On this, the 100th anniversary of the founding of the American College of Surgeons (ACS), the surgical profession finds itself at a pivotal moment in history both for the College and the U.S. health care system. The national emphasis on quality improvement and patient safety has set the stage for the next 100 years of ACS efforts to improve the standards of care for the surgical patient. As regulatory criteria have become more stringent due to an increasing public demand for better outcomes, higher efficiency, and lower resource utilization, it would behoove surgeons to understand and influence the measurement of surgical quality and the standards proposed to achieve exceptional clinical results. For surgeons to maintain a stronghold on the performance metrics set forth on behalf of our patients, we must fully understand how quality is measured and how to evaluate our own performance as well as that of our service lines and hospitals. Surgeons must be well-versed in quality science and engaged in quality improvement initiatives to keep these efforts relevant, effective, and focused on the unique needs of surgical patients.
To date, quality improvement knowledge is not well-integrated into surgical education, yet the fundamentals of quality science and the associated skills are increasingly essential for a successful career as a surgeon. Given its 100-year experience in measuring, analyzing, and improving surgical quality, the ACS is well-positioned to bolster this important endeavor now and in the future by making it easy to incorporate quality science into surgical education. With this objective in mind, the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP®) launched the Quality In-Training Initiative (QITI) at the 2011 annual meeting.
100 years of quality improvement
Surgeons have been informally leading the way to quality improvement in health care outcomes for more than a century, ever since Ernest Amory Codman, MD, FACS, a Boston, MA, surgeon, recognized that to improve hospital conditions, those institutions needed to track patients after delivery of care to ensure that their treatment was effective. The concept became known as the “end-result idea” and laid the foundation for the ACS’ development of the hospital standardization program in 1917.1,2 At the time, Dr. Codman’s idea was controversial to say the least; however, he had the insight to realize that fulfillment of his vision would be years in the making.
The ACS led the effort to ensure that hospitals met at least the five minimum standards for accreditation established through the hospital standardization program. Eventually, the hospital survey and accreditation program grew so large that the ACS joined forces with the American Medical Association and other health care organizations to form the Joint Commission on Accreditation of Hospitals (now known as The Joint Commission) in 1951.3 As time went on, the unstructured peer-review method began to transform into an objective outcome-driven process. In 1966, Avedis Donabedian, MD, published his landmark article “Evaluating the quality of medical care,” which gave a general definition of quality while at the same time proposing a structure-process-outcomes model to measure quality.4 The Joint Commission adopted a more rigorous standard based on this model in the 1980s.
In the late 1980s, the U.S. Congress began cracking down on the Department of Veterans Affairs (VA) with respect to the quality of surgical care provided in the nation’s 133 VA hospitals. The disparity in the operative mortality rate between VA hospitals and the private sector hospitals led Congress to pass P.L. 99-166, which mandated that VA hospitals provide annual risk-adjusted surgical data comparing VA outcomes with national standards, thereby paving the way for the development of the National VA Surgical Risk Study. With the implementation of the study in 44 VA hospitals from 1991 to 1993, the ability to provide comparative measurements in surgical quality across hospitals for multiple procedures became a reality.5 As the rest of the VA hospitals began to recognize the utility of such a database, the National Surgical Quality Improvement Program (NSQIP) was born and implemented in all VA medical centers.6
As the rate of morbidity and mortality began to plummet in VA medical centers, the private sector took notice.7 A pilot program was initiated in 1999 at three nongovernmental medical centers (Emory University, Atlanta, GA; University of Michigan, Ann Arbor; and the University of Kentucky, Lexington) to demonstrate that NSQIP’s comparative measurements in surgical quality could be applied in private sector hospitals. Shortly thereafter, in 2001, a critical mass of private sector hospitals interested in NSQIP teamed up with the ACS to complete the private sector study in 18 hospitals. The collaboration was supported by the Agency for Healthcare Research and Quality (AHRQ) with the goal of achieving prior findings of comparative measurements of surgical quality within private hospitals.
Since the College’s inception, quality of surgical care has been one of the core guiding principles of the organization (see timeline). The continued success of the NSQIP within the private hospitals resulted in the ACS rolling out the program nationwide in 2004, and the formalization of the modern ACS NSQIP. As of July 2013, more than 500 hospitals are enrolled in ACS NSQIP, and the program has become recognized as the most valid and reliable national surgical outcomes data registry available.5
A new generation of young surgeon leaders in quality improvement (QI) already exists. In fact, some surgeons are opting to acquire formal training in clinical research and education in lieu of more traditional pursuits in the basic sciences. Accordingly, surgeons working on education, QI, and the advancement of surgical outcomes through health services research identified an opportunity to translate their knowledge regarding optimal patient outcomes into a future in which surgeons will promulgate a culture of continuous quality improvement. The opportunity came in the form of a union between QI leaders and surgical educators seeking to expand surgical education programs to include coaching future surgeons in QI. To this end, the ACS NSQIP QITI was launched with three main objectives:
- Enable easy manipulation of ACS NSQIP outcomes data to provide standardized reports with benchmarking for use in graduate surgical education
- Develop a national quality improvement curriculum tailored to the needs of the American public centered on real issues in surgical patient care
- Foster a new culture/environment across all surgical programs to teach residents to become surgeons with a quality conscience through collaboration among academic hospitals
The QITI is a partnership between the ACS and hospitals with at least one surgical training program that has Accreditation Council on Graduate Medical Education approval. QITI aims to improve the quality of surgical care now, through data-driven initiatives made possible through the collaboration of ACS NSQIP and teaching hospitals, and in the future, through the use of outcomes data and a QI curriculum for use in graduate medical education. The initiative is designed to equip all surgical residents with the skills needed to address the quality improvement needs of surgical patients to ensure that surgical outcomes continue to improve across the generations.
The QITI is a proactive response to the need to engage surgical residents in quality improvement to protect surgical patients in the future. Thankfully, the importance of this endeavor has been independently recognized by a multitude of governing bodies that provide external motivation for widespread programmatic acceptance. Additionally, as the nature of the support of the governing bodies comes in the form of unfunded mandates, general surgery residency program directors need the help and support of programs like the QITI to meet the new requirements. The role of the QI experts within ACS NSQIP is paramount to developing a curriculum that is focused on the real needs of the patients and providers based not on theories, but on actionable, practical solutions suited to making a difference in the delivery of surgical care.
Congress weighed in on the matter with passage of the Health Care and Education Reconciliation Act in 2010.8 The legislation proposed that resident physicians “participate in continuous quality improvement projects to improve health outcomes of the population the physicians serve.”8 Furthermore, government control over Medicare spending, the primary financial support for graduate medical education (GME), seems to be moving toward the implementation of an outcomes-based model that will tie financial support to performance-based standards.9 These standards have yet to be defined, but it has been suggested that they will reward programs that train residents in quality measurement and improvement, evidence-based medicine, multidisciplinary teamwork, care coordination across settings, and health information technology. The Medicare Payment Advisory Commission has identified these skills as vital to the success of future innovations to improve the value of our health care delivery system.
Along the same lines, the ACGME defines the goal of a surgical residency program as “to prepare residents to function as qualified practitioners of surgery at the advanced level of performance expected of board-certified specialists.”10 The ACGME created the core competencies, including practice-based learning and improvement (PBLI) and systems-based practice (SBP), to guide the outcomes approach to accreditation. Additionally, the new clinical learning environment review (CLER) program will focus on patient safety and quality improvement as key areas of interest. These efforts recognize that embedding the principles of continuous quality improvement in young surgeons may be the first step in moving from a culture of compliance toward a culture committed to quality. Program directors often struggle to demonstrate proof of training in PBLI and SBP.11 The distribution of ACS NSQIP data coupled with formal quality improvement training will encourage surgical trainees to develop these skills using real-life experiences. The QITI will permit program directors to easily satisfy the ACGME requirements for SBP and PBLI while providing trainees with critical skills for their future success as surgeons.
Evidence-based data supports the use of a collaborative to address the unique needs of hospitals focused on GME. Other institutional collaborations consisting of data feedback and training in continuous quality improvement techniques to each hospital have resulted in a reduction in mortality and morbidity, improvements in processes of care, and cost-savings across institutions.12 A partnership between the quality improvement/patient safety personnel and medical educators within each institution, as proposed by the QITI, will unite graduate medical education with efforts to improve the quality of surgical care locally. The QITI also brings together the hospitals that specialize in GME nationally. In so doing, the teaching hospitals will have the opportunity to evaluate aggregated data and foster a relationship designed to improve patient care within all teaching hospitals.
The QITI aims to combine validated outcomes data with a detailed curriculum for QI along with the strength of multidisciplinary collaboration to instill the principles of QI in each surgical resident before they enter independent surgical practice. The ability to use the ACS NSQIP to collect resident-specific and team-specific data and generate outcome reports has proved feasible and required little additional work for chart abstractors.13 Trainees will follow a structured outline, with a year-by-year curriculum allowing residents to learn how to interpret and use applicable outcomes data to create quality improvement projects and initiatives within their own institutions.
The educational components are being developed with several objectives in mind. The first goal is to develop a flexible patient safety and quality improvement curriculum that incorporates sharing of hospital-, resident-, and team-specific outcomes data with surgical residents and among QITI-participating hospitals. The second is to illustrate that an educational initiative based on surgical outcomes satisfies ACGME requirements and can ensure success in the CLER program through a tangible commitment to QI across each surgical program.
Future of surgical quality improvement
The future of the quality improvement movement in surgery depends not simply on bringing the issues into surgeon consciousness, but requires enthusiasm for improved patient outcomes, active involvement in quality improvement efforts, action in response to performance metrics, alignment of patient and provider goals, and strong leadership in redefining the cultural norm. The resident curriculum may be formalized, but for the rest of us, we should also endeavor to learn the material provided by the QITI.
Consider the possibilities. Imagine a world where operating room turnover time would match the amount of time it takes to talk to a patient’s family and check in your next patient. A world where all of the people caring for each patient are familiar with the history, physical examination, and plan as outlined in the medical record; where if the surgeon did a great operation, he or she could rest assured that the patient would recover uneventfully and receive optimal patient care with all of the proper medications prescribed and given as ordered; and where adherence to best practices was expected. Imagine an environment where everyone treated each patient as if he or she were family members. Imagine a world where someone would share data with you regarding your clinical outcomes and identify opportunities for personal improvement and systematic improvements.
Alternatively, imagine a world where surgeons are considered technicians and no one listens to the voice of reason that often speaks up for the needs of the surgical patient. Imagine an environment where a surgeon’s vast knowledge of patient disease and ability to assuage a patient’s anxiety by providing a detailed description of the surgical experience are not valued. Imagine a world where your parent or child went in for an operation and developed a surgical site infection that required months of dressing changes and resulted in depression.
Either of these scenarios could become reality. The choice will be determined by each of us. If surgeons are to remain fully engaged and valued in the transition toward a new health care delivery system, then we must learn to understand and speak the language of quality improvement. Colleagues from a diverse set of medical specialties outnumber us, and therefore our commitment to and knowledge of quality improvement must be more robust if we are to have the same leveraging power.
Although a major component of value-based purchasing centers on surgery (for example, the Surgical Care Improvement Project), very few of these programs are integrated into the formal surgical residency curriculum.14 At present, an obvious disconnect exists between the emphasis on surgical outcomes from a national health care perspective and the lack of emphasis on training surgeons to understand and apply these outcomes to improve quality and patient safety.
Successful improvement in surgical outcomes nationwide requires a concerted effort by surgical programs nationally to educate residents not only in the language of surgery, but also in the language of quality. Engaging residents in quality improvement necessitates more than asking them to participate in a discrete improvement project, whereby they may feign fluency by concentrating on the immediate results. True understanding of the language of quality is gained via a longitudinal approach to the subject matter, and teaching residents that engagement in quality improvement over the lifetime of their career is what translates into lives saved.15 The QITI provides a unified strategy that is designed to become the standard for the integration of a quality curriculum into surgical education, so that all residents enter practice with a basic understanding of performance improvement and outcomes-based practice.
To bring about a successful future of high-quality, safe, and affordable health care in surgery, the QITI strives to lead the development of a new norm, transitioning the surgical community into the next 100 years by embedding the values of quality and patient-centered care early on in training. Thomas H. Lee, MD, posits that in order to fix health care, a “frame shift” must occur in the traditional way in which medicine is practiced, as a result of which the delivery of high-quality care is no longer measured as much by volume as by how patients fare after treatment.16
The current notion that volume trumps outcome is manifest in the way that progress is monitored and feedback is generated in the surgical training process. Typically, the ACGME case requirement/log (a measure of volume) is the only objective measure of residents’ progress; most other feedback involves subjective evaluations. And although it may be difficult to objectively evaluate resident development in the core competencies, even a subjective evaluation/discussion of how a resident’s patients do after surgery is lacking. Existing fears that subpar outcomes may be inappropriately tagged to an individual resident probably would be assuaged if we could truly move beyond a culture of blame to one of continuous quality improvement. By showing residents how their technical and clinical skills translate into real patient outcomes, the QITI will help foster a patient-centered learning environment focused on the delivery of high-quality care.
Having the flexibility to deliver education in quality improvement science in ways that engage surgeons is vital, and a curriculum focused on a variety of practical activities with tangible outcomes will allow us to get to the heart of the matter. Improving the quality of surgical care is now, and has always been, the College’s primary mission. Surgeons want to be in the operating room and other health care settings providing top-notch surgical care, but more so, we want to know that our patients will experience optimal outcomes. Whether adhering to a checklist to minimize surgical site infection or following national guidelines to prevent venous-thromboembolism, the knowledge that our patients will survive to enjoy the fruits of our labor makes all of the hard work and dedication worthwhile.
Generating a buzz and an excitement around the significant difference that surgeons can make in patient care with detailed knowledge of quality improvement techniques is vitally important if we expect surgeons to understand how quality is measured, evaluate their own data, and implement change to improve outcomes in the future. How better to learn the value of these proficiencies than to start evaluating the data during the intern year?
The QITI is in its infancy, and yet the practical, real-time approach to teaching quality science appears to inspire action and improvement. The program will only get better with time. In the end, the path to cultural reform will lie in collaboration with master clinicians, experts in QI, and experts in surgical education all contributing to inspire surgical residents—the future leaders of our profession—to foster a culture of continuous quality improvement in an environment of patient-centered care.
- March of Dimes. Toward Improving the Outcome of Pregnancy III. Enhancing Perinatal Health Through Quality, Safety, and Performance Initiatives. 2010. Available at: http://www.marchofdimes.com/glue/files/TIOPIII_FinalManuscript.pdf. Accessed August 9, 2013.
- Luce JM, Bindman AB, Lee PR. A brief history of health care quality assessment and improvement in the United States. West J Med. 1994;160(3):263-268.
- Roberts J, Coale J, Redman R. A history of the Joint Commission on Accreditation of Hospitals. JAMA. 1987;258:936-940.
- Donabedian A. Evaluating the quality of medical care. Milbank Mem Fund Q. 1966;44(3):166-206
- American College of Surgeons. National Surgical Quality Improvement Program. Available at: www.acsnsqip.org. Accessed August 15, 2013.
- Khuri SF, Daley J, Henderson W. The Department of Veterans Affairs’ NSQIP: The first national, validated, outcome-based, risk-adjusted, and peer-controlled program for the measurement and enhancement of the quality of surgical care. National VA Surgical Quality Improvement Program. Ann Surg. 1998;228(4):491-507.
- Khuri SF, Daley J, Henderson WG. The comparative assessment and improvement of quality of surgical care in the Department of Veterans Affairs. Arch Surg. 2002;137(1):20-27.
- U.S. House of Representatives. 111th session. H.R. 4872: Health Care and Education Reconciliation Act of 2010. Sec. 1505: Improving Accountability for Approved Medical Residency Training. 2010. Available at: http://www.govtrack.us/congress/bills/111/hr4872/text/rh. Accessed September 23, 2013.
- Medicare Payment Advisory Commission. Report to the Congress: Aligning Incentives in Medicare. 2010. Available at: http://www.medpac.gov/documents/jun10_entirereport.pdf. Accessed August 30, 2013.
- Accreditation Council for Graduate Medical Education. Available at: http://www.acgme.org/acWebsite/home/home.asp. Accessed March 6, 2012.
- Kelz, RR, Sellers, MM, Reinke CE, Medbery, RL, Morris J, Ko C. The Quality In-Training Initiative—A solution to the need for education in quality improvement: Results from a survey of program directors. J Am Coll Surg. 2013; In Press. E-pub: July 24, 2013.
- Campell DA. Quality improvement is local. J Am Coll Surg. 2009;209(1):141-143.
- Sellers MM, Reinke CE, Kreider S, Meise C, Nelis K, Vople A, Anzlovar N, Ko C, Kelz RR. American College of Surgeons NSQIP: Quality In-Training Initiative pilot study. J Am Coll Surg. 2013; In Press. E-pub: July 11, 2013.
- Sellers MM, Hanson K, Schuller M, Sherman K, Kelz RR, Fryer J, DaRosa D, Bilimoria KY. Developments and participant assessment of a practical quality improvement educational initiative for surgical residents. J Am Coll Surg. 2013;216(6):1207-1213.
- Wong BM, Etchells EE, Kuper A, Levinson W, Shojania KG. Teaching quality improvement and patient safety to trainees: A systematic review. Acad Med. 2010;85(9):1425-1439.
- Lee TH. Turning doctors into leaders. Harv Bus Rev. 2010;88(4):50-58.