Implementation of a Synoptic Operative Report for Rectal Cancer: A Mixed-Methods Study

Area of Science:

• Surgical Oncology
• Health Informatics
• Quality Improvement

Background:

• The National Accreditation Program for Rectal Cancer aims to enhance care quality through standardized multidisciplinary approaches.
• Synoptic reporting in radiology, pathology, and operative procedures is key to this initiative.

Purpose of the Study:

• To evaluate the implementation and utilization of a synoptic operative report for rectal cancer surgery.
• To assess changes in documentation fidelity and surgeon perceptions.

Main Methods:

• A convergent mixed-methods study involving electronic medical record data, surveys, and qualitative interviews.
• Involved colorectal surgeons from US medical centers using synoptic operative reports.

Main Results:

• Fidelity of documenting 19 critical items increased from <50% to ≥89% post-implementation.
• Surgeons expressed mixed reactions, citing concerns about added burden but also recognizing potential for improved quality and research data.

Conclusions:

• Synoptic operative reports substantially improve rectal cancer surgery documentation.
• Further refinement is needed to address workflow concerns and optimize the report for broader adoption and enhanced quality of care.