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GENERAL

Design of a Consensus-Derived Synoptic OperativeReport for Lung Cancer SurgeryLaura Schneider, BS, Yaron Shargall, MD, Colin Schieman, MD,Andrew J. Seely, MD, PhD, Sadeesh Srinathan, MD, MS, Richard A. Malthaner, MD, MS,Andrew F. Pierre, MD, MS, Najib Safieddine, MD, Rosaire Vaillancourt, MD,Madelaine Plourde, MD, James Bond, MD, Scott Johnson, MD, MS, Shona E. Smith, MD,and Christian J. Finley, MD, MPHDepartment of Surgery, McMaster University, St. Joseph’s Healthcare Hamilton, Hamilton, Ontario; Department of Surgery, Universityof Ottawa, Ottawa Hospital General Campus, Ottawa, Ontario; Department of Surgery, University of Manitoba, Health Sciences Centre,Winnipeg, Manitoba; Departments of Surgery and Epidemiology and Biostatistics, University of Western Ontario, London HealthSciences Centre, London, Ontario; Department of Surgery, University of Toronto, Toronto General Hospital, Toronto, Ontario;Department of Surgery, Toronto East General Hospital, Toronto, Ontario; Department of Surgery, University of Laval, Quebec Heartand Lung Institute, Qu�ebec, Quebec; Department of Surgery, Dalhousie University, Queen Elizabeth II Health Sciences Centre, Halifax,Nova Scotia; Department of Surgery, University of British Columbia, Surrey Memorial Hospital, Surrey, British Columbia; Departmentof Surgery, University of Alberta, Royal Alexandra Hospital, Edmonton, Alberta; and Department of Surgery, Northern Ontario Schoolof Medicine, Sudbury, Ontario, Canada

Background. For lung cancer surgery, a narrativeoperative report is the standard reporting procedure,whereas a synoptic-style report is increasingly utilized byhealthcare professionals in various specialties with greatsuccess. A synoptic operative report more succinctly andaccurately captures vital information and is rapidlygenerated with good intraobserver reliability. Theobjective of this study was to systematically develop asynoptic operative report for lung cancer surgeryfollowing a modified Delphi consensus model with thesupport of the Canadian thoracic surgery community.

Methods. Using online survey software, thoracic sur-geons and related physicians were asked to suggest andrate data elements for a synoptic report following themodified Delphi consensus model. The consensusexercise-derived template was forwarded to a smallworking group, who further refined the definition andpriority designation of elements until the working grouphad reached a satisfactory consensus.

Accepted for publication Dec 18, 2013.

Address correspondence to Dr Finley, St. Joseph’s Healthcare Hamilton,50 Charlton Ave E, Juravinski Tower T-2105B, Hamilton, ON L8N 4A6,Canada; e-mail: finleyc@mcmaster.ca.

� 2014 by The Society of Thoracic SurgeonsPublished by Elsevier Inc

Results. In all, 139 physicians were invited toparticipate in the consensus exercise, with 36.7%, 44.6%,and 19.5% response rates, respectively, in the threerounds. Eighty-nine elements were agreed upon at theconclusion of the exercise, but 141 elements were for-warded to the working group. The working groupagreed upon a final data set of 180 independentlydefined data elements, with 72 mandatory and 108optional elements for implementation in the finalreport.Conclusions. This study demonstrates the process

involved in developing a multidisciplinary, consensus-based synoptic lung cancer operative report. This novelreport style is a quality improvement initiative toimprove the capture, dissemination, readability, andpotential utility of critical surgical information.

(Ann Thorac Surg 2014;97:1163–8)� 2014 by The Society of Thoracic Surgeons

perative reporting is a necessary task after the

Ocompletion of any surgical procedure. In lung can-cer surgery, the primary purpose of the operative reportis to document and communicate information to othersurgeons, physicians, and healthcare providers to ensurecritical information is captured, findings are communi-cated, and care is well coordinated.

Lung cancer represents a tremendous burden of dis-ease on Canadian and international healthcare systems.In Canada and the United States, lung cancer is theleading cause of cancer-related death, more than the

combined annual totals of breast, colorectal, ovarian,liver, and prostate cancers [1]. Good communication be-tween healthcare practitioners is vital to the quality ofcare received by patients and as such, a recent focus onimproving the quality of communication has occurred.The current standard practice for thoracic surgical

reporting is to prepare a narrative operative report. Thisreport is used to understand a patient’s operative proce-dure and to guide their subsequent treatment. This doc-ument’s ability to reliably convey the fundamentalelements of the procedure are central in future treatments

The Appendices can be viewed in the online version ofthis article [http://dx.doi.org/10.1016/j.athoracsur.2013.12.042] on http://www.annalsthoracicsurgery.org.

0003-4975/$36.00http://dx.doi.org/10.1016/j.athoracsur.2013.12.042

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and in establishing the patient’s prognosis. However, theability to succinctly, accurately and reliably capture thisinformation varies widely [2]. Failure to adequatelyconvey the information critical to the prognosis andmanagement of this malignancy results in needlessincreased resource utilization and difficulty in treatmentdecisions [2].

Electronic synoptic reporting captures standardizedinformation at the point of care, and allows the informa-tion to be quickly transmitted to other members ofhealthcare teams. Starting in 2011, a Canadian Partner-ship Against Cancer pilot project tested an electronicsynoptic reporting system for breast, colorectal, ovarian,and head/neck surgeries. The study demonstratedimproved efficiency using synoptic reports rather thanthe currently used narrative reports. The report alsonoted an overall positive experience by surgeons, andthat reports were deemed to be more comprehensivethan narrative versions [3, 4]. Electronic synoptic reportscan also provide secondary gains through structured datafor streaming into databases available for policy makers,researchers, and clinicians in ways that narrative reportentries cannot, resulting in improved efficiencies forhealthcare organizations such as hospitals or cancerregistries [4]. A synoptic report also allows for the abilityto collect standardized data needed for multisite research,further broadening the utility and use of the data [3].Further additions can be made to templates to ensure thatthey include information to allow surgeons to assessadherence to clinical evidence, best practice, and safetyprocedures, actions that can benefit patients by promot-ing safer surgical care and more effective treatment.

Demonstrating the potential of synoptic reports, asynoptic pathology report is actively used across Canada,based on the American Pathologists Cancer Checklists,with good adoption and results [5]. Synoptic pathologyreporting showed great improvements in the quality andcompleteness of reporting. It also provides both commondata fields and elements that offer the ability to comparebetween institutions, facilitating more accurate researchactivities [6]. Synoptic pathology reporting has beenrecognized as an important quality improvement initia-tive and has subsequently gained widespread adoptionwith improvements in report clarity and consistency.

In short, we believe that synoptic operative reportingallows for rapid, complete, reproducible, and concisedocumentation of surgical findings [7], allows for the ac-curate collection and comparison of data affecting patientoutcomes [8], and improves patient safety by reducingcommunication errors [7]. They are rapidly generated andshow good intraobserver reliability [9, 10]. With thesegoals in mind, we created a national consensus-basedsynoptic operative report for lung cancer surgery.

Material and Methods

The creation of the base dataset of the synoptic operativereport for lung cancer surgery utilized an anonymousmodified Delphi method [11, 12] using three iterativerounds. This process was completed electronically using

an electronic survey tool (LimeSurvey) with two remindere-mails per iteration. This project was reviewed by theSt. Joseph’s Healthcare Research Ethics Board, andinformed consent was waived owing to implied consenton account of the study activities.In the initial round, a survey was provided to all

members of the Canadian Association of Thoracic Sur-geons (CATS) and opinion leaders in family medicine,pathology, diagnostic imaging, medical oncology, andradiation oncology requesting key items considered to beimportant in a lung cancer operative report. The firstround was an open-ended questionnaire asking partici-pants to list all parameters within a provided list ofheadings that they believe would be necessary to a lungcancer operative report. A priori, we intended to makethe lung cancer synoptic report compatible with The So-ciety of Thoracic Surgeons (STS) database; therefore,procedures were provided based on those listed in theSTS database [13] with the stipulation that some may beadded. A number of feasibility and uptake questions werealso asked of participants to gauge the utility of the effort.A further round was used to rate and evaluate the

generated information, allowing CATS members to rateeach variable on a 9-point Likert scale [12] and commentwith free text available if necessary. Consensus wasdefined as a mean score of 6.3 or greater (70th percentile)as significant for inclusion of an individual variable and amean score of 2.7 (30th percentile) or less signalingexclusion from the final data set. The third round wastriggered by an a priori protocol indicating that if 70% ormore of all variables reached consensus after the first tworounds, the process would be complete; otherwise, a thirdround was to be included [11, 12], with all results from therounds being forwarded to a small working group. Alldata elements with indeterminate responses that fellwithin the 30th and 70th percentiles were circulated toparticipants through online questionnaires for the thirdround. The same consensus definition was used from thesecond round. After each round, a deidentified summarywas provided to the group outlining the median andfrequency distribution on the Likert scale and qualitativecomments [11, 12]. Figure 1 summarizes the process un-dertaken to conceptualize and produce the resulting finaltemplate. The final, consensus-based dataset wascompleted and forwarded to the aforementioned smallworking group to form the data elements into a workablesynoptic operative report template.The development of the synoptic report template was

coordinated with representatives of the Canadian Part-nership Against Cancer. Following procedures completedfor other cancer disease sites, the results from Delphiconsensus work were refined by a working groupcomposed of national representatives in Canadianthoracic surgery. In the interest of promoting standardi-zation between disease sites, the elements confirmedthrough the Delphi consensus exercise were workedinto a generic template pioneered by the Canadian Part-nership Against Cancer using standardized headings.During four working group teleconferences, the groupwas tasked with making the final designations for the

Fig 1. Graphical representation of development process of synopticoperative report for lung cancer surgery.

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inclusion and exclusion of elements, definitions of eachincluded element to assure a standardized lexicon, valuetype of expected responses in the final operative report,and determination of whether an element is to be amandatory or an optional field in the report interface.

A fundamental goal of this project was to have auseable document with a finite core of mandatory ele-ments with end-user selection flexibility of optional ele-ments. We defined “mandatory” to the group as elementsof an operative report for lung cancer where an absencein the dictation would not meet the standard of care.“Optional” elements were those that participantsbelieved fell within the spectrum of care but did not meetthe threshold for mandatory.

Each facet as defined above reached consensus by a ma-jority (50%þ1) of participants.At the conclusionof activities,the working group had a final template of elements, defi-nitions, anddefined responses, to be formed into a tablet- orcomputer-ready interface and validation testing.

Results

A total of three rounds was completed in the initialconsensus-building phase of the project. Onehundred andthirty-nine physicians were contacted to participate in theconsensus exercise, of which 68.6% were completed bythoracic surgeons and the remainder completed byrespirologists, medical oncologists, radiation oncologists,and family medicine. The highest response rate was inround 2, with 44.6% (n ¼ 62) of invited respondentscompleting the questionnaire. Response rate in round 1was 36.7% (n ¼ 51), and in round 3 it was 19.5% (n ¼ 27).Following the a priori defined trigger for round three,consensus was only reached in 84 of a total 138 indepen-dent elements in round 2, or 60.87% overall agreement. Inall three rounds, elementswere categorized into one of fivegeneral categories including demographic and nondemo-graphic elements. Figure 2 describes the consensus activ-ities, by category at each round. All elements that did notreach consensus at the end of the third round were for-warded to the working group in the second phase ofoperative report development. A total of 89 confirmed el-ements and an additional 52 indeterminate ones wereworked into 12 different heading categories, as listed inTable 1.The working group consisted of 11 thoracic surgeons

representing six provinces. The group met three times byconference call and once in person at the Canadian As-sociation of Thoracic Surgeons Annual Meeting in Cal-gary, Alberta, Canada. Figure 1 summarized the maingoals of each of the meetings. At each meeting, the dataelement definition, response values, and response stylewas refined to be more precise and utilize universallyagreed upon language. An effort was made to designateall element responses to be categorical or dichotomous tominimize the variability of free text, although therequirement for free text in certain instances wasacknowledged and integrated. Although the objective ofthe second meeting was to assess the mandatory andoptional elements, the differentiation between elementsvital to an operative report and those that are lessessential occurred at every meeting, as demonstrated inTable 1. Over the course of discussion, a number of ele-ments were removed, added, or given a separate elementcategory to refine the clarity of the dataset. At theconclusion of the meetings, the final data set included 180independent data elements, with 72 mandatory and 108optional elements with a nationally agreed upon defini-tion, response type, and options for each element. Thecomplete dataset (Appendix 1) and synoptic reportinterface output (Appendix 2) can be accessed from theelectronic version of this article.

Comment

Accurate and timely communication of information toothers caring for the patient is likely important to reducethe number of adverse clinical events and to improveoutcomes [14–19]. The operative report is a fundamentalinstrument in communicating the conduct and obser-vations from a procedure. Ongoing efforts to reduce

Fig 2. Summary of consensus activity results to build initial synoptic operative report template for lung cancer surgeries.

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communication-based medical errors include simplifyingcommunication through the use of standardized in-struments by enhancing teamwork and reducing patientrisks [20–25]. A successful example of this concept is thedevelopment of a safety checklist for surgery [26–28],which has improved safety for patients internationally invarious surgical disciplines [29–34]. The standardizedsynoptic operative report developed through this iterativeprocess should be able to meet the same objectives as itwill produce standardized, structured data that is easy toaccess, complete and reliable for clinicians, policymakers, and researchers, and in ways that narrativereport entries cannot. This novel report is also designedto dovetail with current efforts to create standardizedCanadian surgical quality indicators, which have all beenintegrated into the mandatory elements of the report.This will allow for accurate assessment of qualityimprovement programs and associated improvements inthe quality of care patients receive once validation andreliability studies are completed.

In the last decade, a number of initiatives haveattempted to address the issue of cancer surgical qualityin an attempt to optimize patient outcomes, particularlysurvival. A central focus on establishing lung cancer bestpractice recommendations has led to attempts to institu-tionalize gold-standard care. Working groups in Europe[34], the United States [35], and Canada (Ontario) [36–38]have reviewed the literature and have subsequentlypublished evidence-based guidelines for treating non-small cell lung cancer that are associated with improvedpatient outcomes. To measure the success by which theseguidelines are being followed, government groups suchas Cancer Care Ontario’s Cancer System Quality Indexhave mandatory data submission for each cancer disease

site. These submitted data are matched up against thepublished guidelines to gauge and communicate thesuccess of quality improvement initiatives [5]. The pur-pose of quality improvement initiatives is to improvethe quality of care which patients receive and qualityimprovement programs require an accurate and valid toolto assess initiative success [5]. The reality is that despitethe development of these evidence-based guidelines, veryfew of the benchmarks are being met to the detriment ofthe care received by patients [25]. While this could be theresult of many factors, it is possible incomplete operativereports are contributing to inadequate information uponwhich surgical initiatives are inherently reliant. Whetherthis is indeed the case has not been studied to ourknowledge. Interdisciplinary care teams are becoming thenorm in today’s healthcare, and are included in qualityimprovement guidelines, particularly for complex casessuch as in oncology [36–38], so the need for effectivecommunication is central to improving patient care.Fundamental to this project is adoption and utilization

among practitioners at both academic and nonacademicinstitutions. We have gone to great lengths to facilitatethis. The document will only be a benefit to patient care ifit is a usable document with stakeholder buy-in. Part ofthis process has involved the solicitation of feedback andinvolvement of the greater community of practice in thedevelopment of the report. By selecting mandatory ele-ments that meet medicolegal and quality improvementindicators, the key areas of standardization are capturedwhile allowing the flexibility to ensure the report can beintegrated into existing institutional requirements orpreferences, increasing the likelihood of uptake.The community of practice noted the necessity of

timeliness and the importance of quality interfaces in an

Table 1. Tabular Representation of Mandatory and Optional Element Progression Through Small Working Group MeetingConsensus

Initial Dataset Meeting 1 Meeting 2 Meeting 3 Meeting 4 Final Dataset

1. Template administration 3 Mandatory 3 Mandatory 3 Mandatory 3 Mandatory 3 Mandatory 3 Mandatory2. Patient information 9 Mandatory

6 Optional9 Mandatory7 Optional

9 Mandatory7 Optional

8 Mandatory7 Optional

8 Mandatory7 Optional

8 Mandatory7 Optional

3. Provider details 10 Mandatory11 Optional

6 Mandatory5 Optional

6 Mandatory5 Optional

4 Mandatory7 Optional

4 Mandatory7 Optional

4 Mandatory7 Optional

4. Facility details 2 Mandatory1 Optional

2 Mandatory 2 Mandatory 2 Mandatory 2 Mandatory 2 Mandatory

5. Procedure 5 Mandatory4 Optional

6 Mandatory3 Optional

4 Mandatory5 Optional

5 Mandatory2 Optional

4 Mandatory3 Optional

4 Mandatory3 Optional

6. Previous related surgery 1 Mandatory 4 Mandatory 4 Optional 1 Optional 1 Optional 1 Optional7. Clinical findings 17 Mandatory

10 Optional13 Mandatory17 Optional

30 Optional 1 Mandatory14 Optional

28 Optional 28 Optional

8. Diagnostic interventions 6 Mandatory 6 Mandatory5 Optional

11 Optional 2 Optional 3 Optional 3 Optional

9. Comorbidity 1 Mandatory1 Optional

1 Mandatory1 Optional

2 Optional 2 Optional 2 Optional 2 Optional

10. Pathology 9 items, prioritynot assigned

3 Mandatory 2 Mandatory1 Optional

3 Optional 2 Mandatory1 Optional

2 Mandatory1 Optional

11. Clinical staging 6 items, prioritynot assigned

6 Optional 5 Optional Deleted Deleted Deleted

12. Operative detailsSign in and briefing 9 Mandatory

5 Optional13 Mandatory6 Optional

5 Mandatory12 Optional

6 Mandatory11 Optional

7 Mandatory11 Optional

7 Mandatory11 Optional

Operative details 26 Mandatory1 Optional

41 Mandatory4 Optional

41 Mandatory2 Optional

28 Mandatory20 Optional

29 Mandatory17 Optional

29 Mandatory17 Optional

Intraoperative observations 16 Mandatory 17 Mandatory2 Optional

20 Mandatory 2 Mandatory12 Optional

2 Mandatory12 Optional

2 Mandatory12 Optional

Intraoperative pathology 4 Mandatory 3 Mandatory1 Optional

4 Mandatory 3 Mandatory 3 Mandatory 3 Mandatory

Wound closure 4 Mandatory1 Optional

14 Mandatory5 Optional

10 Mandatory2 Optional

5 Mandatory8 Optional

4 Mandatory9 Optional

4 Mandatory9 Optional

Patient outcomes 6 Mandatory11 Optional

8 Mandatory10 Optional

10 Mandatory7 Optional

9 Mandatory2 Optional

4 Mandatory7 Optional

4 Mandatory7 Optional

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effective report. We anticipate there to be a learning curveduring which users spend more time completing thisreport, but 81% of synoptic report users will completetheir report within 15 minutes [4]. We will also providefree and accessible interfaces in as many formats possibleto increase feasibility. The interface, currently underrefinement, is designed to be intelligent and exclude dataelements that are unnecessary given the type of proce-dure. This will increase the speed with which the opera-tive report can be completed. A previous report onsynoptic operative reports noted that improved reportquality was a fair tradeoff for the potentially smalldecrease in efficiency [4].

This activity was undertaken with the future plan ofdeveloping an electronic Web-based and App-basedinterface using dropdown menus for dichotomous andcategorical variables to reduce the use of less-standardizedfree text options. Through the development of this syn-optic operative report for lung cancer resection andpending implementation across Canada, thoracic sur-gery now has a tool that will allow for better qualityof data collection to assist with evaluating quality met-rics to improve the quality of care received by patients.

Although there is future work to come with validationand postimplementation refinement, the synopticoperative report tool will serve as a strong startingpoint for improving patient-related communication andcare.

Funding and support for this project was provided by the Jura-vinski Cancer Centre Foundation Grant-in-Aid and the Cana-dian Partnership Against Cancer.

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