand surgery, and craniofacial surgery. Reconstructive surgery aims to reconstruct a particular body part or enhance its functioning or operation. Cosmetic surgery, on the other hand, is aimed at enhancing or ameliorating the appearance of a specific body part. Reconstructive and plastic surgery is based on the exploitation of primary principles of surgery, pathology, physiology, and anatomy (Henderson 2012). The proficiency in these precepts and the knowledge on sound surgical techniques enhances the capacity of plastic surgeons to adapt to the extensive variety of cases consistently they encounter in their profession and provide aesthetic and functional solutions. 

In plastic surgery practice, a quality assurance program involves a simple mechanism aimed at ensuring that the consumer (patient) is subjected or exposed to the least threatening environment in the hospital during the treatment period, with a sequel or outcome that is considered acceptable or acknowledged by international standards (Mathis, 2011). Quality assurance procedures typically involve the collection of data and the analysis of results. Additionally, it incorporates the assessment of the outcomes of the patient and organizational procedures, the efficacy of care, and healthcare provider and patient satisfaction (Mathis, 2011). The institutional analysis of these variables inherently impacts the journey of a patient. Quality control in plastic surgery is necessary to enhance the acquisition of the expected outcome from a scheduled surgery in line with the current knowledge in the field. 

Brief Historical Perspective 

The conception of establishing quality assessment in surgical operations is historically ascribed to Ernest Codman, an American surgeon. During the 1900s, Ernest proposed that hospitals or healthcare institutions in general, particularly surgeons should gather their study outcomes sequentially through time, to present comparative information on end-results (Neligan & Gurtner, 2018). Ernest suggests that the outcomes should be made public to allow patients to utilize the data and select the place of treatment and personal surgeon; it was Ernest’s lifelong pursuit to develop an “end results system” to monitor the treatment outcomes as an opportunity to distinguish and solve clinical issues, thereby, providing the basis for enhancing the care of future patients (Neligan &Gurtner, 2018). He emphasized the need to recognize and record individual and institutional measures of performance; these aspects are currently perceived as a significant aspect of ensuring quality assurance in surgical practices. 

Quality Assurance in Plastic Surgery 

Quality in plastic surgery may be analyzed in various aspects: patient, efficacy, equity, efficiency, time, and safety. With regards to safety, it should be noted that treatment should be administered accurately, and be executed efficiently within the precepts based on evidence. Quality management in plastic surgery should be efficient, cost-effective, without excessive diagnosis examinations, without non-tested complications or operations that may increase hospital costs (Neligan & Gurtner, 2018). With regards to equity, surgical management ought to be offered to all patients irrespective of their gender, socioeconomic status, health insurance, ethnic groupings, and age. Surgical therapies often present effective outcomes or results when offered at the proper and right time without unnecessary delays. Quality management in surgery should be executed while focusing on an individual patient, assessing the benefits and risks of the procedure to the patient. 

Some of the precepts of total quality management in healthcare include the fact that quality assurance is often centered on the client, and the ultimate measure of success is the client's satisfaction with the service, and the involvement of all healthcare workers within the department in the quality assurance at a level that guarantees success (Meligan & Gurtner, 2018). Other principles include the fact that strategies and approaches are centered on the procedures and steps that are essential to complete a particular operation, the smooth integration of the different parts of the procedure into a cohesive procedure, the strategic organization of the procedures to attain both short-term and long-term goals, and the indispensable utilization of data and facts to make decisions and initiate change. Additionally, other quality assurance principles include the notion that the implemented strategies should be aimed at the continual improvement of procedures and services, and the use of effective communication approaches to enhance the efficient running of various medical procedures (Mathis, 2011). 

Quality assurance in plastic surgery entails various aspects: Surgical audit to gather information and assess postoperative difficulties, quality assurance through measuring the postoperative long-term outcomes among patients, elaboration of therapeutic guidelines, mensuration of benefits and costs of surgical interventions and this includes the postoperative life quality of a patient and quality assurance of medical publications and clinical trials (Neligan & Gurtner, 2018). Surgical audit relates to a systematic evaluation of the quality or standard of surgical care which is usually appraised by peers against the recognized standards or explicit criteria and later utilized to further inform and better plastic surgery practices with the ultimate objective of improving the standards of patient healthcare (Kalaskar, Butler & Ghali, 2016). The purpose of the surgical audits is to evaluate one’s knowledge in the field of practice and the efficacy of the current practice in achieving the established standards. The elements of a surgical audit include the collection and mensuration of clinical outcomes and activities, evaluation and comparison of data using outcome parameters, performance indicators, and standards, and a peer review procedure with a feedback mechanism aimed at redressing the problems. 

The primary element of a plastic surgery audit is the reviewing of the actual surgical performances, and this includes the outcomes of the performances (Kalaskar, Butler, & Ghali, 2016). The clinical evaluations by team members are then compared with the recognized standards of the performance. The aims of the audit include to identify ways of maintaining and improving the quality of care for plastic surgery patients, to aid in the consistent education of plastic surgery surgeons, and to foster the effective utilization of available resources during the provision of plastic surgery services (Neligan & Gurtner, 2018). The surgical audit cycle involves the following steps: The establishment of the audit scope, selection of standards, data collection, presentation and interpretation of results including peer reviews, and introducing the necessary changes in the practice and monitoring progress. The scope of the audit should be clearly defined to avoid the collection of inadequate or inappropriate data. Common areas in the audit’s scope include thirty-day mortality, the period of hospital stay, negative and positive outcomes, unscheduled re-operation and readmission rates, care process, for instance, pre-operative care, patient satisfaction, and operation-specific health complications (Kalaskar, Butler, Ghali, 2016). One should also decide on the standards of good practice in the field and the needed and relevant data. One may use evidence-based studies and guidelines, use the existing local guidelines, library evidence, and specialty group operations and standards. 

Clinical indicators which are often used as a measure of care outcome or clinical management should be selected. Clinical indicators ought to be relevant to the form of practice, measurable, and supported by scientific evidence. Complications should be ranked in conformity to the Clavien-Dindo form of classification; this form of classification has five primary classes (Henderson, 2012). Grade 1 ranks any deviations from the traditional postoperative course without the demand for endoscopic, radiological, or surgical interventions, pharmacological treatments, for instance, mild wound infections. Grade 2 ranks complications that require pharmacological therapies such as blood transfusion. Grade 3 ranks complications that require radiological, endoscopic, or surgical interventions. Grade 3a ranks complications that require general anesthesia, and grade 3b ranks complications that require general anesthesia. Grade 4 ranks life-threatening conditions which involve ICU management. Grade 4a ranks complications involving single organ dysfunctions. Grade 4b ranks conditions involving multi-organ dysfunctions. Lastly, grade 5 ranks conditions that result in deaths. The data collection may be ranked into three primary data sets: Extra trainee, expanded, and minimum data sets. The data collected should be assessed, verified, and validated. The implementation phase involves the execution of changes in the practice, and ensuring that every individual impacted is informed of the implemented changes. Follow-up strategies should also be performed (Neligan & Gurtner, 2018). 

Outcome research offers scientific evidence concerning the end-results of treatment which factor patients’ experience and societal impact. Outcome research aids in the delineation of the shortcomings in clinical practices and provides the rationale for the establishment of quality standard care. Healthcare practitioners may develop evidence-based treatment rationales and provide patients with detailed consent for their surgical treatment options (Klaskar, Butler, & Ghali, 2016). Additionally, insurance institutions and health care agencies can discern better cost-benefit opportunities in disease prevention strategies and the alleviation of its effects on the patient and community. Outcomes in plastic surgery procedures are ultimately evaluated through their effectiveness in the treatment of a disorder, patient satisfaction, saving lives, normalization of physical measures and laboratory results, and the minimization of symptoms. Tools utilized in the measurement of these outcomes may be categorized into four primary endpoints: Functional measures, health perception, preference-based measures, and patient satisfaction (Methis, 2011). 

Health perception is usually determined using the patient’s symptoms; it aids in the quantification of the overall health of a person and is a good predictor of mortality and the need for health care. Under this procedure, practitioners often inquire about the patient’s validated symptoms using established and published standardized questions. Average scores are then transformed linearly to a scale which ranges from 0 (more severe symptoms) to 100 (less and fewer severe symptoms) (Kalskar, Butler & Ghali, 2016). Tools used in the assessment of health perception include Symptoms Questionnaire. Functional measures are often utilized in the measurement of the overall impact of health care provided to a patient on his overall health and the effects on the patient’s specific disorder; they objectively assess a patient’s capacity to perform significant activities. Functional measures may be contrasted to those acquired after and before an intervention to evaluate the impacts of the intervention on an individual’s functional status. Functional measures incorporate inquiries on a patient’s overall health perceptions, social interactions, psychological stress, mental function, and physical function. Tools used in the assessment of functional measures include SF-36, PROMIS global, and veterans RAND-36 (Mathis, 2011). 

Preference-based measures often enhance the objective standardization of a patient’ well-being and health status. Utility scores are the approved preference-based measures which can be utilized in the study of plastic surgery outcomes. Utility evaluations are published and established recognized procedures of ascertaining health state preferences in medicine and health economics. Utility scores measures range from zero (death) to one (perfect health) (Neligan & Gurtner, 2018). Tools used in utility score measures include visual analog scale, time trade-off, and standard gamble. Studies on the outcomes of patient satisfaction attempt to objectify the subjective impressions of patients' treatment procedures or health state. These strategies may also measure patient satisfaction through health care experience, comparing outcomes to expectations, and health care providers. Tools used in the assessment of patient satisfaction include EuroQol and HR-QOL (Mathis, 2011). 

The elaboration of therapeutic guidelines may be significant in the assessment of the advantages of the interventions and for the prevention of insignificant surgical operations (Mathis, 2011). Quality clinical research performed in line with the GCP regulations with biometrical planning incorporates the delineation of the study purpose and list of exclusion and inclusion criteria which are the prerequisites of detailed therapeutic guidelines (Kalaskar, Butler, & Ghali, 2016). With regards to clinical trials and publications, quality assurance incorporates a variety of tasks, for instance, the validation of the eligibility of a patient to enter the trial, reassurance that all toxicity measures and tests are performed at the period stipulated in the protocol, verification that the information entered into CRFs (Case Report Forms) are precise and have been incorporated in the trial database efficiently, and the reassurance that the research procedure was executed according to the trial approach. The significance of a quality assurance program in clinical trials is to minimize the likelihood of systematic discrepancies in the management of treatment procedures amid participating organizations (Neligan & Gurtner, 2018). The quality assurance program in clinical trials ought to incorporate procedures that can be readily executed, enhance the identification and the quantification of variations in relevant parameters, foster the detection and efficacy of significant variations, and demonstrate an impact on the sequel of the trial. Under the ever-increasing economic pressures, the costs and benefits of treatment are of significant importance. One may evaluate the effectiveness of the cost ratio by assessing the cost per quality against lives saved (yearly); this is deemed crucial for ensuing therapeutic recommendations. 

Quality Control in Plastic Surgery 

Quality control is a set of processes aimed at ensuring that the healthcare services provided conform to the delineated set of quality criteria or addressed the needs of the client (Henderson, 2012). The primary goals of quality control in plastic surgery include to better the quality of service provided, to enhance one’s knowledge, and schedule procedures effectively to control or avoid non-compliances and possible errors, and to distinguish non-compliance practices, to evaluate the underlying reasons, to reduce relevant costs, and probable damages (Kalaskar, Butler, & Ghali, 2016). Other goals include to ensure compliance with operational and professional requirements, to ameliorate the propriety requirements systems, to consider patients’ claims, rights, and opinions, and to provide an environment that supports effective and secure work. Quality control in plastic surgery procedures depends on the health system, hospital unit, and surgical team. The plastic surgery department ought to delineate the specific standards of their surgical services and later determine the extent of quality control operations as a strategy for implementing an efficient quality control program. The collection of data, for instance, the percentage of failed plastic surgery operations then follows swiftly. A report incorporating the results of the collected outcomes should then be presented to the management team. Corrective approaches should then be decided upon and implemented, for instance, the implementation of changes with regards to the defective units. Quality control procedures should be a continuous process that ensures that remedial approaches have generated satisfactory outcomes and to discern the recurrences or existence of new issues. Some of the proposed principles of quality control in plastic surgery include the need for hospitals to be updated on the ultimate plastic surgery outcomes in the performed operations, the need for hospitals to distinguish their weak and strong points in various plastic surgery procedures, and the need for hospitals to compare their plastic surgery outcomes with the outcomes from other hospitals (Neligan & Gurther, 2018). Other precepts include the fact that hospitals ought to describe their successes and failures in various plastic surgery procedures and the need for institutions with satisfactory plastic surgery outcomes to implement better payment for their surgical services. 

Advantages of Quality Assurance and Quality Control 

Quality assurance and control programs in plastic surgery are deemed crucial by healthcare providers, for instance, hospitals, doctors, and patients for various reasons. In plastic surgery procedures, quality assurance and control enhances the significant reduction of costs in various surgical operations (Kalsakar, Butler & Ghali, 2016). The application of QA in various surgical operations through time enhances the significant reduction of costs in the organization, particularly in fields such as field operations, and rework. The reduction of costs often flows through to the institution’s bottom-line profits, thereby, reducing the probabilities of incurring additional costs and this, in turn, enhances profitability. Secondly, QA/QC enhances significant increases in the rates of client satisfaction primarily due to the capacity of the organization to offer improved healthcare services, free of errors (Maeligan & Gurtner, 2018). The provision of quality services often fosters a significant reduction in customer complaints and increases in client satisfaction which subsequently leads to significant increases in market share. Patients ought to be reassured about the efficacy of the procedure of surgical treatment to which they have consented to before the execution of the process; they need the assurance that the surgical treatment procedure will be administered effectively and that the outcome of the treatment procedure is acceptable or acknowledged by the international standards. Hospitals and plastic surgeons should, therefore, present the patient with data concerning the aftermath of the surgical treatment procedure which is often based on the risk-adjusted for case-mix and verifiable data. Quality assurance and control procedures are significant for plastic surgeons worldwide. 

Thirdly, quality assurance and control enhances significant reduction in the prevalence of defects thereby, ensuring improved quality performance in every field of activity (Henderson, 2012). Quality assurance often emphasizes the need for improving service quality within a procedure as opposed to analyzing the quality of a process; this subsequently leads to the reduction of time required to fix errors. Lastly, quality assurance and control enhances the continuous review of various healthcare procedures (Nleigan & Gurtner, 2018). Quality assurance plays a significant role in enhancing the evaluation of procedures required to establish the strategy or approach of never-ending improvement. The strategies of quality improvement ought to be undertaken consistently to address the dynamic challenges and advances effectively. Advancements in risk stratification during quality assurance allows plastic surgeons to contrast their case-loads and their respective outcomes or sequels with other healthcare practitioners in the area of specialty both internationally and locally and ensure that the surgical department within their organizations is enhancing their capacity to perform their duties or operations in an appropriate and standard level. The hospital management should analyze surgeons’ group and individual surgical outcomes to ensure that their overall organizational procedures meet the recognized standards. 

Conclusion 

Plastic surgery is a branch of surgery which incorporates the alteration, reconstruction, or restoration of the different parts of the human body. Plastic surgery may be categorized into two primary divisions: aesthetic or cosmetic surgery and reconstructive surgery. Quality assurance procedures typically involve the collection of data and the analysis of outcomes. Additionally, it incorporates the assessment of the results of the patient and the organizational procedures, the efficacy of care, and healthcare provider and patient satisfaction. Quality assurance in plastic surgery entails various aspects: Surgical audit, the measurement the postoperative long-term outcomes among patients, elaboration of therapeutic guidelines, mensuration of benefits and costs of surgical interventions, and quality assurance of medical publications and clinical trials. Quality control is a set of processes aimed at ensuring that the healthcare services provided conform to the delineated set of quality criteria or addressed the needs of the client. 

References 

Henderson J. (2012 ). Issues in Aesthetic, Craniofacial, Maxillofacial, Oral, and Plastic Surgery . Atlanta; Georgia: Scholarly Editions. 

Kalaskar, D., Butler, P. E., & Ghali, S. (2016). Textbook of plastic & reconstructive surgery . London: UCL Press. 

Mathis, D. H. (2011). Plastic and Reconstructive Surgery: An Issue of Perioperative Nursing Clinics . London; New York: Elsevier Saunders. 

Neligan, P., & Gurtner, G. (2018). Plastic surgery: Volume one . London; New York: Elsevier Saunders.