A Method for Continuous Surgeon Improvement in Rectal Cancer: Risk-adjusted Cumulative Sum

To develop and analyze a risk-adjusted cumulative sum (RA-CUSUM) chart as a potential method to monitor individual surgeon performance in robotic total mesorectal excision (TME) for rectal cancer.

Currently, surgeons lack real-time tools to monitor and enhance their performance beyond residency completion. While national quality programs exist, granular, individual-level data are crucial for continuous improvement. Previous studies suggest cumulative sum charts hold promise in identifying performance trends and outliers.

This retrospective study analyzed data from 640 robotic TME cases performed by 12 surgeons at 2 institutions. RA-CUSUM charts were generated for 3 outcomes: (1) complications, (2) operative time, and (3) length of stay.

The overall RA-CUSUM curves for operative time and complications showed an initial learning phase, followed by a plateau or downward slope, indicating proficiency or improvement. However, individual surgeon curves revealed significant heterogeneity. Three surgeons consistently excelled in operative time, while 5 minimized complications most effectively. Potential quality improvement could be implemented to drive performance toward positive outliers. No differences were found in unadjusted outcomes, including conversion, number of lymph nodes harvested, and positive circumferential margins.

The RA-CUSUM chart is a promising method for identifying individual surgeon performance in robotic TME. It could help surgeons, teams, and leaders identify improvement areas and benchmark themselves against positive outliers. Further studies are needed to explore the potential of RA-CUSUM for implementing interventions to improve surgical quality.