Quality auditing in breast reconstruction using funnel plots and indicators: a semi-anonymous and practical method for your practice

Inge Smits, Nikki Beudeker, Byrthe J. P. R. Vos*, Narda Hendriks-Brouwer, Ute Schmidbauer, Yvonne C. M. M. Smulders, Oliver T. Zophel, Hinne A. Rakhorst

*Corresponding author for this work

Research output: Contribution to journalArticleAcademicpeer-review


BackgroundIn recent years, there is an increasing focus on the delivery of high-quality care in a cost-efficient fashion. A key strategy in improving practice is gaining insight in outcome differences. We present a simple and quick method of quality auditing in a local practice, aiming to start a discussion between surgeons and reduce complication rates by improving protocols.MethodsPatients who underwent breast reconstruction with implants were evaluated on explantation rate within 60days of insertion. Patients were traced using administrative data. Results were compared during yearly audits between 2014 and 2017. Each year, a meeting was held in which the data of all surgeons were compared using funnel plots in a semi-anonymous manner.ResultsAt baseline, 6.1% (15/244) of all implants and 9.9% (9/91) of all tissue expanders had to be explanted, mainly due to infection (60.0% and 77.8%, resp.). Discussion at the audit led to the implementation of an anti-infection protocol. In the following years, explantation rates decreased to 3.8% (8/208) and 7.8% (8/102) in 2015 (infection 55.6% and 63%), and 3.4% (6/176) and 3.1% (2/64) in 2017 (infection 50% and 100%) and in 2016.ConclusionAudit feedback and the subsequent discussion about the causes of inter-surgeon differences led to a change in practice protocols for breast implant surgery and a reduction of breast implant explantation in our center.Level of Evidence: Level III, risk / prognostic study

Original languageEnglish
Pages (from-to)155-160
Number of pages6
JournalEuropean Journal of Plastic Surgery
Issue number2
Publication statusPublished - Apr-2019
Externally publishedYes


  • Funnel plot
  • Quality indicator
  • Complication
  • Breast reconstruction
  • Plastic surgery

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