{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,6]],"date-time":"2026-07-06T14:23:05Z","timestamp":1783347785758,"version":"3.54.6"},"reference-count":28,"publisher":"BMJ","issue":"3","license":[{"start":{"date-parts":[[2026,7,6]],"date-time":"2026-07-06T00:00:00Z","timestamp":1783296000000},"content-version":"unspecified","delay-in-days":5,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Open Qual"],"accepted":{"date-parts":[[2026,6,22]]},"published-print":{"date-parts":[[2026,7]]},"abstract":"<jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Enhanced Recovery After Surgery (ERAS) programmes improve perioperative outcomes, but real-world adherence varies widely across institutions, limiting their effectiveness. Disease-Specific Care Certification (DSCC) provides governance and standardisation but lacks operational mechanisms for frontline implementation. This study evaluates an integrated Quality Control Circle (QCC) model aligned with DSCC and ERAS protocols to improve perioperative reliability and patient-centred outcomes in joint replacement.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>A pre\u2013post quasi-experimental study was conducted involving 515 patients undergoing elective total joint replacement. A multidisciplinary QCC team employed root-cause analysis, Pareto prioritisation and iterative Plan\u2013Do\u2013Study\u2013Act cycles to refine processes. DSCC governance principles were used to structure standardised pathways, unify documentation and reinforce interdisciplinary communication. Outcomes included ERAS compliance, length of stay (LOS), preoperative discomfort (thirst, dry mouth), unnecessary blood preparation, complications and staff competency.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>ERAS compliance increased from 80.9% to 100% after implementation. Preoperative thirst (p=0.0156) and dry mouth scores (p=0.0073) improved significantly. LOS decreased from 6.63 to 5.98\u2009days. Unnecessary blood preparation was reduced from 237 units to zero. Staff competency improved across all domains. No increase in postoperative complications or readmissions was observed.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Integration of QCC operational tools, DSCC governance and ERAS clinical elements yielded substantial improvements in perioperative reliability, efficiency and patient comfort. The QCC\u2013DSCC\u2013ERAS hybrid model is feasible, scalable and potentially generalisable to other institutions seeking high-reliability perioperative care.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/bmjoq-2026-004147","type":"journal-article","created":{"date-parts":[[2026,7,6]],"date-time":"2026-07-06T13:29:51Z","timestamp":1783344591000},"page":"e004147","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":0,"title":["Impact of integrating Quality Control Circle, Disease-Specific Care Certification and Enhanced Recovery After Surgery on perioperative outcomes in joint replacement"],"prefix":"10.1136","volume":"15","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-3456-3285","authenticated-orcid":false,"given":"Tuoh","family":"Wu","sequence":"first","affiliation":[{"name":"Department of Orthopaedic Surgery, National Taiwan University Hospital Hsin-Chu Branch Hsin-Chu Hospital, Hsinchu, Taiwan"},{"name":"Department of Biological Science and Technology, National Yang Ming Chiao Tung University, Hsinchu, Taiwan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2202-5420","authenticated-orcid":false,"given":"Wo-Jan","family":"Tseng","sequence":"additional","affiliation":[{"name":"Department of Orthopaedic Surgery, National Taiwan University Hospital Hsin-Chu Branch Hsin-Chu Hospital, Hsinchu, Taiwan"},{"name":"Department of Biological Science and Technology, National Yang Ming Chiao Tung University, Hsinchu, Taiwan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Cheng-Yo","family":"Lai","sequence":"additional","affiliation":[{"name":"Department of Orthopaedic Surgery, National Taiwan University Hospital Hsin-Chu Branch Hsin-Chu Hospital, Hsinchu, Taiwan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tze-Hong","family":"Wong","sequence":"additional","affiliation":[{"name":"Department of Orthopaedic Surgery, National Taiwan University Hospital Hsin-Chu Branch Hsin-Chu Hospital, Hsinchu, Taiwan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ying-Chi","family":"Wu","sequence":"additional","affiliation":[{"name":"Department of Nursing, National Taiwan University Hospital Hsin-Chu Branch Hsin-Chu Hospital, Hsinchu, Taiwan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Wei-Tso","family":"Chia","sequence":"additional","affiliation":[{"name":"Department of Orthopaedic Surgery, National Taiwan University Hospital Hsin-Chu Branch Hsin-Chu Hospital, Hsinchu, Taiwan"},{"name":"Department of Nursing, Yuanpei University of Medical Technology, Hsinchu, Taiwan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tung-Kung","family":"Wu","sequence":"additional","affiliation":[{"name":"Department of Biological Science and Technology, National Yang Ming Chiao Tung University, Hsinchu, Taiwan"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2026,7,6]]},"reference":[{"key":"2026070606101513000_15.3.e004147.1","doi-asserted-by":"publisher","DOI":"10.1136\/postgradmedj-2018-136166"},{"key":"2026070606101513000_15.3.e004147.2","doi-asserted-by":"publisher","DOI":"10.1136\/postgradmedj-2017-134991"},{"key":"2026070606101513000_15.3.e004147.3","doi-asserted-by":"publisher","DOI":"10.1080\/17453674.2019.1683790"},{"key":"2026070606101513000_15.3.e004147.4","doi-asserted-by":"crossref","DOI":"10.1051\/sicotj\/2023030","article-title":"Enhanced recovery after surgery (ERAS) protocols for total joint replacement surgery","volume":"9","author":"Riga","year":"2023","journal-title":"SICOT J"},{"key":"2026070606101513000_15.3.e004147.5","first-page":"361","article-title":"How Does Disease-Specific Care Certification Affect Quality and How Can We Measure It?","volume":"42","author":"Baker","year":"2016","journal-title":"Jt Comm J Qual Patient Saf"},{"key":"2026070606101513000_15.3.e004147.6","first-page":"364","article-title":"Hospital Disease-Specific Care Certification Programs and Quality of Care: A Narrative Review","volume":"42","author":"Musallam","year":"2016","journal-title":"Jt Comm J Qual Patient Saf"},{"key":"2026070606101513000_15.3.e004147.7","doi-asserted-by":"publisher","DOI":"10.1097\/JNN.0000000000000472"},{"key":"2026070606101513000_15.3.e004147.8","doi-asserted-by":"crossref","first-page":"273","DOI":"10.1097\/NUR.0000000000000483","article-title":"Achieving Disease-Specific Care Joint Commission Certification: The Impact of Clinical Nurse Specialist Practice","volume":"33","author":"Frost","year":"2019","journal-title":"Clin Nurse Spec"},{"key":"2026070606101513000_15.3.e004147.9","unstructured":"The Joint Commission . Benefits of joint commission certification. 2018."},{"key":"2026070606101513000_15.3.e004147.10","unstructured":"The Joint Commission . Disease-specific care certification process guide. 2023."},{"key":"2026070606101513000_15.3.e004147.11","doi-asserted-by":"crossref","first-page":"89","DOI":"10.1097\/NOR.0b013e31820f5110","article-title":"A clinical nurse specialist led journey to the Joint Commission disease-specific certification in hip fractures","volume":"30","author":"McWilliam-Ross","year":"2011","journal-title":"Orthop Nurs"},{"key":"2026070606101513000_15.3.e004147.12","doi-asserted-by":"crossref","first-page":"31","DOI":"10.1300\/J147v08n01_03","article-title":"The quality circle: fad, fix, fiction?","volume":"8","author":"Middleman","year":"1984","journal-title":"Adm Soc Work"},{"key":"2026070606101513000_15.3.e004147.13","doi-asserted-by":"crossref","DOI":"10.1186\/2193-1801-2-141","article-title":"The role of quality control circles in sustained improvement of medical quality","volume":"2","author":"Wang","year":"2013","journal-title":"Springerplus"},{"key":"2026070606101513000_15.3.e004147.14","doi-asserted-by":"crossref","first-page":"875","DOI":"10.1080\/14737140.2023.2219899","article-title":"Impact of Quality Control Circle on Patient Outcomes after Hepatocellular Carcinoma Intervention: A Meta-Analysis","volume":"23","author":"Wang","year":"2023","journal-title":"Expert Rev Anticancer Ther"},{"key":"2026070606101513000_15.3.e004147.15","doi-asserted-by":"crossref","first-page":"127","DOI":"10.1016\/j.jor.2016.03.007","article-title":"A randomized comparative study of topical versus intravenous tranexamic acid administration in enhanced recovery after surgery (ERAS) total knee replacement","volume":"13","author":"Drosos","year":"2016","journal-title":"J Orthop"},{"key":"2026070606101513000_15.3.e004147.16","doi-asserted-by":"publisher","DOI":"10.1177\/0884533615594013"},{"key":"2026070606101513000_15.3.e004147.17","doi-asserted-by":"crossref","unstructured":"Tall J , Nygren J . Preoperative fasting and carbohydrate treatment. In: Ljungqvist O , Francis N , Urman R , eds. Enhanced recovery after surgery. Springer, 2020.","DOI":"10.1007\/978-3-030-33443-7_4"},{"key":"2026070606101513000_15.3.e004147.18","doi-asserted-by":"crossref","first-page":"999","DOI":"10.1016\/j.amjsurg.2020.03.032","article-title":"The impact of preoperative carbohydrate loading on patients with type II diabetes in an enhanced recovery after surgery protocol","volume":"220","author":"Talutis","year":"2020","journal-title":"Am J Surg"},{"key":"2026070606101513000_15.3.e004147.19","doi-asserted-by":"crossref","first-page":"246","DOI":"10.1002\/ncp.10427","article-title":"Review and evaluation of preoperative carbohydrate loading in ERAS","volume":"35","author":"Ackerman","year":"2020","journal-title":"Nutr Clin Pract"},{"key":"2026070606101513000_15.3.e004147.20","doi-asserted-by":"crossref","first-page":"24","DOI":"10.1186\/s13741-016-0049-9","article-title":"ASER\/POQI consensus statement on perioperative fluid management in ERAS","volume":"5","author":"Thiele","year":"2016","journal-title":"Perioper Med"},{"key":"2026070606101513000_15.3.e004147.21","doi-asserted-by":"crossref","first-page":"229","DOI":"10.1111\/os.12441","article-title":"Effects of ERAS in total knee arthroplasty for patients older than 65 years","volume":"11","author":"Jiang","year":"2019","journal-title":"Orthop Surg"},{"key":"2026070606101513000_15.3.e004147.22","doi-asserted-by":"crossref","DOI":"10.1097\/MD.0000000000015669","article-title":"Effects of preoperative oral carbohydrates on patients undergoing ESD surgery: a randomized controlled study","volume":"98","author":"Wang","year":"2019","journal-title":"Medicine (Baltimore)"},{"key":"2026070606101513000_15.3.e004147.23","doi-asserted-by":"crossref","first-page":"68","DOI":"10.4274\/TJAR.2024.231506","article-title":"Effect of Preoperative Oral Carbohydrate Intake on Perioperative Hyperglycemia in Indian Patients Undergoing Hip Fracture Fixation","volume":"52","author":"Minz","year":"2024","journal-title":"Turk J Anaesthesiol Reanim"},{"key":"2026070606101513000_15.3.e004147.24","doi-asserted-by":"crossref","DOI":"10.1016\/j.jcot.2025.102928","article-title":"A systematic review and meta-analysis of preoperative carbohydrate drink loading prior to elective hip and knee arthroplasty","volume":"63","author":"Pradhan","year":"2025","journal-title":"J Clin Orthop Trauma"},{"key":"2026070606101513000_15.3.e004147.25","doi-asserted-by":"crossref","first-page":"602","DOI":"10.1016\/j.clnesp.2025.05.049","article-title":"Preoperative carbohydrate loading as part of ERAS protocol in elective total hip arthroplasty","volume":"68","author":"Haselton","year":"2025","journal-title":"Clin Nutr ESPEN"},{"key":"2026070606101513000_15.3.e004147.26","doi-asserted-by":"crossref","first-page":"2907","DOI":"10.3390\/curroncol31060222","article-title":"Outcomes before and after ERAS implementation in colorectal surgery: a real-world study","volume":"31","author":"Mangone","year":"2024","journal-title":"Curr Oncol"},{"key":"2026070606101513000_15.3.e004147.27","unstructured":"Wu T , Chia WT , Wu TK . Data from: national health insurance healthcare quality information disclosure portal, total knee replacement. Taiwan Ministry of Health and Welfare National Health Insurance Bureau; 2026. Available: https:\/\/med.nhi.gov.tw\/ihqe0000\/IHQE0010S01.aspx?Type=TKA"},{"key":"2026070606101513000_15.3.e004147.28","unstructured":"Wu T , Chia WT , Wu TK . Data from: national health insurance healthcare quality information disclosure portal, total hip replacement. Taiwan Ministry of Health and Welfare National Health Insurance Bureau; 2026. Available: https:\/\/med.nhi.gov.tw\/ihqe0000\/IHQE0010S01.aspx?Type=THR"}],"container-title":["BMJ Open Quality"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/syndication.highwire.org\/content\/doi\/10.1136\/bmjoq-2026-004147","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,7,6]],"date-time":"2026-07-06T13:30:05Z","timestamp":1783344605000},"score":1,"resource":{"primary":{"URL":"https:\/\/qir.bmj.com\/lookup\/doi\/10.1136\/bmjoq-2026-004147"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,7]]},"references-count":28,"journal-issue":{"issue":"3","published-online":{"date-parts":[[2026,7,6]]},"published-print":{"date-parts":[[2026,7]]}},"alternative-id":["10.1136\/bmjoq-2026-004147"],"URL":"https:\/\/doi.org\/10.1136\/bmjoq-2026-004147","relation":{},"ISSN":["2399-6641"],"issn-type":[{"value":"2399-6641","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,7]]}}}