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Become a member and receive career-enhancing benefits
Our top priority is providing value to members. Your Member Services team is here to ensure you maximize your ACS member benefits, participate in College activities, and engage with your ACS colleagues. It's all here.
New ACS Quality Framework and Toolkit Offer Organized Approach to QI
Karen Pollitt and Lynn Modla
June 7, 2023
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ACS Quality Program hospitals perform more than 3,500 quality improvement (QI) efforts annually as part of the accreditation/verification process. These small-scale efforts are usually local and conducted by frontline clinicians and clinical teams.*†
Resources for implementing QI projects vary by local setting but fundamentally include leadership, personnel, time, skills and expertise, access to evidence, and organizational capacity to make improvements.‡
To support this QI work, the College released the ACS Quality Framework and Toolkit, which was developed by surgeon and staff representatives from seven ACS accreditation/verification programs—trauma, cancer, breast disease, rectal cancer, children’s surgery, bariatric surgery, and geriatric surgery.
These resources provide an organized approach to guide surgeons and quality teams in planning, conducting, evaluating, and reporting of improvement projects.
The Quality Framework consists of eight components with associated criteria organized around the three phases of a QI initiative—planning, conducting, and reflecting.
Planning Phase
An effective improvement plan begins with assessing the current situation to determine the project focus and implementation process, and then developing strategies to put the plan in place. The three components in the Planning Phase are:
Problem detailing: A problem statement defines the challenge and outlines the scope of the project. The process of problem detailing will guide the project team through analyzing what data are available as a baseline, assessing why the problem matters and who it impacts at a local level, and determining what stakeholders need to be involved in the project.
Aim specification: Creating an aim statement helps clarify and define the goal of the project. The aim statement should be specific, measurable, achievable, relevant, and time-bound (SMART). An impactful aim statement succinctly describes the project goals and presents them in a manner that is understandable to clinical teams and leadership.
Strategic planning: The strategic plan is the blueprint for carrying out a successful improvement intervention. Discussing implementation strategies with the project team ensures that all members understand the rationale behind the intervention, which drives stakeholder buy-in throughout the project. Strategic planning also drives the team to define the resources and data needed, and potential limitations and barriers of the plan to ensure an effective project.
Conducting Phase
Developing a plan of action to successfully implement the project and evaluate results at regular intervals is key to a successful project. There are three components in the Conducting Phase:
Process Evaluation: Process evaluation involves periodically checking whether the intervention is being performed as planned (regular data collection within the specified timeframe, and so on). Analyzing the implementation process also can reveal whether any problems encountered were caused by a design flaw in the intervention, an unforeseen barrier in the operating environment, or other factors. This information can be used to adapt the intervention if necessary, and help others understand the mechanisms behind the success of the project so that it can be replicated and developed for other contexts.
Outcome Evaluation: Outcome evaluation helps the team reflect on the results and assess effects on other processes or outcomes. This evaluation includes determining whether the project aims were met and why (or why not); identifying limitations to the outcomes of the project; noting any unintended consequences of the intervention; and assisting the team with informing stakeholders of the project’s results.
Cost Evaluation: Performing cost evaluation can help the team, project sponsors, and stakeholders examine the cost and value of a QI project after implementation. Cost evaluation includes both fiscal (e.g., return on investment) and nonfiscal (e.g., reflections on the implicit value of a project) considerations and can be used to make more informed decisions about resource allocation for future initiatives.
Reflecting Phase
Sharing the results and lessons learned from the project contributes to a culture of QI. The two components of the Reflecting Phase are:
Knowledge Acquisition: Documenting lessons learned enables the team to record the experience gained (both positive and negative) while executing a project. Promoting the process of sharing results also allows organizations to apply the knowledge from previous projects to new initiatives and contributes to a culture of QI.
End-of-Project Decision-Making: The end-of-project stage allows teams to reflect on the overall project and, if needed, determine new strategies for ensuring its continued success. These strategies could include a sustainability plan to evaluate the long-term effectiveness of their intervention, an analysis of how the project might translate to other clinical arenas, or testing the improvement intervention in another care setting.
The accompanying Toolkit includes a range of optional resources to support QI efforts, including a project charter, communication plan, data plan, and planning worksheet. A User Guide was developed to help QI teams plan and execute QI projects.
The ACS would like to ensure that the initial version of the Quality Framework is improving and evolving to meet the needs of surgeons and clinical teams. The College welcomes your feedback, which is critical to future versions of this tool: surveymonkey.com/r/ VR86P7P.
In addition, the ACS has developed a range of resources to help build skills and knowledge and support your team’s quality improvement work. The ACS Quality Improvement Course: The Basics is a self-paced, online course on the basic principles of surgical quality and safety. The course—intended for anyone working in a healthcare setting who is learning the foundations of QI—can help QI teams learn the necessary concepts, processes, and tools needed to meet the criteria of the Quality Framework. Visit facs.org/quality-programs/quality-improvement-education for all available resources.
Learn more about the Quality Framework and other resources at the Quality and Safety Conference, July 10-13, in Minneapolis, Minnesota, at facs.org/qsc2023. Three sessions will be dedicated to understanding and implementing the Quality Framework.
The ACS is launching a case study repository later this summer to share how participating hospitals use programmatic data to improve their performance and outcomes. This collection of QI initiatives will allow the ACS to share lessons learned and educate surgical teams on small-scale quality initiatives that have been deployed in hospitals around the country to improve patient outcomes.
Karen Pollitt is the Senior Manager of the Quality Resource Team in the ACS Division of Research and Optimal Patient Care in Chicago, IL.
*Harvey G, Wensing M. Methods for evaluation of small scale quality improvement projects. Qual Saf Health Care. 2003;12(3):210-214.
†Ko CY, Tejen S, Nelson H, Nathens A. Developing the American College of Surgeons Quality Improvement Framework to Evaluate Local Surgical Improvement Efforts. JAMA Surg. 2022;157(8);737-739.
‡Ko CY, Shah T, Nathens A, Grant C, et al. How well is surgical improvement being conducted? Evaluation of 50 local surgery-related improvement efforts. J Am Coll Surg. 2022;235(4):573-580.
