Quality and Safety Conference Focuses on Visions of Value in Surgery

In a rapidly changing healthcare environment, “quality is more critical than ever before,” according to Clifford Y. Ko, MD, MS, MSHS, FACS, Director of the ACS Division of Research and Optimal Patient Care, in his introductory remarks at the 2024 Quality and Safety Conference.

“There isn’t enough funding, there isn’t enough workforce, there isn’t enough wellness—all of these challenges are happening right now in medicine, and perhaps in surgery most of all,” he said, making it clear that the power of value is a multifaceted and core part of improving care.

More than 1,500 surgeons, nurses, registrars, surgical quality officers, and other members of the healthcare community joined Dr. Ko and other leaders in quality improvement (QI) at the conference, themed “The Power of Value: Expanding Your Impact,” which took place July 18–21 in Denver, Colorado, to share and learn how value is inextricably linked to surgical quality improvement and patient safety.

In addition to key general sessions summarized in this article, the conference featured new and engaging activities, including a “Quality Rumble: Family Feud Showdown,” as well as an interactive “General Session Workshop on Measuring Value—From Stakeholder to Stakeholder.” Dozens of breakout sessions, poster abstracts, several preconference workshops and courses, including the popular “QI Basics Preconference Workshop” and social events rounded out the meeting.

With quality as an undeniable partner to achieving value, Dr. Ko placed emphasis on the seismic impact of the ACS National Surgical Quality Program^® (NSQIP^®) in this space, which is particularly notable in 2024—the 20-year anniversary of the introduction of NSQIP to the US health system.  

“NSQIP has changed the way surgical safety is evaluated and achieved, and it continues to be recognized as the gold standard for clinical data registries and QI,” Dr. Ko said.

There is more to value than finances, according to Lillian S. Kao, MD, MS, FACS, the Jack H. Mayfield, MD, Chair in Surgery at the McGovern Medical School at The University of Texas Health Houston. In a session immediately following Dr. Ko, Dr. Kao laid out the key questions on the power of value.

“Value is in the eye of the beholder,” Dr. Kao said. “Through what lens should we be measuring value? And what does value mean to you? There are different answers for different stakeholders.”

She also explained that while patients will value personalized treatment, a healthcare team will value clinical outcomes, caregivers will value communication and compassion, and insurers will value cost containment. It is incumbent upon QI leaders to align the different definitions of value, she said.

Expanding Your Impact through Leadership and Technology

Affecting long-lasting change comes with a learning curve and a need to understand your team and environment.

Part of the challenge is helping your team (e.g., hospital leadership, other surgeons, nurses, and technicians) understand that change is taking place and that the approach matters, according to Benjamin C. DuBois, MD, FACS, surgical quality director at CHRISTUS St. Michael Health System in Texarkana, Texas.

“It’s not the change itself, it’s how you change—it’s your approach to the change that you’re seeking,” he said, noting that change management incorporates three key skills: recognizing you are going through a change, communicating accurately about your change to stakeholders, and leading with introspection.

Dr. DuBois described how he managed change by introducing enhanced recovery after surgery (ERAS) and Strong for Surgery^® checklists at his hospital-based preoperative clinic, and by creating buy-in and building a team of enthusiastic volunteers from across the five phases of surgical care, the institution was able to decrease overall complications, lengths of stay, and costs.

Modern technology such as artificial intelligence (AI) has the potential to change surgeons’ speed and effectiveness in effecting change, noted Catherine Buck, MS, MBA, director of clinical informatics at Liberty University in Lynchburg, Virginia, and Jacob R. Gillen, MD, FACS, MHCDS, associate professor of surgery at the Virginia Tech Carilion School of Medicine in Roanoke.

Effective use of the technology comes with recognizing that it is more accurately described as “augmented” intelligence, not artificial, according to Buck.

AI is being used in forms such as ambient listening to summarize conversations and notes in the OR or for gathering quality data based on human-designed parameters. It is, as of now, dependent upon healthcare worker input to guide its actions. But if used correctly, AI can be useful for “balancing efficiency and accuracy with cost,” she said, adding that “humans need to make a choice in what to focus on, but technology can help solve that problem.”

Dr. Gillen added that AI can have an impact today by taking disparate information in a medical chart, such as progress notes, radiology reports, and lab values, and synthesizing the information and bringing relevant information forward.

The tool can turn “surgical clinical reviewers from scavengers into auditors who spend more time as clinical decision-makers, using their medical expertise to its fullest,” he said.

Different Perspectives on Value

Practicing surgeons are likely to have broadly similar perspectives on the how and why of achieving surgical quality and safety. However, other groups of stakeholders, who can overlap with surgeons, will place value on distinct aspects of care.

Julie Ann Sosa, MD, MA, FACS, chair of the Department of Surgery at the University of California (UC) San Francisco, offered an account of what is important for patient caregivers, a role she has taken on for her elderly parents.

She explained that caregivers value a variety of things, including empathy, acknowledgement of difficulties, and authenticity, from the patient’s medical team. As a surgeon, she knows that these elements can be difficult to provide in a stressed health system, but professionals should be expected to handle the burden, not families.

“If the burden of care is dropped by a system that is overwhelmed, the caregiver is left to assume the burden,” Dr. Sosa said.

Ensuring that surgeons and care teams are meeting patient needs for value, along with quality and safety in their various forms, falls in the realm of regulatory and compliance entities, and “no other safety or quality entity has feet on the ground with the same reach and impact as The Joint Commission (TJC),” said Haytham M. Kaafarani, MD, MPH, FACS, medical director of quality and safety at Massachusetts General Hospital in Boston.

Dr. Kaafarani, who formerly served as TJC chief patient safety officer, provided a brief rundown of the commission’s role in performing surveys to certify US hospitals as compliant to provide care.

He explained that although the organization has specific standards hospitals must meet, surveyors may need to take a nuanced approach to understanding how hospitals are applying the standards to ensure that the aim of quality care is being met.

All initiatives to achieve lasting quality and safety need to run through, and ideally be fully supported by, hospital leadership. Jacqueline M. Saito, MD, MSCI, MBA, FACS, chief quality and safety officer at Children’s National Hospital in Washington, DC, offered the C-suite perspective on creating value for surgical teams and patients.

The starting point—from clinicians to hospitals leaders to policymakers to payers—must be the patient’s needs, Dr. Saito said, noting that all parties must decide on what metrics really matter. It may be impossible in each situation to achieve your exact intent, but teams need to start somewhere, and focusing on intent, feasibility, and reliability of a measure are critical.

Importantly, “stakeholders must partner with patients, who can help find creative ways to capture the patient’s voice and to find out what really matters to them,” she said.

Link between Collaboration and Value

A running subtheme of the Quality and Safety Conference was an emphasis on teamwork and a truly collaborative spirit.

The modern medical environment continues to reveal that interdisciplinary teamwork is a winning formula in healthcare, according to Michelle Humeidan, MD, PhD, an anesthesiologist and medical director of enhanced recovery at The Ohio State University Wexner Medical Center in Columbus.

“Interdependent collaboration, open communication, and shared decision-making generates value-added patient, organizational, and staff outcomes,” Dr. Humeidan said. She noted that the complexity of modern health leads to more fragmentation, and teamwork based on communication—a notorious weak point in healthcare settings—is critical ensure continuity of care.

A key stakeholder that is often overlooked in a collaborative team is the patient, according to Laurie J. Kirstein, MD, FACS, attending breast surgeon at Memorial Sloan Kettering Cancer Center in Monmouth, New Jersey.

Dr. Kirstein described a project undertaken at one of her institutions to address financial toxicity in patients. The professional team came together with a plan to assist patients that was created with validated tools, and which involved reaching out to patients by phone to discuss their needs.

“The majority of patients who received the phone call either didn’t answer or didn’t want to talk about financial services,” she said. “The project didn’t meet patient needs—it had good intentions, but failed implementation.”

Dr. Kirstein said the problem was that patients were not stakeholders when creating the process. After reviewing facilitators and barriers to patient engagement, she explained that simply asking patients if they wanted to be contacted led to a substantial increase in calls being answered, indicating that communicating with patients directly can lead to success in some initiatives.

One of the arenas where surgical safety, efficacy, and quality are challenged directly is in the morbidity and mortality (M&M) conference. According to Mary Brindle, MD, MPH, director of the Safe Surgery/Safe Systems Program at Ariadne Labs in the Harvard School of Public Health in Boston, Massachusetts, the scope of an M&M should be expanded to multiprofessional sessions.

M&M conferences help improve the quality of a clinician’s work by evaluating decision-making and technical performance and then sharing lessons learned. However, M&Ms are typically “single-discipline silos that don’t bear resemblance to how we actually treat our patients,” Dr. Brindle said.

Nurses traditionally have little representation in these conferences, but they gain the greatest value from attending them, Dr. Brindle noted. As frontline communicators in an OR, nurses are attuned to deficits in communication between members of a surgical team, and their perspective could provide value of clarifying where errors might have occurred in a case.

Navigating the Future of Value

The conference’s final session looked ahead to where visions of value in surgical QI may converge.

It will behoove surgeons to understand how payers play a part in value, according to Kenric M. Murayama, MD, MBA, FACS, executive vice-president and chief health officer in insurer Hawaii Medical Services Association.

Dr. Murayama, a retired surgeon, explained that “payers are trying more and more to be a part of the healthcare ecosystem.”

This reality in the US healthcare system means that surgeons need to be able to converse with and educate payers about value in a way that they can incorporate into their structures. Opportunities to work collaboratively can take the relationship from transactional to a partnership, which can aid in delivering better value outcomes for hospitals and patients.

One of the most direct ways that patients can observe the power of value in healthcare is by taking advantage of public reporting.

David Tom Cooke, MD, FACS, professor and founding chief in the Division of General Thoracic Surgery at UC Davis Medical Center in Sacramento, discussed the tools that are being increasingly offered by federal mandate or internal organization decision and whether they affect patient or hospital actions.

The Society of Thoracic Surgeons, Dr. Cooke noted, has been publicly reporting thoracic surgery data for years, assigning institutions one, two, or three stars (worse than expected/as expected/better than expected). Does public reporting help? According to Dr. Cooke, it motivates institutions to at least raise their baseline.

“The fastest path to becoming a two-star program is having to tell the world you’re a one-star program,” he said, adding that fear, trust, and the complexity of information can encourage patients to take advantage of public reporting, though there is much more data needed to demonstrate value.

The 2025 Quality and Safety Conference—the 20th anniversary of the conference, dating back to its time as the ACS NSQIP Annual Conference—will take place July 17–20 in San Diego, California.

Top 10 Abstracts

More than 800 abstracts were submitted for consideration at the Quality and Safety Conference, and the top 10 were featured in a General Session with brief presentations.

• Comparing Post Lumpectomy Analgesia
  Irada Mamukadze, MD, University of Michigan Health Sparrow, Lansing
• Creating a Toolkit for SCRs New to EG Abstraction
  Christae A. Smith, MSN, RN, CPHQ, Atrium Health, Charlotte, North Carolina
• Development and Implementation of Paging and Escalation Guidelines to Improve Multidisciplinary Communication on Surgical Units
  Michael Kochis, MD, EdM, Massachusetts General Hospital, Boston
• Establishing Outpatient Appendectomy Guidelines in a New Emergency General Surgery Program
  Sioned K. Kirkpatrick, DO, Texas Health Resources Fort Worth
• From Chaos to Coordination OR Case Classification Renovation
  Valerie E. Vralbic, RN, BSN, CEN, Novant Health New Hanover Regional Medical Center, Wilmington, North Carolina
• Improving Discharge Home Post Implementation of the Geriatric Surgery Verification Standards
  Julie M. Giles, AGNP-C, Rochester Regional Health, New York
• Optimizing Initial Case on Time Starts in VA Operating Rooms: A QI Initiative
  Elizabeth Dale Slater, MD, Vanderbilt University Medical Center, Nashville, Tennessee
• Refining Pain Management in Pectus Excavatum Repair through QI
  Krysta M. Sutyak, DO, The University of Texas Health Science Center in Houston
• Sustained Success of a Caprini Postoperative Venous Thromboembolism Prevention Protocol over One Decade
  Anna Kobzeva-Herzog, MD, Boston Medical Center, Massachusetts
• Transition from Paper to Paperless Trauma Flowsheet: Enhancing Trauma Quality Documentation
  Junky De Castro Singson, RN, MSN/INF, CCRN, SBH Health System, Bronx, New York

Matthew Fox is the Digital Managing Editor in the ACS Division of Integrated Communications in Chicago, IL.