training, a detailed record describing the procedure
was generated (‘‘do’’). The documentation, surgical
images, and additional assessments after operation
provided the data for the analysis in respect to the predefined
quality criteria (‘‘check’’). Based on this analysis,
the trainee made a self-evaluation regarding the
quality of his/her surgical maneuvers. This evaluation
was the basis for the subsequent action, and for the decision
whether his surgical maneuver needed further
improvement or whether quality criteria were reached
(‘‘action’’). If further improvement was necessary, corresponding
solutions were formulated as the ‘‘plan’’ of
next PDCA cycle. Chance for success was directly related
to the quality of analysis and to the quality of
the ‘‘plan’’. A detailed analysis was performed not only
after each procedure, but also after a set of procedures
(n ¼ 3–5) to evaluate progress and to better understand
the reasons behind errors.
Application of Quality-Control Criteria for Training Progress
The quality of each procedure (cycle), step and phase
were evaluated with respect to predefined quality
criteria (Table 1A–C) such as operation time, distance
between sutures, maximal body weight loss (%). Completion
of a training step was judged upon meeting
a set of criteria. Transition from one step to the next
one was only permitted upon meeting the predefined
quality criteria.
The criteria and their cut-off values were determined
based on literature work-ups and on our own data obtained
in previous experiments. Application of quality
criteria was used to ensure the similar quality of procedures
performed by different surgeons. Following the
principles of ‘‘quality management’’, the criteria and
their cut-off values were subjected to constant refinement
with the increase in number of procedures