Michigan hospital participates in first pilot site visit for new ACS rural surgery verification program

To assist rural surgeons and rural hospitals in their efforts to provide consistent, high-quality surgical care and continually improve the care of surgical patients, the American College of Surgeons (ACS) is developing a new standards-based verification program for rural surgery (see related article for details). An initial pilot site visit for this program was conducted September 12−13, 2019, at the MidMichigan Medical Center-Alpena (MMMC-Alpena).

MMMC-Alpena

Alpena is a town with a population of 10,000 in the northeast portion of Michigan’s lower peninsula. The pilot hospital, MMMC-Alpena, is a geographically remote hospital located at least 96 miles away from larger medical centers. MMMC-Alpena is part of the MidMichigan Medical System, a seven-hospital system based in Midland. MMMC-Alpena has an average daily patient census of 60−65 patients. The surgical staff consists of four general surgeons, including the author; four orthopaedic surgeons; three obstetrician-gynecologist surgeons; three podiatrists; one ophthalmologist; and one urologist. I am a general surgeon at MMMC-Alpena.

Based on the many positive benefits that MMMC-Alpena has seen through its participation in the ACS Trauma Verification Program and Commission on Cancer Program, our hospital was eager to participate as a pilot site for the new rural surgery verification program that the ACS is developing under the purview of the Advisory Council on Rural Surgery (ACRS). The hospital leadership feels that participation in this program will assist in the recruitment and retention of surgeons. Hospital leadership also anticipates that the quality improvement portion of the program will lead to decreased complications, which translates into better patient-centered care and satisfaction, as well as improved financial viability.

Program standards

The leadership at MMMC-Alpena received a detailed list of the 38 program standards that would be evaluated during the site visit. The thought of meeting 38 standards may generate a sense of foreboding, but these standards are common-sense principles that address what a hospital needs to do to properly provide care to surgical patients. This program is not pass/fail. These 38 guidelines provide a framework to evaluate how well we are doing to ensure quality and safety for the surgical patient and give us an organized structure to continually improve. The standards are summarized under the following categories:

• Institutional administrative commitment. These standards ensure ongoing participation in the program and communication and alignment at all levels of the institution.
• Program scope and governance. These standards show the need for our surgeons and hospital to clearly define our scope of practice; that is, the types of surgical patients and conditions that can safely be cared for at our hospital. This program will apply to all surgical procedures performed at our hospital. Additionally, these standards describe how we can use our surgeons and other hospital personnel involved in the care of the surgical patient to develop a Surgical Quality and Safety Committee, which will oversee the program.
• Facilities and equipment resources. These standards help us to evaluate whether we have the proper resources in our emergency department (ED), operating room (OR), postanesthesia care unit, inpatient treatment areas, laboratory, blood bank, pharmacy, and radiology department to care for surgical patients within our defined scope of practice.
• Personnel and services resources. These standards help us to evaluate whether we have the qualified surgeons, nursing services, surgical OR team, on-call coverage, anesthesia services, and medical specialty services to care for surgical patients within our defined scope of practice.
• Patient care: Expectations and protocols. These standards show the benefits of developing standardized and team-based processes to ensure quality, safety, and reliability in the five phases of surgical care (preoperative, immediate preoperative, intraoperative, postoperative, and postdischarge), and help us evaluate and improve our efforts in the areas of patient education, informed consent, risk assessment and prehabilitation, infection prevention, rapid response and rescue protocols, enhanced recovery and rehabilitation, and discharge planning and social services.
• Data surveillance and systems. These standards show us how to develop a system to collect and use objective clinical data to surveil for and identify potential surgical quality and safety issues.
• Quality improvement. These standards help us to develop our case review, peer review, and surgical credentialing and privileging programs so that they work together to develop a hospitalwide culture of patient safety and high reliability. By following the principles in these standards, continuous quality improvement efforts can be driven through proper data analysis.

Previsit preparation

Before the site visit, hospital leadership at MMMC-Alpena received a detailed prereview questionnaire (PRQ) which the hospital completed and returned to the ACS for consideration prior to the site visit. The PRQ contained many questions related to the standards listed previously. A lot of time and effort was required to gather the information to complete the PRQ; however, this process helped to lay the foundation for the teamwork necessary to successfully implement the program.

General surgeons and specialty surgeons also completed a detailed questionnaire prior to the site visit. This questionnaire asked the surgeons to evaluate the adequacy of the hospital’s facilities and equipment resources, surgical team call coverage, medical specialty services, data collection, and data surveillance. The questionnaire also gave the surgeons the opportunity to comment on the case review/peer review/credentialing/privileging process and the overall strengths and weaknesses of the hospital. Hospital leadership completed a series of previsit checklists to assess the resources in the OR, lab, ED, radiology department, and medical specialty services.

MMMC-Alpena pilot site visit

ACS site reviewers included David B. Hoyt, MD, FACS, Executive Director; Clifford Y. Ko, MD, MS, MSHS, Director, Division of Research and Optimal Patient Care; and Chelsea Fischer, MD, ACS Clinical Scholar.

The first day of the site visit began in the early afternoon of September 12, 2019. The ACS site reviewers met with hospital leadership, nursing administration, and surgeons. After opening statements by Dr. Hoyt, a discussion took place to evaluate how well the hospital was meeting the program standards for peer review, case review, patient care, data collection, and data surveillance.

The ACS site reviewers then conducted a detailed chart review of surgical patients treated at our hospital in the last year. Our medical records department printed charts from each surgical specialty that showed examples of preoperative risk management, intraoperative complication management, postoperative complication management, as well as all cases that had been pulled for internal quality review through our case review system. These charts were reviewed to determine how well our hospital was meeting the program standards for patient care, case review, facilities and equipment resources, personnel and services resources, data collection, data surveillance, and quality improvement.

Following the chart review, a working dinner took place in the hospital cafeteria. A large group attended, including the ACS site reviewers, the hospital president, vice-president of medical affairs (VPMA), chief nursing officer, surgeons, and representatives from virtually every area of the hospital involved in providing care to surgical patients. After Dr. Hoyt gave a brief summary of the program, attendees had the opportunity to ask questions and learn how the work they already are doing will be incorporated into the program.

The site visit continued the following morning with individual meetings with representatives from general surgery and the surgical specialties to determine how they conduct case review, peer review, credentialing, and privileging. Each group also was asked whether they did any specific data collection and, if so, how they used the information to guide quality improvement activities.

Checklists that had been previously completed to assess the resources in the OR, lab, ED, radiology department, and medical specialty services were thoroughly evaluated to assure that these departments had the proper resources to care for surgical patients. Individual interviews were then conducted with the VPMA, chief of anesthesia, chief nursing officer, and the surgeon who would be leading the Surgical Quality and Safety Committee to review their roles in the program.

A final summary conference then took place that same day, with approximately 20 health care professionals who had participated in the site visit in attendance. The ACS site reviewers gave a detailed summary of their findings and offered suggestions for areas for us to work on.

The ACS pilot site visit report

In October 2019 our hospital received a comprehensive and detailed site visit report from the ACS listing a numeric score and comment section for each of the 38 standards. In the comment sections, 28 recommendations were made, which we will begin working to implement.

What we learned

We learned a great deal from this site visit. We learned our strengths and weaknesses as a health care institution. We received many specific suggestions for improving patient care and driving quality improvement. It is clear to the surgeon leaders at MMMC-Alpena that achieving the standards developed for this program always will be a work in progress, but the program provides a structure for us to evaluate our level of care and a working framework that we can use to continually improve quality and safety. As the surgeon who will be leading the Surgical Quality and Safety Committee at MMMC-Alpena, I look forward to the team approach to problem solving that will develop.

According to Deb Pokorzynski, RN, chief nursing officer, MMMC-Alpena, “This was a great review of our current processes. We also learned of many outside resources that will help us to improve the level of care of our surgical patients. The leadership structure that this program develops will be very valuable.” Describing what he views as the main benefits to participating in the improvement program, Chuck Sherwin, president of MMMC-Alpena, said, “The ACS gives us a great platform to work from and then comes onsite to support our efforts and provides the opportunity to learn from others. Another benefit is the confidence it will give to our region. When you come to our hospital for surgery, you can be assured that high-quality care will be delivered and that the necessary support structures are in place to provide exceptional care.”

Rural surgeons or hospital administrators interested in learning more about or participating in this program should contact Stephanie Mistretta, Project Manager, ACS Accreditation and Verification Program Development, at smistretta@facs.org, or Amy Robinson-Gerace, Senior Manager, ACS Accreditation and Verification Program Development, at agerace@facs.org.