The American College of Surgeons (ACS) has been introducing quality improvement (QI) programs since its inception, starting with standards for hospitals and graduate medical education. This legacy lives on and has become increasingly pertinent. Panelists at a Special Session on Wednesday, October 27, will discuss ACS QI programs that are emerging and likely will set a course for the future of patient care. Late Breaking Quality Initiatives in Surgery begins at 12:00 noon Central Time.
ACS Quality Improvement Course: The Basics
“Quality improvement is an integral part of our day-to-day activities,” says Lillian S. Kao, MD, FACS, MAMSE, ACS Governor and Pillar Lead, Board of Governors Surgical Care Delivery Workgroup. For example, if a hospital receives an ACS National Surgical Quality Improvement Program (ACS NSQIP®) report showing that it is an outlier for surgical site infection, the tendency is often to skip directly to finding a solution to the problem. However, this approach is unlikely to yield the long-term QI results the hospital and its surgeons want to experience.
Because many surgeons and other health care professionals have had limited exposure to QI techniques during medical school and their surgical training, the ACS has developed a new Quality Program. “The purpose of the ACS Quality Improvement Course: The Basics is to provide a quality improvement course for practitioners, including surgeons, residents, trainees, program directors, and anyone else involved in overseeing quality improvement efforts,” Dr. Kao says.
The course comprises the following six modules:
- Introduction to Quality Improvement
- The Quality Improvement Process
- Data Measurement and Analysis
- Change Management
- Patient Safety
- The Quality Improvement Team
The Quality Improvement Course will be available in three formats, according to Dr. Kao. The Self-Paced Course, which is for independent study and work, will be available in mid-November. The Instructor-led Course will roll out at the 2022 ACS Quality and Safety Course. In this nine-month program, “participants will complete a quality improvement project at their hospitals concurrently with the course,” she notes. A one-day workshop will also roll out next year.
Participants in all courses will receive the ACS Quality Improvement Course Workbook, and all ACS members will be able to download it at cqi.facs.org/qi/workbook.html.
Quality Verification Program
Michael Chang, MD, FACS, Chair, ACS Committee on Trauma Quality Pillar, and a member of the ACS Task Force for Future of Quality Programs, describes the newly launched ACS Quality Verification Program (QVP). He outlines current challenges in surgery, including: variability in care delivery and outcomes, inefficient use of resources, inconsistent utilization, and a changing health care environment.
“The ACS QVP is an opportunity to confront some of the gaps in surgical care by setting a new baseline,” Dr. Chang says. Three common opportunities identified include confronting the following issues: lack of standardized communication, inadequately aligned surgical quality leadership and individual disciplines, and a reactive quality culture.
“The ACS QVP gives us one safe and effective way to address all of these shortcomings,” Dr. Chang says. For example, it “provides a model for standardized communication” about quality issues through the establishment of a Surgical Quality Officer (SQO) position and a Surgical Quality and Safety Committee (SQSC). The SQO and SQSC can provide a forum for surgical teams to work across surgical departments to share best practices, set quality goals, and establish aligned processes and expectations for common practices like case review, data review, and QI.
The ACS QVP also calls for prospective use of audit filters and benchmarking in the context of good clinical data and consistent capture and evaluation of complications. These tools can be used to develop “action plans to address and prevent future complications, which, after all, is the basis of quality improvement anyway,” Dr. Chang states. They also provide a means to discern between system problems and provider problems.
According to Dr. Chang, hospitals can participate in the ACS QVP through either focused or comprehensive site visits. The ACS QVP Focused verification visit is intended for hospitals that are still in the process of building out their quality infrastructure to meet the standards and can serve as a gap analysis and feedback mechanism to help them attain the ACS QVP Comprehensive verified status. To prepare for the verification process, he recommends the following:
- Review the ACS QVP Standards and online resources at www.facs.org/qvp
- Review levels of participation
- Gather all stakeholders
- Submit an application and prereview questionnaire (PRQ)
The ACS recently launched the ACS QVP and interested hospitals can apply now. For more information regarding program standards and participation options, see the website at facs.org/qvp or contact [email protected].
Geriatric Surgery Verification
Ronnie A. Rosenthal, MS, MD, FACS, Chair, ACS Committee on Geriatric Surgery Verification (GSV), says that as the nation’s population ages, it is increasingly important to ensure that hospitals have the resources in place to provide care that meets the unique needs of older adult patients. “More than 50 percent of people older than the age of 65 will have some surgical procedure in the remainder of their lifetime,” she notes.
“Currently, surgical mortality and traditional morbidity are worse in older adults,” Dr. Rosenthal says. “It’s also important to remember that older adults have complications that are relatively specific to their age group,” such as delirium, aspiration, malnutrition, and so forth. These complications can lead to deconditioning, functional decline, cognitive decline, and loss of independence.
Recognizing that older adults are at risk for poorer surgical outcomes, in 2015, the ACS and a coalition of 60 stakeholders, with the support of the John A. Hartford Foundation, began the development of the GSV to improve surgical care and outcomes for all older patients, she said.
Focus areas of the GSV standards are patient-centric and are as follows:
- Goals of care and decision-making
- Cognition and delirium screening
- Maintenance of function and mobility
- Nutrition and hydration optimization
The GSV offers two levels of verification. Level 1 is Comprehensive Excellence and is offered to hospitals where more than 50 percent of the patients are 75 years old and older. Level 2 is Focused Excellence and is available to hospitals where 25 percent to 49 percent of patients are 75 years old and older, Dr. Rosenthal says. Hospitals may also apply for nonverification at the Commitment Level.
The ACS GSV recently awarded Level 1 verification to its first institution—Unity Hospital, Rochester, NY, she added.
David B. Hoyt, MD, FACS, ACS Executive Director, speaks about ACS THRIVE (Transforming Health care Resources to Increase Value and Efficiency)—a collaboration between the College and the Harvard Business School (HBS). According to Dr. Hoyt, THRIVE is “one of the College’s first attempts to look at cost of care and a way to improve quality of care.” Value, he says, is an equation with quality measured against cost.
“[The College’s] ability to both define quality and to measure quality is quite robust. Having said that, there’s a huge problem that still exists, which is that the economics to support health care delivery have not kept up,” Dr. Hoyt says. Consequently, care is fragmented and wasteful of resources, “resulting in a health care system that has unknown value, is unaffordable, and unsustainable.”
The goal of ACS THRIVE is to create value for patients. While the ACS was has been measuring and evaluating quality for more than 100 years, the HBS has been looking at ways to control health care costs in recent decades. The ACS and the HBS have both sought to create value for patients and payors but from different perspectives, so they teamed up to create THRIVE.
Strategic goals include reorganizing care around patient conditions or groups of related conditions in integrated practice units to improve coordination care, measuring outcomes and costs for every patient, and moving toward value-based reimbursement and, ultimately, bundled payment for health care conditions, Dr. Hoyt said.
Details about these and other ACS Quality Programs are posted on the ACS website. For a detailed discussion on this Special Session, watch the video interview with the session moderators, Sara Cooper, MD, FACS, and Rachel Kelz, MD, FACS.
This and other Clinical Congress 2021 sessions are available to registered attendees for on-demand viewing for a full year following Congress on the virtual meeting platform.