Quality Of Surgical Care Research Articles

Beyond Policy: Strengthening District Level Access to Surgery Is Critical to Achieving Surgical Equity in Universal Health Coverage Comment on "Improving Access to Surgery Through Surgical Team Mentoring - Policy Lessons From Group Model Building With Local Stakeholders in Malawi".

District level access to surgical care has been identified as the rate limiting step to increasing access to the bottom billion and relies on a complex interplay of patient-related and system-based factors that underlie the provision of quality surgical care at point of care. Surgical mentoring via visiting teams, use of current proprietary technologies to enhance communication, establishment of a national surgical coordinator and multi-stakeholder engagement with creative cost-sharing have all demonstrated promising results. Regardless of strategic implementation frameworks, system-based thinking coupled with implementation science with practical solutions will be necessary to inform stakeholders on the best way forward in their respective geographic field of work charting a path towards surgical equity in universal health coverage (UHC).

Positive margin rates for colorectal cancer vary significantly by hospital in Michigan: Can we achieve a 0 % positive margin rate?

BackgroundHigh quality surgical care for colorectal cancer (CRC) includes obtaining a negative surgical margin. The Michigan Surgical Quality Collaborative (MSQC) is a statewide consortium of hospitals dedicated to quality improvement; a subset of MSQC hospitals abstract quality of care measures for CRC surgery, including positive margin rate. The purpose of this study was to determine whether positive margin rates vary significantly by hospital, and whether positive margin rates should be a target for quality improvement. MethodsWe performed a retrospective cohort study of patients who underwent CRC resection from 2016 to 2020. The primary outcome was the presence of a positive margin. Univariate and multivariable analyses were performed to test the association of positive margins with patient, hospital, and tumor characteristics. ResultsThe cohort consisted of 4211 patients from 42 hospitals (85 % colon cancer and 15 % rectal cancer). The crude positive margin rate was 6.15 % (95 % CI 4.6–7.4 %); this ranged from 0 % to 22 % at individual hospitals. In multivariable analysis, factors independently associated with positive margins included male sex, underweight BMI, metastatic cancer, rectal cancer (vs. colon), T4 T-stage, N1c/N2 N-stage, and open surgical approach. After adjusting for these factors, there remained significant variation by hospital, with 8 hospitals being statistically-significant outliers. ConclusionsPositive margins rates for CRC vary by hospital in Michigan, even after rigorous adjustment for case-mix. Furthermore, several hospitals achieved near-zero positive margin rates, suggesting opportunities for quality improvement through the identification of best practices among CRC surgery centers.

Health-Related Quality of Life after Cataract Surgery in Armenia: A Cross-Sectional Survey.

Cataract surgery helps to enhance visual function and improve the quality of life of cataract patients. The present study assessed visual outcomes and explored health-related quality of life (HRQoL) and factors associated with it following cataract surgery in Armenia. An interviewer-administered survey along with the ophthalmologic examination was conducted among 248 patients. It explored socio-demographic characteristics, use of eye care services, smoking status, comorbidities, and receiving and giving social support. A Short Form Health Survey (SF-36) was used to measure HRQoL. Simple and multivariable linear regression was used for the analysis. About 72.8% of examined eyes had good visual outcomes, while 17.7% had borderline outcomes. Poor visual outcomes were detected in 9.5% of the eyes. The mean composite SF-36 score for physical health was 50.8, while the mean composite score for mental health was 49.9. Gender, socioeconomic status, having a non-communicable disease, and receiving and giving tangible social support were significantly associated with SF-36 physical component in the adjusted analysis, while the variables which demonstrated significant association with the mental component included socioeconomic status, having a non-communicable disease, and giving tangible support. The visual outcome after cataract surgery in Armenian patients is below WHO-recommended standards. The quality of ophthalmological surgical care should be monitored to maximize the visual outcome in Armenian patients, with a focus on women, patients with poor socioeconomic status, and those with non-communicable diseases.

Post-operative outcomes in Indigenous patients in North America and Oceania: A systematic review and meta-analysis.

Indigenous Peoples across North America and Oceania experience worse health outcomes compared to non-Indigenous people, including increased post-operative mortality. Several gaps in data exist regarding global differences in surgical morbidity and mortality for Indigenous populations based on geographic locations and across surgical specialties. The aim of this study is to evaluate disparities in post-operative outcomes between Indigenous and non-Indigenous populations. This systematic review and meta-analysis was conducted in accordance with PRISMA and MOOSE guidelines. Eight electronic databases were searched with no language restriction. Studies reporting on Indigenous populations outside of Canada, the USA, New Zealand, or Australia, or on interventional procedures were excluded. Primary outcomes were post-operative morbidity and mortality. Secondary outcomes included reoperations, readmission rates, and length of hospital stay. The Newcastle Ottawa Scale was used for quality assessment. Eighty-four unique observational studies were included in this review. Of these, 67 studies were included in the meta-analysis (Oceania n = 31, North America n = 36). Extensive heterogeneity existed among studies and 50% were of poor quality. Indigenous patients had 1.26 times odds of post-operative morbidity (OR = 1.26, 95% CI: 1.10-1.44, p<0.01) and 1.34 times odds of post-operative infection (OR = 1.34, 95% CI: 1.12-1.59, p<0.01) than non-Indigenous patients. Indigenous patients also had 1.33 times odds of reoperation (OR = 1.33, 95% CI: 1.02-1.74, p = 0.04). In conclusion, we found that Indigenous patients in North American and Oceania experience significantly poorer surgical outcomes than their non-Indigenous counterparts. Additionally, there is a low proportion of high-quality research focusing on assessing surgical equity for Indigenous patients in these regions, despite multiple international and national calls to action for reconciliation and decolonization to improve quality surgical care for Indigenous populations.

Defining a Framework and Evaluation Metrics for Sustainable Global Surgical Partnerships: A Modified Delphi Study.

The aim of this study was to use expert consensus to build a concrete and realistic framework and checklist to evaluate sustainability in global surgery partnerships (GSPs). Partnerships between high-resourced and low-resourced settings are often created to address the burden of unmet surgical need. Reflecting on the negative, unintended consequences of asymmetrical partnerships, global surgery community members have proposed frameworks and best practices to promote sustainable engagement between partners, though these frameworks lack consensus. This project proposes a cohesive, consensus-driven framework with accompanying evaluation metrics to guide sustainability in GSPs. A modified Delphi technique with purposive sampling was used to build consensus on the definitions and associated evaluation metrics of previously proposed pillars (Stakeholder Engagement, Multidisciplinary Collaboration, Context-Relevant Education and Training, Bilateral Authorship, Multisource Funding, Outcome Measurement) of sustainable GSPs. Fifty global surgery experts from 34 countries with a median of 9.5 years of experience in the field of global surgery participated in 3 Delphi rounds. Consensus was achieved on the identity, definitions, and a 47-item checklist for the evaluation of the 6 pillars of sustainability in GSPs. In all, 29% of items achieved consensus in the first round, whereas 100% achieved consensus in the second and third rounds. We present the first framework for building sustainable GSPs using the input of experts from all World Health Organization regions. We hope this tool will help the global surgery community to find noncolonial solutions to addressing the gap in access to quality surgical care in low-resource settings.

Quality indicators and outcomes in ambulatory surgery.

Quality indicators are used to monitor the quality and safety of care in ambulatory surgery, a specialty in which major morbidity and mortality remain low. As the demand for safe and cost-effective ambulatory surgical care continues to increase, quality indicators and metrics are becoming critical tools used to provide optimal care for these patients. Quality indicators are tools used by both regulatory agencies and surgical centers to improve safety and quality of ambulatory surgical and anesthetic care. These metrics are also being used to develop value-based payment models that focus on efficient, safe, and effective patient care. Patient reported outcome measures are a growing method of collecting data on the satisfaction and postoperative recovery period for ambulatory surgical patients. Monitoring of perioperative efficiency and utilization using quality metrics are important to the financial health of ambulatory surgical centers. Quality indicators will continue to play a growing role in the monitoring of quality and safety in ambulatory surgery, especially with the trend towards value-based reimbursement models and efficient, cost-effective surgical care. Additionally, quality indicators are useful tools to monitor postoperative patient outcomes and recovery pathways and the efficiency of operating room utilization and scheduling.

Effectiveness of the Global Surgical and Medical Support Group (GSMSG) activities in Ukraine.

Targeting of healthcare infrastructures in Ukraine has served as a tactical warfare strategy. The goal of the Global Surgical and Medical Support Group (GSMSG) is to provide sustainable, high quality medical and surgical care in war zones. GSMSG deployed United States (US) Special Operations veterans and highly specialized licensed medical experts. Training of Ukrainian civilians was implemented. Over 20,000 Ukrainians trained and over 100 major surgeries performed with assistance of world experts. Specialized medical equipment was also provided. GSMSG lays the groundwork for effective, high quality, and sustainable surgical interventions into a nation in conflict.

Mentoring approaches in a safe surgery program in Tanzania: Lessons learned during COVID-19 and recommendations for the future

BackgroundCOVID-19 has dramatically affected the delivery of health care and technical assistance. This is true in Tanzania, where maternal mortality and surgical infection rates are significantly higher than in high-income countries. This paper describes lessons learned about the optimal application of in-person and virtual mentorship in the Safe Surgery 2020 program to improve the quality of surgical services in Tanzania before and after the COVID-19 pandemic. MethodsFrom January 2018 through December 2020, Safe Surgery 2020 supported 40 health facilities in Tanzania's Lake Zone to improve the quality of surgical care. A blended surgical mentorship model, employing both onsite and virtual mentorship, was central to the program's capacity development approach. With COVID-19, the program pivoted to full virtual mentorship. Through continuous learning and adaptation processes, including a human-centered design workshop, surveys assessing mentors' confidence with different competencies, and focus group discussions with mentors, mentees and safe surgery program staff, the program distilled the optimal use of mentorship models. ResultsDeveloping complex surgical skills, addressing contextual considerations, problem-solving, and building trusting relationships were best suited to in-person mentorship, whereas virtual mentorship was most effective in supporting mentees' quality improvement projects, data use, case discussions, and reinforcing clinical practices. Leading successful virtual learning required enhanced facilitation skills and active engagement of health facility leadership. ConclusionsIn-person and virtual mentorship offer distinct benefits and complement each other when combined. Investing more in-person mentorship at the beginning of programs allows for the establishment of trust that is foundational to effective mentorship.

Examining readmissions following outpatient microlaryngeal surgery.

The objective of this study was to examine readmissions following microlaryngeal surgery. It was hypothesized that airway surgical procedures would have higher rates of readmission. Retrospective review. Outpatient microlaryngeal surgeries from May 1, 2018 to November 27, 2022 were reviewed. Readmissions related to the original surgery within a 30-day postoperative period were examined. Patient demographics, body mass index, American Society of Anesthesiologist class, comorbidities, type of surgery, ventilation techniques, and operative times were examined and compared. Out of 480 procedures analyzed, 19 (4.0%) resulted in a readmission, 9 (1.9%) of which were for glottic stenosis management. Undergoing an airway procedure was significantly associated with a readmission (p = .002) and increased the odds of readmission by 5.99 (95% confidence interval [CI]: 2.22-16.16, p < .001). Current/former smoking status increased the odds of readmission by 4.50 (95% CI: 1.33-15.19, p = .016). Each additional minute of operating time increased the odds of readmission by 1.03 (95% CI: 1.00-1.05, p = .04). Readmissions from microlaryngeal surgery are seldom reported but nonetheless occur. Identifying factors that may place a procedure at risk for readmission can help improve surgical quality of care. 4.

Comparing surgeon perception of complication rates to publicly reported data using NSQIP

BackgroundPast studies have demonstrated that surgeons' perceptions of their own postsurgical complications may not be accurate. The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database is a nationally validated, risk-adjusted, outcomes-based program created to measure and improve the quality of surgical care. Using information acquired through survey data, the purpose of this study is to determine how surgeons' perceptions of their own postoperative complications rates compare to the NSQIP database that tracks these outcome metrics. Hypothesis/purposeWe hypothesize that surgeons underestimate their rates of morbidity, readmission, and reoperation within thirty days postoperatively when compared to NSQIP data. Study designData elements such as perceived morbidity, readmission, and reoperation were collected through surveys distributed at a large level one trauma center. Survey respondents were asked how their rates compared to their peers and physician survey responses were then compared to institutional NSQIP data. Results87.5% of surgeons underestimated their rates of morbidity, 35.4% underestimated their rates of readmission, 22.9% underestimated their rates of reoperation. When comparing themselves to their departmental averages, 57.78% accurately estimated their morbidity rates, 75.56% accurately estimated readmission rates, and 86.67% accurately estimated reoperation rates. ConclusionSurgeons are poor predictors of individual 30-day postoperative complication rates including morbidity, readmission, and reoperation. However, surgeons are more accurate in estimating these same outcomes when asked to compare to the average of their department.

Identification of predictive factors for surgical site infections in gastrointestinal surgeries: A retrospective cross-sectional study in a resource-limited setting

Background: Surgical site infection (SSI), albeit infrequent, drastically impact the quality of care. This article endeavors to investigate the predictive factors of SSIs following surgical interventions that involve the gastrointestinal (GI) tract within a single institution in a resource-limited setting. Methods: Over seven years from June 2015 to Oct 2022, patients who underwent GI surgery and developed SSI were retrospectively matched with an unaffected case-control cohort of patients. Standardized techniques for wound culture, laboratory evaluation of bacterial isolates, and antibiotic susceptibility tests were employed. Logistic regression analysis was utilized to investigate the predictive factors associated with 30-day postoperative SSI. Results: A total of 525 patients who underwent GI surgical procedures were included, among whom, 79 (15%) developed SSI. The majority of SSIs were superficial (67.10%), Escherichia coli was the most commonly isolated bacterium (54.4%), and a high percentage of multidrug-resistant organisms were observed (63.8%). In multivariate Cox regression analysis, illiteracy (Odds ratio [OR]:40.31; 95% confidence interval [CI]: 9.54-170.26), smoking (OR: 21.15; 95% CI: 4.63-96.67), diabetes (OR: 5.07; 95% CI: 2.27-11.35), leukocytosis (OR: 2.62; 95% CI: 1.24-5.53), hypoalbuminemia (OR: 3.70; 95% CI: 1.35-10.16), contaminated and dirty wounds (OR: 6.51; 95% CI:1.62-26.09), longer operative time (OR: 1.02; 95% CI: 1.01-1.03), emergency operations (OR: 12.58; 95% CI: 2.91-54.30), and extending antibiotic prophylaxis duration (OR: 3.01; 95% CI: 1.28-7.10) were the independent risk factors for SSI (all p &lt; 0.05). Conclusions: This study highlights significant predictors of SSI, including illiteracy, smoking, diabetes, leukocytosis, hypoalbuminemia, contaminated and dirty wounds, longer operative time, emergency operations, and extending antibiotic prophylaxis duration. Identifying these risk factors can help surgeons adopt appropriate measures to reduce postoperative SSI and improve the quality of surgical care, especially in a resource-limited setting with no obvious and strict policy for reducing SSI.

Surgical training in the Caribbean: The past, the present, and the future.

The six million inhabitants of these diverse English-speaking Caribbean countries are grateful to the University of the West Indies, which has been central in the independent training of surgical specialists in all areas of surgery for the past 50 years. Similar to the per capita income, the quality of surgical care, albeit acceptable, is quite variable throughout the region. Globalization and access to information have revealed that the quality of training and surgical care being delivered can be further improved. Technological advances will perhaps never be on par with higher-income countries, but collaborative ventures with global health partners and institutions can ensure that the people of the region will have appropriately trained surgical doctors and, therefore, the provision of accessible quality care will remain a staple, with even the possibility of income generation. This study reviews the journey of our structured surgical training program delivered in the region and outlines our growth plans.

Hospital Detention for the Inability to Pay: A Qualitative Study of Patient Experiences in Cameroon

IntroductionEquitable access to quality surgical care and low-cost healthcare services for all segments of the population remains a big problem in many African health systems. In Cameroon, it is very common to find medically discharged patients who have received surgical treatment and are unable to pay the resulting bills. These patients can be held in detention in hospitals until payments are complete. Even the corpses of patients who die with unpaid medical bills can be withheld until their family members pay off the debt. While this practice has been ongoing for many y, there remains very little scholarship on the issue reported in the literature. The main objective of this study was to uncover the lived experiences of discharged patients residing in hospital detention for being unable to pay their medical bills. MethodsIn-depth interviews, focus group discussions, and observations were conducted with purposefully selected patients living in detention in 2 rural private hospitals in the Fundong Health District in Cameroon. A thematic framework technique was used to analyze the transcribed data. The study was ethically approved by the Cameroon Bioethics Initiative, and informed consent was obtained from all participants. ResultsLiving in hospital detention after receiving treatment constitutes an economic, social, and psychological burden for patients. Economically, it exacerbated poverty for the patients unable to purchase food, medications, and clothing due to lack of jobs and financial support. Socially, many of these individuals suffered from isolation, loneliness, shame, stigma, risk of contracting other diseases, and precarious sleeping conditions. The psychological burden was comprised of stress, depression, trauma, nightmares, and suicidal thoughts. ConclusionsThe experiences of discharged patients in hospital detention suggest that they live in very deplorable conditions. There is a need for a functional healthcare protection mechanism, such as universal health coverage, to reduce the cost of healthcare services and surgical operations. Alternative payment mechanisms should also be considered.

From research to a political commitment to strengthen access to surgical, obstetric, and anesthesia care in Africa by 2030.

This study aimed to engage African leaders and key stakeholders to commit themselves toward the strengthening of surgical, obstetric, and anesthesia care systems by 2030 in Africa. From research to a political commitment, a baseline assessment was performed to foster the identification of the gaps in surgical care as a first step of an inclusive process. The preliminary findings were discussed during the International Symposium on Surgical, Obstetric, and Anesthesia Systems Strengthening by 2030 in Africa. The conclusions served to draft the Dakar Declaration and its Regional Action Plan 2022-2030 to improve access to surgical care by 2030 in Africa, endorsed by Heads of State. The International Symposium was composed of two meetings that gathered (i) 85 scientific experts and (ii) 28 ministers of health or representatives from 28 sub-Saharan African countries. The 28 African countries represent (i) 51% of the continent's total population, (ii) 68% of the 47 African countries of the WHO Africa Region, (iii) 58% of all African Union countries, and (vi) 79% (3,371) of the WHO Africa Region's total (4,271) health districts. The International Symposium and the Heads of State Summit successfully produced the Dakar Declaration on access to equitable, affordable, and quality Surgical, Obstetric, and Anesthesia Care by 2030 in Africa and its Regional Actions Plan 2022-2030 which prioritizes 12 urgent actions needed to be implemented, six strategic priorities, 16 key indicators, and an annual dashboard to monitor progress. The Dakar Declaration and its Regional Action Plan 2022-2030 are a commitment to establish quality and sustainable surgical, obstetric, and anesthesia care in each African country within the ambitious framework of "The Africa we want" Agenda 2063.

Assessing textbook outcome after single large hepatocellular carcinoma resection

BackgroundThis study aimed to investigate the impact and predictors of an ideal surgical care following SLHCC resection. MethodsSLHCC patients who underwent LR in two tertiary hepatobiliary centers between 2000 and 2021 were retrieved from prospectively maintained databases. The quality of surgical care was measured by the textbook outcome (TO). Tumor burden was defined by the tumor burden score (TBS). Factors associated with TO were determined on multivariate analysis. The impact of TO on oncological outcomes was assessed using Cox regressions. ResultsOverall, 103 SLHCC patients were included. Laparoscopic approach was considered in 65 (63.1%) patients and 79 (76.7%) patients presented with moderate TBS. TO was achieved in 54 (52.4%) patients. Laparoscopic approach was independently associated with TO (OR 2.57; 95% CI 1.03–6.64; p = 0.045). Within 19 (6–38) months of median follow up, patients who achieved TO had better OS compared to non-TO patients (1-year OS: 91.7% vs. 66.9%; 5-year OS: 83.4% vs. 37.0%, p < 0.0001). On multivariate analysis, TO was independently associated with improved OS, especially in non-cirrhotic patients (HR 0.11; 95% CI 0.02–0.52, p = 0.005). ConclusionsTO achievement could be a relevant surrogate marker of improved oncological care following SLHCC resection in non-cirrhotic patients.

Levels of Gynecologic Care: A Task Force Consensus Statement.

Systems of care have been established for obstetrics, trauma, and neonatology. An American College of Obstetricians and Gynecologists Presidential Task Force was established to develop a care system for gynecologic surgery. A group of experts who represent diverse perspectives in gynecologic practice proposed definitions of levels of gynecologic care using the Delphi method. The goal is to improve the quality of gynecologic surgical care performed in the United States by providing a framework of minimal institutional requirements for each level. Subgroups developed draft criteria for each level of care. The entire Task Force then met to reach consensus regarding the levels of care final definitions and parameters. The levels of gynecologic care framework focuses on systems of care by considering institutional resources and expertise, providing guidance on the provision of care in appropriate level facilities. These levels were defined by the ability to care for patients of increasing risk, complexity, and comorbidities, organizing gynecologic care around hospital capability. This framework can also be used to inform the escalation of care to appropriate facilities by identifying patients at risk and guiding them to facilities with the skills, expertise, and capabilities to safely and effectively meet their needs. The levels of gynecologic care framework is intended for use by patients, hospitals, and clinicians in the United States to guide where elective surgery can be done most safely and effectively by specialists and subspecialists in obstetrics and gynecology. The key features of the levels of gynecologic care include ensuring provision of risk-appropriate care and regionalization of care by facility capabilities.

AB066. SOH23ABS_177. Colon cancer resectional surgery in a model III hospital—an important piece of the jigsaw

Background: Cancer service centralisation improves outcomes. There are proposals to centralise colon cancer care into model IV hospitals. However, these hospitals lack resources and unintended consequences include deskilling of model III hospitals and resource underutilisation. This study examines the quality of oncological and surgical colon cancer care in a model III hospital with co-located surgeons.

Evaluation of the regional distribution of the pediatric surgery workforce and surgical load in Brazil

ObjectiveThe purpose of this study is to examine the regional distribution of the pediatric surgery workforce and the expected local demand for pediatric surgical procedures in Brazil.MethodsWe collected data on...

Sustainable Healthcare to Provide Quality Care in the Surgical Industry in the United Kingdom.

The surgical industry makes a major contribution to sustainable healthcare. This article aims to critically evaluate sustainable healthcare to provide quality surgical care in the United Kingdom. For this study, a systematic review was conducted using peer-reviewed studies and articles from the United Kingdom related to surgical and anesthetic fields that were published within the last five years. The journal articles were selected based on their relevance to the sustainability and performance of the healthcare system, including risks, and subsequently screened using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 model screening approach. The findings of the relevant journal articles were then critically evaluated for each theme. A total of 79 studies were retrieved, and 15 of the retrieved studies met the inclusion criteria. Of those, 10 articles evaluated existing sustainability practices, only seven articles discussed significant determinants of quality healthcare, and only 86.67% of the articles highlighted the implications of sustainability. The key predictors of high-quality medical care are effective resource management, the acquisition of a moral surgical team, the provision of professional services, integration, short hospital stays, and low mortality and morbidity rates. Conserving water, optimizing treatment routes and transportation, and creating cultural change were found to be the pillars of high-quality, sustainable healthcare. The concept of sustainability varied between these studies, and limitations on sustainability as a result of reduced mortality, morbidity, and business services were observed. Anesthetic gas emissions from operating rooms continue to have the most detrimental effect on the sustainability of the surgical industry. A significant gap was noted between the available data and their implications.

Validation of surgical care quality indicators in the Brazilian Unified Health System.

To validate a set of indicators for monitoring the quality of surgical procedures in the Brazilian Unified Health System (SUS). Validation study developed in 5 stages: 1) literature review; 2) prioritization of indicators; 3) content validation of indicators by RAND/UCLA consensus method; 4) pilot study for reliability analysis; and 5) development of instruction for tabulation of outcome indicators for monitoring via official information systems. From the literature review, 217 indicators of surgical quality were identified. The excluded indicators were: those based on scientific evidence lower than 1A, similar, specific, which corresponded to sentinel events; and those that did not apply to the SUS context. Twenty-six indicators with a high level of scientific evidence were submitted to expert consensus. Twenty-two indicators were validated, of which 14 process indicators and 8 outcome indicators with content validation index ≥80%. Of the validated process indicators, 6 were considered substantially reliable (Kappa coefficient between 0.6 and 0.8; p < 0.05) and 2 had almost perfect reliability (Kappa coefficient > 0.8, p < 0.05), when the inter-rater agreement was analyzed. One could measure and establish tabulation mechanism for TabWin for 7 outcome indicators. The study contributes to the development of a set of potentially effective surgical indicators for monitoring the quality of care and patient safety in SUS hospital services.