New study findings show the vast majority of small-scale quality improvement (QI) projects in surgery suffer from poor planning that can doom the effort from the start. To address this challenge, researchers have developed and tested a new tool, the Early Planning of Small-Scale Surgical Improvement (EPoSSI) framework, to guide surgeons and their teams through a comprehensive planning process.
The findings are published in the Journal of the American College of Surgeons.
The development of the EPoSSI framework was motivated by a previous evaluation of 50 surgical QI projects, which found that only one met more than 70% of the criteria for a well-conducted effort. A separate review of 242 projects found major deficits in the essential “front-end” planning phase. Earnest health care providers undertake scores of QI projects annually to improve patient care, often focusing on efforts to reduce mortality or days in the hospital, for example.
“Many teams enter QI projects with the best intentions, but the evidence shows that, unfortunately, our improvement efforts need improving,” said lead author Clifford Y. Ko, MD, MS, MSHS, FACS, Senior Vice President of the ACS Division of Research and Optimal Patient Care. “EPoSSI is designed to provide that critical support for frontline clinicians to get the planning stage right for their quality improvement project and set it up to achieve its goal.”
Key findings
- Significant planning gap: When asked to plan a QI project based on a clinical vignette without any guidance, participants’ plans met an average of just 6.3 out of 26 criteria (24%).
- Major improvement with EPoSSI: When using the full EPoSSI framework (a nine-step diagram plus a detailed guidance table), participants’ plans met all 26 criteria (100%), a statistically significant improvement.
- Universal benefit: The framework was effective for both attending/consultant surgeons and resident surgeons, as well as for individuals working alone or in teams.
The EPoSSI framework was developed through a rigorous, five-phase process that included a literature review of nearly 400 existing frameworks, a sorting exercise with clinicians, and a four-round modified Delphi consensus process involving over 133 frontline clinicians and improvement experts. The final tool consists of nine action-oriented steps: seven for planning, one for a “go/no-go” decision, and one for transitioning to project delivery.
“In sectors like construction, projects with the best front-end planning have 20% lower costs and deliver 10-15% faster,” said Dr. Ko. “If improvement efforts in surgery are to succeed, recognition of the importance of the front-end of QI projects is key. EPoSSI helps teams visualize the process they need to go through in a systematic and low-burden way.”
The nine steps of the EPoSSI framework:
- Assemble the improvement team
- Detail the problem
- Define project aims
- Identify an intervention
- Implement the plan
- Plan in-project monitoring
- Plan end-of-project decisions
- Make a go/no-go decision
- Plan the transition to project delivery
The framework is designed to be agnostic to a specific improvement methodology (e.g., Lean, Six Sigma, Model for Improvement) and functions as a “read-do” checklist to prevent critical omissions in planning. The EPoSSI framework is available for use on the ACS website.
Co-authors are Alessandra Giusti; Graham Martin; and Mary Dixon-Woods, of THIS Institute at the University of Cambridge, United Kingdom.
More information:
Clifford Y Ko et al, Development and Testing of a Framework to Support the Planning of Small-scale Improvement Projects in Surgery: A Multi-Stage Process including a Modified Delphi Exercise, Journal of the American College of Surgeons (2025). DOI: 10.1097/xcs.0000000000001656
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