Debate: what is the best method to monitor surgical performance?

Background: There is considerable recent interest in the monitoring of individual surgeon or hospital surgical outcomes. If one aggregates data over time and assesses performance with a funnel plot, then the detection of any process deterioration or improvement could be delayed. The variable life adjusted display (VLAD) is widely used for monitoring on a case-by-case basis, but we show that use of the risk-adjusted Bernoulli cumulative sum (RA-CUSUM) chart leads to much better performance. Discussion: We use simulation to illustrate that the RA-CUSUM chart has better performance than the VLAD in detecting changes in the rates of adverse events. Summary: We recommend the RA-CUSUM approach over the VLAD approach for monitoring surgical performance. If the VLAD is used, we recommend running the RA-CUSUM chart in the background to generate signals that the process performance has changed.