Annals of Surgical Oncology

, Volume 18, Issue 3, pp 629–635 | Cite as

A Qualitative Assessment of a Provincial Quality Improvement Strategy for Pancreatic Cancer Surgery

  • Frances C. Wright
  • Margaret Fitch
  • Angela J. Coates
  • Marko Simunovic
Pancreatic Tumors



A study released in Ontario, Canada (1999) found a positive relationship between surgical volume and patient outcomes after pancreatic resection for cancer. In response, a province-level quality improvement (QI) strategy was initiated, which included the development and dissemination of a standards document and an audit and feedback exercise with surgeons. We assessed perceptions and actions of Ontario surgeons to this QI strategy.


We conducted semistructured interviews with surgeons and chiefs of surgery at three types of hospitals providing pancreatic cancer surgery, including hospitals that provided high volumes of surgery after 2001, hospitals that provided low volumes of surgery after 2001, and hospitals that provided low volumes of surgery before 2001 and stopped after year 2001. High-volume hospitals performed ten or more surgeries annually. The interview guide was based on Pathman’s model of physician practice change (i.e., awareness, agreement, adoption, and adherence). Grounded theory guided data collection and analysis.


Twenty-four interviews were completed. All groups were aware of the 1999 province-level QI strategy and agreed in principle with the standards document recommendations. Many surgeons had concerns regarding the number of cases necessary to be considered high-volume. Decisions to cease pancreas cancer surgery were occurring before 1999 and made at the surgeon level, often with input from the chief of surgery, but rarely with input from hospital administration.


Surgeons were aware of and agreed in principle with the province-level QI strategy for pancreas cancer surgery. Decisions to continue or cease performing surgery were made by individual surgeons.


Pancreas Cancer Standard Document Semistructured Interview Quality Improvement Strategy Hospital Administrative Data 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


Funding Support

Funding for this project was provided by the Canadian Cancer Society


  1. 1.
    Simunovic M, To T, Theriault T, Langer B. Relation between hospital surgical volume and outcome for pancreatic resection for neoplasm in a publicly funded health care system. CMAJ. 1999;160(5):643–8.PubMedGoogle Scholar
  2. 2.
    Bachmann MO, Alderson D, Peters TJ, Bedford C, Edwards D, Wotton S, Harvey IM. Influence of specialization on the management and outcome of patients with pancreatic cancer. Br J Surg. 2003;90(2):171–7.PubMedCrossRefGoogle Scholar
  3. 3.
    Sosa JA, Bowman HM, Gordon TA, et al. Importance of hospital volume in the overall management of pancreatic cancer. Ann Surg. 1998;228:429–38.PubMedCrossRefGoogle Scholar
  4. 4.
    Simunovic M, Urbach D, Major D, et al. Assessing the volume outcome hypothesis: a natural experiment involving pancreas cancer surgery in two Canadian provinces. Ann Surg Oncol. (in press).Google Scholar
  5. 5.
    Pathman DE, Konrad TR, Freed GL, Freeman VA, Koch GG. The awareness-to-adherence model of the steps to clinical guideline compliance: the case of pediatric vaccine recommendations. Med Care. 1996;34(9):873–89.PubMedCrossRefGoogle Scholar
  6. 6.
    Hutchison SA. Grounded theory: the method. In: Munhall PL, Oiler C, editors. Nursing research: a qualitative perspective. Norwalk, CT: Appleton-Century-Crofts; 1986. p. 111–30.Google Scholar
  7. 7.
    Pope C, Ziebland S, Mays N. Analyzing qualitative data. BMJ. 2000;320(7227):114–6.PubMedCrossRefGoogle Scholar
  8. 8.
    Auerbach CF, Silverstein LB. Qualitative data: an introduction to coding and analysis. New York: New York University Press; 2003.Google Scholar
  9. 9.
    Grol R, Grimshaw J. From best evidence to best practice: effective implementation of change in patients’ care. Lancet. 2003;262:1225–30.CrossRefGoogle Scholar
  10. 10.
    Grol R, Dalhuijsen J, Thomas S, Veld C, Rutten G, Mokkink H. Attributes of clinical guidelines that influence use of guidelines in general practice: observational study. BMJ. 1998;317(7162):858–61.PubMedGoogle Scholar
  11. 11.
    Foy R, MacLennan G, Grimshaw J, Penney G, Campbell M, Grol R. Attributes of clinical recommendations that influence change in practice following audit and feedback. J Clin Epidemiol. 2002;55:717–22.PubMedCrossRefGoogle Scholar
  12. 12.
    Stitzenberg KB, Sheldon GF. Progressive specialization within general surgery: adding to the complexity of workforce planning. JACS. 2005;201(6):925–32.Google Scholar
  13. 13.
    Fischer JE. The impending disappearance of the general surgeon. JAMA. 2007;298(18):2191–3.PubMedCrossRefGoogle Scholar
  14. 14.
    Berwick DM, Godfrey AB, Roessner J. 10 key lessons for quality improvement. In: Berwick DM, Godfrey AB, Roessner J, (eds) Curing health care: new strategies for quality improvement. San Francisco: Jossey-Bass; 2002. p. 144–58.Google Scholar
  15. 15.
    West E, Barron DN, Dowsett J, Newton JN. Hierarchies and cliques in the social networks of health care professionals: Implications for the design of dissemination strategies. Soc Sci Med. 1999;48(5):633–46.PubMedCrossRefGoogle Scholar
  16. 16.
    Jamtvedt G, Young JM, Kristoffersen DT, et al. Audit and feedback: effects on professional practice and health care outcomes. Cochrane Database Syst Rev. doi: 10/1002/14651858. CD000259.pub2 [Online June 21, 2009].
  17. 17.
    van Heek NT, Kuhlmann KFD, Scholten RJ, et al. Hospital volume and mortality after pancreatic resection: a systematic review and an evaluation of intervention in The Netherlands. Ann Surg. 2005;242(6):781–90.PubMedCrossRefGoogle Scholar
  18. 18.
    Turaga K, Kaushik M, Forse RA, Sasson AR. In hospital outcomes after pancreatectomies: an analysis of national database from 1996 to 2004. J Surg Oncol. 2008;98:156–60.PubMedCrossRefGoogle Scholar
  19. 19.
    Kahn JM, Asch RJ, Iwashyna TJ, Rubenfeld GD, Angus DC, Asch DA. Perceived barriers to the regionalization of adult critical care in the United States: a qualitative preliminary study. BMC Health Serv Res. 2008;8:239.PubMedCrossRefGoogle Scholar

Copyright information

© Society of Surgical Oncology 2010

Authors and Affiliations

  • Frances C. Wright
    • 1
  • Margaret Fitch
    • 2
  • Angela J. Coates
    • 3
  • Marko Simunovic
    • 3
    • 4
  1. 1.Division of General SurgerySunnybrook Health Sciences CentreTorontoCanada
  2. 2.Sunnybrook Research Institute, Sunnybrook Health Sciences CentreTorontoCanada
  3. 3.Department of SurgeryMcMaster UniversityHamiltonCanada
  4. 4.Department of Surgical OncologyJuravinski Cancer Centre, Hamilton Health SciencesHamiltonCanada

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