Introduction

Variations in the quality of healthcare can arise from patient, institution and system-level factors.1–4 For example, patients who are elderly, African American and with multiple comorbidities experience increased complications, mortality and longer hospital stays.5 Hospitals with a higher annual caseload and teaching status are associated with reduced surgical complications, readmissions and mortality rates.6–9 Within hospitals, the number of staff and their culture around teamwork and safety influences patient rescue rates following high-risk surgery.10 11 Interventions such as the implementation of the Safe Surgery Checklists over the past decade in various hospitals, systems and countries exemplify efforts to standardise procedures and reduce errors to improve healthcare quality.12 Systemically, interprofessional collaboration between healthcare services can improve health outcomes, reduce patient time in the healthcare system and lower costs.13

Physician factors are another important element that can influence the quality of healthcare. Examples of physician factors include caseloads, training, age, sex, personality traits and psychological safety. In surgery, variation in intraoperative performance by the surgeon can immediately affect patient outcomes and even increase the risk of mortality. Studies have shown that specialised surgeons with higher annual caseloads demonstrate lower rates of patient complications, mortality and length of stay.9 13 14 Orthopaedic surgical trainees may subject their patients to increased radiation exposure and complications.15 The age of a surgeon can also influence patient outcomes. Surgeons who are nearing 60 years of age are associated with greater patient morbidity and mortality than younger surgeons.16 Studies have also described the impact of surgeon sex on patient outcomes. When treated by a female surgeon or a surgeon of the same sex, patients experience lower 30-day complications and mortality rates.17 Literature has even shown inconspicuous differences, such as surgeon personality and fatigue, to increase rates of septicaemia and complications following bariatric surgery. Residency selection processes are increasingly considering personality assessments like the Big Five and Jungian Type Index to identify surgeons less prone to unwanted variations in performance.18–20 In psychologically safe teams, physicians are more likely to speak up about uncertainties, ask questions and admit mistakes, leading to a culture of continuous learning and error reduction.21 While we can appreciate the impact of surgeon variation on the quality of healthcare, there has been no systematic assessment of the extent of the literature about modifiable surgeon behavioural factors influencing the quality of healthcare.

The objective of this scoping review is to further identify surgeon behavioural factors influencing the quality of healthcare and to assess the effect of interventions aimed at modifying surgeon factors.

Methods

The proposed scoping review will be reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for scoping review (PRISMA-ScR) and JBI methodology for scoping reviews.22 The protocol was drafted according to JBI Best Practice Guidance and Reporting Items for the Development of Scoping Review Protocols.1 2

Patient and public involvement

Patients and the public were not involved in the design of the study; however, they will be involved in the final stages of the review to support the interpretation of the findings and dissemination of the review. We will hold a stakeholder meeting to present a draft of the findings. Stakeholders will be asked to discuss the implications of the findings. Stakeholders will also be involved in planning how to share the results and agree on the dissemination strategy.

Participants

Studies describing at least one intervention or policy aimed at modifying a behavioural surgeon factor influencing the quality of healthcare will be included. Studies describing institutional or system factors but not behavioural surgeon factors will be excluded. Interventions and policies influencing behaviour are defined using the behaviour change wheel. The behaviour change wheel categorises the interventions as restrictions, education, persuasion, incentivisation, coercion, training, enablement, modelling and environmental restructuring.23 Policies are categorised as guidelines, environmental/social planning, communication/marketing, legislation, service provision, regulation and fiscal measures. The behaviour surgeon factors are defined as surgeon factors influencing the quality of healthcare which can be categorised in the COM-B framework. COM-B is a theoretical framework describing factors that constitute behaviour.23 These factors are capability, opportunity and motivation. Capability is a person’s physical and psychological ability to perform a behaviour. Opportunity refers to external factors, whether physical or social, that enable behaviour. Motivation refers to internal processes that initiate or inhibit behaviour.

Concept

The overarching concept of interest for this scoping review is the quality of healthcare following surgery. Further elements of this overarching concept include the domains of quality of care as defined by the WHO. These domains are safety, effectiveness, patient-centred, timely, efficiency, equitable and integration.24

Context

Searches were limited from 1 January 2000 to 1 January 2024. Otherwise, the context of the review is ‘open’ as sources of evidence pertaining to any contextual setting would be eligible for inclusion. Only articles after the year 2000 were included as these articles are more likely to reflect current medical practices and advancements, as surgical techniques, technologies and guidelines have evolved significantly in recent decades. This period has seen the introduction of innovations like robotic surgery and minimally invasive techniques, which are crucial to current practices. Additionally, there have been notable changes in medical education and surgical training, making recent literature more representative of current surgeon competencies. The last two decades also witnessed shifts in healthcare policies, affecting surgical quality and outcomes, making more recent studies more relevant to today’s healthcare environment. Recent articles are also more aligned with the principles of evidence-based medicine, featuring improved reporting standards and methodologies. Even within this recent period, we recognise there have been notable structural, organisational and cultural changes. Therefore, we will perform subgroup analyses to explore temporal trends as described in the Data analyses section below.

Types of sources

This scoping review will include interventional studies defined as studies where researchers directly intervened and changes in outcomes were assessed. Observational studies where differences were observed without direct intervention, including comparative case-control and cohort studies, will be excluded.

Search strategy

Details of the search strategy can be found in online supplemental appendix I of the supplementary material ‘Exploring Surgeon Factors Appendices’. A preliminary search of MEDLINE, the Cochrane Database of Systematic Reviews and JBI Evidence Synthesis was conducted, and there are no current or underway systematic reviews or scoping reviews on the topic.

An initial limited search of MEDLINE and CINAHL was undertaken to identify articles on the topic. The text words contained in the titles and abstracts of relevant articles and the index terms used to describe the articles were used to develop a full search strategy for OVID Medline, OVID EMBASE, Cochrane Library (Central) and SCOPUS (see online supplemental appendix I in the supplementary material ‘Exploring Surgeon Factors Appendices’). The search strategy, including all identified keywords and index terms, will be adapted for each included database and/or information source. The reference list of all included sources of evidence will be screened for additional studies. Sources of unpublished studies/grey literature to be searched include trial registries, conference proceedings and abstracts, theses and dissertations, institutional repositories and preprint servers.

Only full-length articles published in English since 2000 will be included.

Study/source of evidence selection

Following the search, all identified citations will be collated and uploaded into Zotero (V. 6.0.30) and duplicates removed. Following a pilot test, titles and abstracts will then be screened by two or more independent reviewers for assessment against the inclusion criteria for the review using DistillerSR.4 Potentially relevant sources will be retrieved in full, and their citation details will be imported into the JBI System for the Unified Management, Assessment and Review of Information (JBI, Adelaide, Australia).25 The full text of selected citations will be assessed in detail against the inclusion criteria by two or more independent reviewers. Reasons for the exclusion of sources of evidence in full text that do not meet the inclusion criteria will be recorded and reported in the scoping review. Any disagreements that arise between the reviewers at each stage of the selection process will be resolved through discussion or with an additional reviewer/s. The results of the search and the study inclusion process will be reported in full in the final scoping review and presented in a PRISMA-ScR flow diagram.2 22

Data extraction

Data will be extracted from papers included in the scoping review by two or more independent reviewers using a data extraction tool developed by the reviewers. The data extracted will include specific details about the participants, concept, context, study methods and key findings relevant to the review questions.

A draft extraction form is provided in online supplemental appendix II of the supplementary material ‘Exploring Surgeon Factors Appendices’. The draft data extraction tool will be modified and revised as necessary during the process of extracting data from each included evidence source. Modifications will be detailed in the scoping review. Any disagreements that arise between the reviewers will be resolved through discussion or with an additional reviewer/s. If appropriate, authors of papers will be contacted to request missing or additional data, where required.

Outcome measures included are quality-of-care measures as defined by the WHO. These measures are effectiveness, patient-centred, timely, efficiency, equitable and integration.24 Safety is the degree to which patient harm is avoided. Effectiveness is the use of evidence-based healthcare. Patient-centred care is the incorporation of patient preferences, values and needs. Timely care is the elimination of harmful delays. Efficiency is maximising the benefits of available resources. Efficiency also involves cost analyses to determine if the treatment is appropriate. Equitable care does not vary based on patient gender, ethnicity, socioeconomic status or geographic location. Integrated care makes use of all required health services.

We will use the Donabedian framework to organise the WHO’s quality-of-care outcome measures. The categories in the Donabedian framework are structure measures, process measures and outcome measures.26 The Donabedian theory is that changes in structure will lead to changes in processes and finally changes in outcome. Structure measures include integration. Process measures include timely, efficient, equitable and patient-centred care. Outcome measures include safety and efficacy. The Donabedian framework can also have balance measures which are any unexpected data but do not fit within the other categories. All extracted outcome data will be represented according to the primary statistical analyses reported in the original study.

Data analysis and presentation

The data will be presented both graphically and in tabular form. A narrative summary will accompany the tabulated and/or charted results and will describe how the results relate to the reviews objective and questions. No additional statistical analyses on previously published data will be completed for this scoping review. Extracted data will be qualitatively analysed, summarised and organised by surgeon factor as per the COM-B framework previously described. Surgeon factors will be grouped into three themes: surgeon capability, surgeon opportunity and surgeon motivation. Non-modifiable surgeon factors such as surgeon age, gender and years in practice will also be recorded. We will also perform subgroup analyses to explore temporal trends and developments in the literature. Specifically, we will divide the included studies into two time periods: 2000–2010 and 2010 to the present. We will perform thematic analyses on these separate subgroups to assess and compare the evolution of key themes and concepts across these two decades. This approach will allow us to identify shifts in research focus, emerging patterns and potential changes in the field over time.

Expected outcomes

The expected outcomes are threefold. First, we expect to compile a list of existing interventions that are modifying surgeon factors. Second, we expect to find an analysis on the effectiveness of which approaches have been most successful and which have not been successful in improving the quality of care. Finally, we expect to identify gaps regarding interventions on modifiable surgeon factors that impact the quality of care. For example, patient feedback on their surgeon’s efforts to reduce their anxiety while waiting for surgery may not be reported. This is a modifiable surgeon factor that could be measured, and the feedback could help surgeons improve their patient’s experience.