Despite major advances in surgery, anesthesia and improvements in perioperative care, patients continue to have variations in their surgical outcomes [5]. The incidence of postoperative complications ranges from ∼6 % for patients undergoing noncardiac surgery to >30 % for patients undergoing high-risk surgery [9, 10]. When surgeons are asked, if they practice safe surgery, the unanimous answer will be “yes”; however, the definition of “safe” surgery will most likely vary for each, and it is out of scope of this chapter to address the whole range of surgical safety and quality issues. We focus on four broad areas as suggested by the surgical care improvement project (SCIP ) : prevention of SSIs, prevention of adverse cardiovascular events, prevention of venous thromboembolism , and prevention of respiratory complications . The incidence and cost of complications in surgery is high and there are significant opportunities for prevention [11].

Surgical site infections (SSI) continue to represent a significant portion of health care-associated infections . The SSI rate in developed countries is around 1–3 % for elective clean surgery [12]. However, some limited data available from developing countries shows a SSI rate ranging from 1.2 to 23.6 % and higher [12, 13]. Patients with SSI infections have a higher mortality and an increased length of stay in the hospital and in the ICU and higher risk of hospital readmissions. The impact on morbidity, mortality, and the cost of care has resulted in SSI reduction being identified as a top priority worldwide. The majority of SSIs are largely preventable and evidence-based strategies have been available and implemented in many hospitals, as recognized by the SCIP and Society for Healthcare Epidemiology of America (SHEA) in the US. Worldwide attention to safer surgery including the prevention of SSI led to the development of the WHO Surgical Safety Checklist demonstrating the importance of teamwork and communication in addition to evidence-based care for preventing SSI. With the SSIs becoming an integral issue of patient safety not only in the operating room, but also up to hospital discharge and beyond; multimodal, multicenter or global preventive intervention programs based on guidelines, bundles or safety checklists are gaining momentum on a global scale [13]. Table 51.2 lists the WHO recommendations to prevent SSIs. Some other recommendations include effective hand hygiene throughout the care period, smoking cessation 30 days before surgery, optimal glycemic control of diabetic patients during the perioperative period and active surveillance for SSIs. Growing evidence demonstrated that surgical hand hygiene upon coming to the operating room ranges from 3 to 10 % [14]. These interventions do not require new and sophisticated technology. An improved adherence to established basic principles such as surgical hand preparation, skin antisepsis, adequate antibiotic prophylaxis, less traumatic, less invasive and shorter surgery duration, improved hemostasis and avoidance of hypothermia or hyperglycemia will remain cornerstones for SSI prevention . Raising awareness at different levels, including local/national authorities and especially inviting the public to assist, may trigger efforts for reporting SSIs and international benchmarking, and possibly contribute towards a further decrease of current infection rates. This goal requires multidisciplinary, multifaceted commitment, dedicated infection control teams and efforts, and institutional and behavioral elements, all of which could be achievable with education, determination and minimal cost. Active and direct feedback is at least equally as effective in reducing SSIs without even further precautions. In 1985, the Study on the Efficacy of Nosocomial Infection Control (SENIC) demonstrated that the presence of a dedicated infection control team, together with surveillance and feedback of observed data to the team, resulted in a 38 % decrease of SSIs among participating hospitals [15]. However, this required not only implementing a structural mechanism but as also a behavioral and cultural change package of interventions which were deployed gradually and after deep consultation. Another speculative issue is will public/mandatory reporting of outcomes and transparency initiatives influence SSI incidence [16]. The supporting data for such public reporting benefits are scarce and a recent review could not identify any studies showing public reporting benefits that investigated SSI reduction as an outcome, as well as compared associated costs [17].

Venous thromboembolism (VTE ) occurs in ∼25 % of all major operations if appropriate prophylaxis has not been started and almost a one-fourth end up with pulmonary embolism which appears as sudden death [18]. Cohen et al. found that nearly three quarters of VTE-related deaths were from hospital acquired thrombosis, but only seven percent were diagnosed ante-mortem; 34 % were caused by sudden fatal PE, and 59 % were undiagnosed pulmonary embolism [19]. In a recent report, VTE associated with hospitalization, in addition to increased hospital costs, was the leading cause of disability-adjusted life-years in low-income and middle-income countries, and the second most common cause in high-income countries [20]. Surgical procedures associated with a high risk of VTE include neurosurgery, major orthopedic surgery of the leg, renal transplantation, cardiovascular surgery, and thoracic, abdominal, or pelvic surgery for cancer. Obesity and poor physical status according to American Society of Anesthesiology criteria are risk factors for VTE after total hip arthroplasty [21]. Observational studies continue to report underuse of prophylaxis for postoperative pulmonary embolism/deep vein thrombosis despite the long-standing evidence-based guidelines [22]. The Institute of Medicine considers failure to provide appropriate VTE prophylaxis to hospitalized at risk patients a medical error, and yet the use of prophylaxis is nonuniform and often varies by physician within a given institution, leading to variability in types and complication rates. A VTE prophylaxis protocol was implemented at Anadolu Medical Center in 2011 to decrease VTE complications, based on standardized electronic physician orders that specify early postoperative mobilization and mandatory VTE risk stratification for every patient, using the “Caprini” grading system [18]. The derived scores dictate the nature and duration of VTE prophylaxis. Both mechanical (pneumatic compression boots) and pharmacologic prophylaxis (unfractionated or low molecular weight heparin) are used, as indicated by risk level. Data has been analyzed every 3 months, feedback was given to physicians individually and adherence rate to VTE prophylaxis protocol was defined as a performance criteria. The adherence rates to VTE prophylaxis protocol for low, medium, high, and very high risk groups were 51, 67, 47, and 41 %, respectively, for 2011 and 79, 81, 71, and 87 %, respectively, for 2012. The total adherence rate to protocol increased from 48 % in 2011 to 76 % in 2012 and reached to a record breaking 98 % in 2015. With the increasing number of sicker patients and more complex procedures augmenting the risk of postoperative VTE, there is a clear need to establish and implement risk assessment tools and thromboprophylaxis guidelines in an effort to curb rising rates of postoperative VTE.

Ventilator associated pneumonia (VAP ) is among the most common health care infections occurring in 9–27 % of all intubated patients and is associated with significant morbidity and mortality [23]. It has been reported that between 10 and 20 % of patients receiving >48 h of mechanical ventilation will develop VAP; critically ill patients who develop VAP appear to be twice as likely to die compared with similar patients without VAP and patients who develop VAP incur ≥ $10,019 in additional hospital costs [23]. Considering the huge economic and clinical burden and preventable nature, lowering the incidence of VAP would be an important goal to achieve patient safety. The National Quality Forum [24], and the Institute for Healthcare Improvement 100,000 Lives Campaign [25] were among the firsts to include VAP prevention as a quality indicator. They used a so-called ventilator bundle consisting of four key components: elevation of the head of the bed to 30–45°, daily “sedation vacation,” peptic ulcer prophylaxis , and deep venous thrombosis prophylaxis . The bundle was an all-or-nothing measurement (process indicator). However, difficulties remain in reporting and benchmarking VAP rates due to very heterogeneous patient case mix, and variability in diagnosis and surveillance protocols.

Adverse cardiac events such as myocardial infarction and cardiac death are common complications of surgery occurring in 1–5 % of patients undergoing noncardiac surgery , and in as many as 30 % of patients undergoing vascular surgery [26]. These events are associated with increased mortality as high as 60 % per event, and result in longer hospitalizations and high costs of treatment [27]. The prevalence and high mortality associated with these events make prevention an important priority and has been the subject of many quality improvement projects [28]. Many recent studies suggest that perioperative use of beta blockers may reduce risk of adverse cardiovascular events in patients undergoing surgery [27–29]. Evidence from these papers has led to initiatives for cardiovascular adverse event prevention becoming a priority.

Delivering surgical care is complex, complicated and requires multidisciplinary collaboration , and interdisciplinary action. Complicated procedures and advanced technology increases complexity; concomitantly, sophisticated organizational structures emerge. All these factors make team-based approach a necessity [30]. Many years of psychological research in organizational behavior has shown that individuals possessing high levels of expertise, technical knowledge and resources might easily fail unless a teamwork environment is created and maintained [31]. The essence of a multidisciplinary team (MDT) is a common commitment, which in medical practice, amounts to the provision of optimal care by as many specialists as the individual case requires, who not only are experts in their field, but communicate effectively among themselves as well [32]. A team-based approach has become the standard of practice in fields such as oncology and organ transplantation, where it has been observed that decisions made by MDTs are more likely to conform to evidence-based guidelines than those made by individual clinicians [33–35]. These teams were established after evidence showed better outcomes and less variability in survival among participating hospitals. Kesson et al. recently reported that introduction of teams providing multidisciplinary care for the treatment of breast cancer was associated with 18 % lower mortality at 5 years, compared with the outcomes in neighboring areas, where similar patients were treated over the same period of time [36]. In “Crossing the Quality Chasm: A New Health System for the 21st Century,” teamwork is recognized as an integral part of medical practice, cited as essential in caring for patients with complex problems, and strongly recommended as a practice that must be created and maintained [37]. These and numerous similar examples provide convincing evidence that MDTs strengthen the ability to provide higher quality and more efficient care. Although a multidisciplinary heart team is considered a standard practice in many countries, access to such care still shows high variability among neighboring institutions [38]. Such variability can definitely be reduced, if not prevented altogether, by reinforcing a variety of measures such as implementing joint learning and debriefing arrangements, linked reimbursement or bundle strategies, administrative policies, quality and transparency reporting guidelines [39]. The Public Hospitals Association (KHB) of Turkey recently implemented an obligatory heart team decision for any elective myocardial revascularization procedure . Concurrently, the Ministry of Health (MOH) started an appropriateness control program, in which all myocardial revascularization data are sent to a group of surgeons and cardiologists who are blinded as to the data source with feedback provided to the participating centers. The final goal is linking of reimbursement to the appropriateness of the procedure. Although the program is still in its infancy, it is well received and is being closely monitored. One very important factor to facilitate implementation of a multidisciplinary approach is to educate patients and accept them as members of the team during the decision making process. This approach, in which the patient is at the center of the clinical microsystem has been shown to create many benefits and suggested improved outcomes [40, 41].