1. Having regular discussions about the quality of surgical performance between individual surgeons and their teams.
2. Acting on concerns at an early stage before they affect patient care.
3. Considering the value of an independent external perspective on the situation.
4. Ensuring your surgeons have appropriate facilities and resources to support them to deliver safe care.
5. Ensuring that your surgical services have clearly identified clinical leaders that these leaders want to do the job, and have the time and resources to make a success of it.
6. Reviewing the performance of your multidisciplinary teams regularly to ensure they are focused on supporting patients to get access to the best possible care.
7. Regularly reviewing the quality of the behaviour of all those involved in delivering surgical care within your services and addressing poor behaviour at an early stage.
8. Focusing on the immediate impact on patient care and safety when your surgical service goes through a significant period of organisational change.
9. Regularly reviewing your surgical service’s processes for gaining consent from patients for operations, as well as the way in which your team introduces new technologies and techniques.
10. Regularly reviewing the standard of teamworking between groups of consultant surgeons to ensure that it supports the
    delivery of high-quality surgical care. 
11. Using the experience of trainees to learn about the quality of a service, and the team dynamics that underpin it. 
12. Ensure that your surgical service undertakes regular reflective practice. Including ensuring your service has: 
    a. high-quality morbidity and mortality review meetings; 
    b. programmes of clinical audit that demonstrate surgical safety and promote improvements in quality; 
    c. comprehensive appraisal of individual surgical practice and the use of this appraisal to improve performance; and 
    d. structured and effective learning from patient experience and patient complaints. 
13. Ensuring your service has well designed systems for collating detailed, accurate and timely data on surgical activity and surgical outcomes. This data should be given high priority and sufficient resource for it to be used comprehensively to assure standards and improve quality. 

We hope that this resource has been helpful to you in exploring how you can further improve your own surgical services. If you feel that you would benefit from external support and would like discuss a possible invited review please call us on 020 7869 6222 or email irm@rcseng.ac.uk. You can also visit www.rcseng.ac.uk/irm for more information.