Developing a national standard for surgical quality
Throughout the long history of established ACS Quality Programs and the development of several new specialty- and population-based programs, common themes between programs have emerged as critical to success. Using these themes as a basis, the ACS has sought to establish a single framework for quality to underpin the entire House of Surgery within a hospital. To this end, Optimal Resources for Surgical Quality and Safety, informally known as the “Red Book,” was published in 2017 to serve as a manual for establishing a cohesive infrastructure for surgical quality. The Red Book quickly gained traction with surgeon leaders across the country to serve as a national model and taxonomy, giving shape to the core tenets of quality by emphasizing principles of the following areas:
- Organizational management and communication
- Effective leadership
- Safety culture and high reliability
- Standardization across the five phases of care
- Development of integrated practice units
- Quality measurement and surveillance
- Active quality and process improvement
Following the four-part model to evaluate quality of care, the ACS has extracted salient elements of the Red Book to create standards for a hospital verification program, now known as the ACS QVP. In the fall of 2018, the ACS began piloting the standards and verification process at 20 volunteer hospitals across the U.S., Japan, and Australia. The hospitals visited represented a diverse profile with variation in size, setting, and geography, as well as differences in academic, community, and public designation with various surgeon employment models.
ACS QVP and the onset of the COVID-19 pandemic
In early 2020, pilot visits for ACS QVP were being conducted just before the onset of the COVID-19 pandemic. Several of the visited hospitals, including New York Health + Hospitals Jacobi Medical Center, Bronx, NY, and Carolinas Medical Center, Charlotte, NC, were faced with the challenge of transforming their surgery departments in the early phases of the pandemic to respond immediately to this public health crisis. Hospital leadership found that many of the core principles behind the ACS QVP standards were key to their ability to effectively respond to the COVID-19 pandemic. Ongoing conversations between these hospitals and ACS leadership demonstrate how their hospital’s preparation for the ACS QVP site visit was critical to their success in responding to the pandemic, aspects of which represent valuable insights for other hospitals.
Common themes shared by pilot hospitals
As one might expect of early adopters, nearly all the volunteer participants in the ACS QVP pilot had some evidence of demonstrable commitment to surgical quality or had given considerable thought to the organization and implementation of their surgical quality infrastructure.
A striking common thread in participants’ site visit reflections was the assumption that their hospital had at minimum informal mechanisms for communication, ongoing quality assurance (that is, case review and peer review), and quality improvement (QI) that spanned all surgical specialties. However, as a result of site visit preparation, most found this infrastructure was less robust or wide-reaching than they had assumed. After some investigation, most found that quality infrastructure was highly variable between pockets of surgery; some had virtually no mechanism of outcome evaluation or connection to surgical quality initiatives. Nearly all pilot hospitals lacked an established surgical quality leader with purview across all surgical specialties to lead, communicate, and provide accountability to larger quality goals within surgery. For many, the site visit was the first time a diverse group of leaders from across surgical subspecialties, anesthesia, nursing, and critical care came together to discuss surgical quality. Even in hospitals with robust quality initiatives, much work was done within silos or by ad hoc committees without a formal tie-in to an organizational framework spanning surgical specialties. A common example is in the implementation of enhanced recovery protocols, where there is often sporadic resource allocation, outcomes measurement, and pathway adoption and interpretation.
Looking across all 20 pilot hospitals, the models for surgical quality infrastructure become even more diffuse. Many described a multiple-hospital, system-level approach to establish common practices within specialties across hospitals, but noted how variable infrastructure, resource allocation, and a top-down approach undermined meaningful execution and wide adoption by frontline surgeons.
COVID-19 pandemic response reveals gaps in quality infrastructure
In the face of a rapid and dramatic onset of the COVID-19 pandemic, hospitals in hard-hit regions were restructured on the fly to conserve and redirect human and physical resources. They were forced to define and cease all elective operations, interpret new and occasionally conflicting guidelines, and convert recommendations into real-life protocols to protect patients and staff that continued to change week after week. In many cases, new leaders and communication tools were identified overnight. Confusion about the flood of new information and its interpretation left hospitals overwhelmed and struggling to maintain the morale of valuable frontline providers who were putting themselves at personal risk. Even the nation’s leading hospitals struggled to respond internally, while also facing demand to coordinate with other hospitals locally and nationally to share ideas and prepare for peak resource demand.
During this time, the ACS convened daily meetings with surgeon leaders across the country, conducted interviews with ACS QVP pilot hospitals, and reviewed available literature, including nationwide surveys on hospital responses to the COVID-19 pandemic. Through this investigation, several common areas identified for improvement emerged, as follows:
- A need for leadership and centralized decision-making across departments/specialties
- Established avenues for frequent communication across and up and down the organization, using an established taxonomy, in a time of rapidly changing circumstances and policies
- Organizational management infrastructure that gives voice to a wide range of perspectives and fosters innovative approaches to problem solving
- The need for a foundation of a positive safety culture built on trust and transparency to support surgeons and staff when under intense pressure, responding to a rapidly changing environment, working long hours, and at increased personal risk
- The need for established, trained quality and process improvement resources to quickly innovate and implement new policies and procedures
- A common model for organizational infrastructure addressing surgical issues at the specialty level, hospital level, system level, and between systems in the community that may need to work together to create a coordinated response
- Data and surveillance mechanisms for monitoring patient outcomes and evidence-based decision-making
ACS QVP pilot helps hospitals prepare for the COVID-19 pandemic
ACS QVP pilot hospitals identified elements of the ACS QVP standards that specifically prepared them to respond to the pandemic. These standards address surgical quality but are based on universal principles of organizational management that could be broadly applied. The principles are common to all ACS programs, but what is unique to ACS QVP is the alignment of quality efforts across all surgical specialties and patient populations, many of which are without dedicated verification programs.
The ACS QVP standards articulate a single, national model for organizational management and infrastructure for surgical quality.
The following themes are common to both the COVID-19 response and standards in the ACS QVP. For a complete listing of the ACS QVP standards, visit https://www.facs.org/quality-programs/quality-verification/program-standards.
- Leadership and the Surgical Quality Officer
- Organizational Management, Communication, and the Surgical Quality and Safety Committee
- Safety Culture and Staff Morale in a Time of Crisis Management
- Leveraging QI Resources During Pandemic Response
- Standardization Across the Five Phases of Care Creates a More Nimble and Reliable Care Model
Leadership and the Surgical Quality Officer
The COVID-19 pandemic highlighted the need for coordinated leadership at every level of the institution. The ACS QVP articulates the need for a formal surgical quality leader known as the Surgical Quality Officer (SQO). The SQO has purview and accountability across the entire House of Surgery and is positioned within the hospital’s organizational framework with reporting relationships to the hospital administration, quality department, nursing, anesthesia, critical care, and identified leaders within each surgical specialty. In the context of the COVID-19 pandemic, the SQO was uniquely positioned to do the following:
- Quickly convene surgeon leaders across the institution to gather input and guide inclusive, thoughtful policy-making through established communication channels
- Collectively represent surgeon perspectives to hospital administration when making sweeping policies affecting surgery in preparation for the pandemic, such as the following:
- Limiting personal protective equipment (PPE) use
- Changing operating room policies
- Categorizing and canceling elective surgery
And following pandemic surges:
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- Resuming elective surgery
- Managing prioritization of patients
- Addressing the backlog of procedures
- Centralize and prioritize response initiatives to ensure implementation of rapidly changing policies were met within surgery
- Serve as a decision-maker when navigating conflicting guidelines (for example, laparoscopic versus open procedures) and address issues with interpretation of policies (such as creation of surgery cohorts, policies for at-risk providers, provider wellness initiatives, and so on)
- Provide a global perspective on surgery with the ability to unite specialties and ensure there were not duplicate efforts or conflicting initiatives between individual specialties
- Establish alignment between hospital administration, nursing, anesthesia, critical care, and surgery policies
The Surgical Quality and Safety Committee
The ACS QVP requires the establishment of a formal Surgical Quality and Safety Committee (SQSC). This committee includes representation from identified leaders within each surgical specialty to represent the breadth of surgery and involves leadership from departments such as nursing, anesthesia, and critical care. The committee serves as a forum for collaboration, sharing of best practices, data review, and standardization. Led by the SQO, this committee identifies and monitors opportunities for improvement and sets quality goals across surgery.
While the ACS QVP standards articulate the infrastructure and resources specific to surgical quality, its foundation is based on general principles of organizational management, which are applicable beyond surgery. In the context of the COVID-19 pandemic, the SQSC served as the primary vehicle for bi-directional communication and decision-making on rapidly changing policies through previously established channels. As a result, surgery was positioned within the overarching hospital framework as a valuable contributor to decision-making, problem solving, and communication efforts both leading up to and following pandemic responses. Following are some examples of these activities:
- Classification and postponement of elective surgery
- Guidelines on open versus laparoscopic procedures
- Creation of surgeon and operating room team platoons
- Preoperative and postoperative COVID-19 testing and management of surgical patients
- Postpandemic resumption of surgery to appropriately prioritize and manage backlog of patients
- Navigate postpandemic financial pressures and constraints on staff and resources
Safety culture and staff morale in a time of crisis
The ACS QVP positions safety culture as the foundation for quality in surgery. Participating hospitals are asked to demonstrate the highest level of commitment to safety, with the goal of creating a generative work environment that anticipates both sentinel and morbidity events and positions quality and safety at the core of every aspect of the hospital’s infrastructure. This environment, in turn, creates a community of trust, transparency, and pride among all staff.
Amid a pandemic response, with staff under intense pressure and at personal risk, the foundation of a positive safety culture was paramount to ensuring stability in the workplace, ensuring the safety of both patients and staff, and to supporting a sense of collective and collaborative responsibility to serving patients. Facing adversity can sometimes bring teams closer together, but first a foundation of trust, transparency, and shared commitment must be established. The ACS QVP verifies that the hospital’s commitment to safety culture is at the core of its mission and pursued and evaluated actively and continuously across all surgical teams.
Leveraging QI resources
An infrastructure for QI implementation, in the form of formalized case review, peer review, a quality control committee, and dedicated leadership in quality is critical to the success of quality programs. An infrastructure modeled on the success of the ACS trauma and bariatric verification programs creates an organized flow of information to ensure adequate detection of problems and appropriate resource allocation to implement solutions and monitor progress. A variety of QI methodologies can be implemented within this framework, including Lean Six Sigma, plan-do-study-act, and others. The ACS QVP verifies that trained, experienced, and dedicated personnel are available to support formal QI activities.
The COVID-19 pandemic spurred rapid innovation and change management. Whether it was to find ways of preserving or extending use of limited PPE and mechanical ventilators or to quickly develop educational materials to safely redeploy providers, having an experienced team, dedicated QI resources, and overall hospital culture experienced in QI and change management prepared hospitals to be nimble and innovative in their response. Quality initiatives focused both on innovating care for patients and safeguarding hospital staff during a critical time of need.
Standardization across the five phases of care
The ACS QVP standards emphasize the need to minimize unnecessary variation in surgical care. Without the use of standardized protocols and care pathways, there is more room for error, duplication of efforts, increased use of resources, and missed opportunities to mitigate patient risk. The ACS QVP creates a framework for identifying opportunities for standardization across the five phases of care.
In response to the COVID-19 pandemic, hospitals were quickly changing policies, sometimes weekly, regarding the availability of in-person evaluation at preoperative and postoperative clinics, OR preoperative testing, and management of suspected COVID-19 patients, among others. This change was compounded by surgical teams working staggered shifts to limit exposure and burnout. Hospitals with previously established standardized protocols for surgical patients across the phases of care were positioned to be nimble in their ability to quickly adapt to a pandemic response.
A national model
The ACS QVP establishes a national model for surgical quality that can be leveraged to support communication and decision-making, and provide leadership and necessary infrastructure in a time of pandemic response. ACS QVP pilot hospitals have drawn direct correlations between their implementation of the ACS QVP standards and their improved ability to respond to the COVID-19 pandemic. The ACS QVP has been developed using common elements from other ACS Quality Programs with proven track records for improving quality and is built on the long-established four-part ACS Quality Model of setting standards, building infrastructure, using data, and ongoing verification.
Although these concepts alone are not new to the surgical realm, the ACS QVP is unique in that it sets forth a structured model for implementation, measurement, and verification of these principles across surgical specialties to help hospitals on the journey to improving care for all surgical patients. It is the cross-specialty nature of the ACS QVP, combined with the clearly defined infrastructure that allows it to be ideally suited to assist surgical communities to respond to any crisis in a way that optimizes the care of surgical patients and the well-being of surgeons and staff.
For more information about ACS QVP, visit https://www.facs.org/quality-programs/quality-verification.
Bibliography
American College of Surgeons. COVID-19 and surgery: Resources for the surgical community. Available at: https://www.facs.org/covid-19. Accessed August 12, 2021.
American College of Surgeons. Making quality stick: Optimal Resources for Surgical Quality and Safety: The SQSC and credentialing and privileging processes ensure sustainability of standards. December 6, 2017. Available at: https://bulletin.facs.org/2017/12/making-quality-stick-optimal-resources-for-surgical-quality-and-safety-the-sqsc-and-credentialing-and-privileging-processes-ensure-sustainability-of-standards/. Accessed August 12, 2021.
Ellison A, Gamble M. 73 hospital leaders in 10 states hit hardest by COVID-19 offer advice to colleagues: If you do nothing else, at least do this. Becker’s Hospital Review. Available at: https://www.beckershospitalreview.com/hospital-management-administration/65-hospital-leaders-in-10-states-hit-hardest-by-covid-19-offer-advice-to-colleagues-if-you-do-nothing-else-at-least-do-this.html. Accessed August 12, 2021.
Fischer CP, Hu QL, Wescott AB, Maggard-Gibbons M, Hoyt DB, Ko CY. Evidence review for the American College of Surgeons quality verification part II: Processes for reliable quality improvement. J Am Coll Surg. 2021;233(2):294-311.e1.
Hu QL, Fischer CP, Wescott AB, Maggard-Gibbons M, Hoyt DB, Ko CY. Evidence review for the American College of Surgeons quality verification part I: Building quality and safety resources and infrastructure. J Am Coll Surg. 2020;231(5):557-569.e1.
Institute of Medicine. Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations: A Letter Report. Washington, DC: The National Academies Press; 2009. Available at: https://www.nap.edu/catalog/12749/guidance-for-establishing-crisis-standards-of-care-for-use-in-disaster-situations. Accessed August 12, 2021.
U.S. Department of Health and Human Services Office of Inspector General. Hospital experiences responding to the COVID-19 pandemic: Results of a national pulse survey March 23–27, 2020. Available at: https://oig.hhs.gov. Accessed August 12, 2021.
World Health Organization. Coronavirus disease (COVID-19) pandemic guidelines. Available at: https://www.who.int/emergencies/diseases/novel-coronavirus-2019. Accessed August 12, 2021.
