The ACS has promoted the advancement of surgical quality for more than a century. Today, these efforts are reflected in surgical quality programs in more than 2,500 hospitals across the US. Tailored to be both condition-specific (e.g., trauma and cancer) and population-specific (e.g., children’s surgery verification, geriatric surgery verification), each program is built on the ACS’s four pillars that guide continuous quality improvement—standards, infrastructure, data, and performance.1
From the onset of these programs, the College has recognized the need to integrate these foundational principles across each institution, consolidating and aligning resources and infrastructure for quality improvement across specialties and patient populations. As a result, the ACS introduced the Quality Verification Program (QVP) in 2021, which includes 12 foundational principles of quality and safety to guide hospitals in improving patient care.2 More than 60 academic, community, and military hospitals currently participate in this program.
To date, two articles published in the Journal of the American College of Surgeons (JACS) have reported evidence in support of several QVP standards, such as institutional administrative commitment, program scope and governance, infrastructure necessary for quality,3 data surveillance, and systems like peer review and credentialing.4 In a recently published article in JACS, the authors report current evidence in support of team-based and disease-based clinical programs, compliance with hospital-level regulatory metrics, and the programs’ effects on patient outcomes.5
Current Evidence Supporting Perioperative, Multidisciplinary Surgical Care
Increasingly familiar to most surgeons, enhanced recovery has become synonymous with standardized perioperative care pathways. These programs have expanded broadly from their initial application in colorectal surgery to include several other patient populations seen in this recent review, such as head-and-neck and hepatopancreatobiliary surgery. These programs incorporate several integral components for the perioperative recovery of the patient, including preoperative education and counseling, perioperative nutritional optimization, and standardized pain control. Across several different types of perioperative protocols, improved outcomes have been demonstrated, including reduced hospital length of stay (LOS), readmissions, costs, and complications; increased likelihood of home discharge; reduced time to operation; and improved guideline-concordant care in cancer patients.
Similarly, multidisciplinary, disease-based management is increasingly identified throughout the healthcare landscape as an essential component of high-quality patient care. Targeting cancer and a variety of other conditions, these efforts frequently take the form of multidisciplinary treatment meetings, resembling tumor boards with perioperative care protocols, as well as clinical teams coordinating care in real time. Again, improved outcomes have been associated with reduced LOS, readmissions, adverse events, and death; and improved patient satisfaction and quality of life.
Improving Targeted Perioperative Care Pathways
The findings noted earlier in this article from the evidence review in JACS5 are becoming more widely intuitive for practicing surgeons and their clinical teams. However, gaps in the literature reflect opportunities for improvement. Within the perioperative care pathways reviewed, preoperative elements were largely confined to patient education elements. Opportunity exists to expand these preoperative elements, tailored to individual patient needs beyond nutritional optimization.
For example, screening for geriatric-specific conditions may allow for improved optimization of physical function and the incorporation of social determinants (e.g., family support, home living situation) into treatment and discharge planning. Additionally, the literature evaluating standardization of postoperative care after hospital discharge (postdischarge phase) is severely lacking, likely due to feasibility of data collection. Leveraging technology (e.g., smart tech, wearable tech, mobile applications) may help bridge this gap.
The outcome measures most tracked in evaluating standardized processes of care were regarding hospital use, specifically LOS and cost. While these are clearly important measures to demonstrate return on investment for hospital administrators and decrease hospital waste, future studies also should consider incorporating patient-reported outcomes to ensure pathway development is as advantageous to patients as it is to hospitals.
Much like the growing trend of multiphasic standardized surgical care, many surgeons are familiar with these types of initiatives. Given the advancing knowledge, increasing specialization, and rapidly developing nonsurgical treatment options, multidisciplinary care for complex cancer patients appears intuitive and may additionally help identify patients eligible for clinical trials.
However, these trends are increasingly observed in other diseases (e.g., obesity). Not all conditions will require rigorous multidisciplinary management, and the potential value added by incorporating these practices appears to correlate with the complexity of both the disease itself (advanced cancer) and the available treatment options. Therefore, these programs should be applied strategically to maximize quality benefits in light of resource and timing costs.
Verification and Accreditation Enhance Value
Participation and compliance with hospital-level regulatory and accreditation mechanisms is incorporated within the ACS QVP. Evidence exists to support the value of adhering to externally mandated process measures such as those advocated by the Surgical Care Improvement Project, The Joint Commission, and the Agency for Healthcare Research and Quality. Reported improved outcomes include reduced complications such as infection, venous thromboembolism, and death.
Other studies demonstrated little to no effect on outcomes, including single institution and large multicenter observational data. Evaluation of outcomes at accredited versus nonaccredited hospitals showed similarly mixed results, though most facilities reported reduced unplanned hospitalizations, death, and readmissions, as well as increased adherence to process measures.
Coupled with the mixed evidence in favor of process measure compliance, these findings suggest process measure compliance may be insufficient alone to effectively promote quality. A possible explanation for observing benefits in accredited centers is the added value of external oversight, incorporation of structural and process measures, and infrastructure investment that accompanies participation in external verification. Despite variable evidence of the effects of externally promoted process measures on improving patient outcomes, reductions in mortality and unplanned hospitalizations were observed for select populations.
ACS QVP
The ACS QVP was designed to define, assess, and ensure that healthcare institutions have the structures and processes necessary for safe, high-quality care. Evidence supports the validity and potential impact of these standards when applied independently. However, we anticipate exponential benefits resulting from the application of all 12 standards of the ACS QVP, which represent a comprehensive collection of essential principles to promote surgical quality across all surgical specialties.
