Systematic review of the application of quality improvement methodologies from the manufacturing industry to surgical healthcare

Br J Surg. 2012 Mar;99(3):324-35. doi: 10.1002/bjs.7803. Epub 2011 Nov 18.


Background: The demand for the highest-quality patient care coupled with pressure on funding has led to the increasing use of quality improvement (QI) methodologies from the manufacturing industry. The aim of this systematic review was to identify and evaluate the application and effectiveness of these QI methodologies to the field of surgery.

Methods: MEDLINE, the Cochrane Database, Allied and Complementary Medicine Database, British Nursing Index, Cumulative Index to Nursing and Allied Health Literature, Embase, Health Business(™) Elite, the Health Management Information Consortium and PsycINFO(®) were searched according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Empirical studies were included that implemented a described QI methodology to surgical care and analysed a named outcome statistically.

Results: Some 34 of 1595 articles identified met the inclusion criteria after consensus from two independent investigators. Nine studies described continuous quality improvement (CQI), five Six Sigma, five total quality management (TQM), five plan-do-study-act (PDSA) or plan-do-check-act (PDCA) cycles, five statistical process control (SPC) or statistical quality control (SQC), four Lean and one Lean Six Sigma; 20 of the studies were undertaken in the USA. The most common aims were to reduce complications or improve outcomes (11), to reduce infection (7), and to reduce theatre delays (7). There was one randomized controlled trial.

Conclusion: QI methodologies from industry can have significant effects on improving surgical care, from reducing infection rates to increasing operating room efficiency. The evidence is generally of suboptimal quality, and rigorous randomized multicentre studies are needed to bring evidence-based management into the same league as evidence-based medicine.

Publication types

  • Evaluation Study
  • Review
  • Systematic Review

MeSH terms

  • Anti-Bacterial Agents / therapeutic use
  • Costs and Cost Analysis
  • Humans
  • Infection Control / standards
  • Length of Stay
  • Pain, Postoperative / prevention & control
  • Postoperative Complications / prevention & control
  • Quality Control
  • Quality Improvement / organization & administration*
  • Quality of Health Care / organization & administration*
  • Quality of Health Care / standards
  • Selection Bias
  • Surgical Procedures, Operative / standards*
  • Waiting Lists


  • Anti-Bacterial Agents