Looking forward – November 2015

David B. Hoyt

David B. Hoyt, MD, FACS

The “Looking forward” column in the April Bulletin focused on the importance of delivering coordinated, team-based perioperative care. That column delineated the actions that the American College of Surgeons (ACS) and other organizations are taking to improve the quality and safety of perioperative care. As previously noted, the perioperative phase of care begins with the decision to operate and intensifies 24 to 48 hours before an operation.

That column also indicated that the ACS and other stakeholders were in the process of developing recommendations on how best to ensure patients receive safe, high-quality surgical care. As an example, I noted that the American Society of Anesthesiologists (ASA) had been working to establish a perioperative surgical home.

Since then, the ASA and the College have been collaborating to develop mutually agreed-upon principles of team-based surgical care. In addition, a number of professional societies, including the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), American Surgical Association, and Central Surgical Association, have started to look more closely at the issue.

The ACS and ASA work toward consensus

At a meeting in August, several ACS Regents and leaders of the ASA joined forces to develop a joint “Statement on Team-Based Surgical Care,” which, at press time, was scheduled for review at the October ACS Board of Regents meeting. This statement articulates that perioperative care is focused on consistent, efficient, safe, high-quality, patient-centered medical care, with timely access and full recovery being the ultimate goal.

We further determined that optimal care is best provided by a coordinated, multidisciplinary team in which each health care professional recognizes and respects the expertise each specialty brings to the operating table. This type of care leads to better outcomes, lower costs, and greater patient satisfaction.

Several approaches to coordinated care involving a patient’s surgeon, anesthesiologist, primary care physician, medical specialist, hospitalist, nurses, and other health care professionals are in development. These models emphasize consistency, high reliability, and effective communication and handoffs.

The participants in these meetings agree that redesigned perioperative care models should be based on what best meets the needs of the individual patient and of the institution and health care practitioners that are providing the care. Perioperative care also should apply the following principles:

  • Patient involvement with shared decision making, patient education and engagement, and alignment of expectations, including risk-based informed consent
  • Risk stratification, risk reduction, and optimization of patients prior to surgery, including medication reconciliation
  • Standardized adherence to high-reliability and safety standards
  • Evidence-based care to reduce variability and perioperative complications
  • Effective coordination of care among all health care providers involved in the perioperative care of the patient

ACS activities

Optimal team-based care involves a range of health care providers, including physicians, nurses, technicians, and other health care professionals. The contributions of each group will vary by practice and local environment. With this knowledge in mind, each organization continues to develop programs and guidelines that will enable its members to deliver high-quality perioperative care.

Examples of what the College has accomplished in recent months to establish standards for the provision of perioperative care to specific patient populations include the launch of the four-year Coalition for Quality in Geriatric Surgery Project. The aim of this program, which is supported with funding from the John A. Hartford Foundation, is to improve care of older patients. This project has seven key deliverables: set the standards, engage key stakeholders, develop meaningful measures, establish a verification program, educate providers and patients, pilot the program, and launch the Geriatric Surgery Quality Campaign.

Leading this effort are Clifford Y. Ko, MD, MS, MSHS, FACS, Director of the ACS Division of Research and Optimal Patient Care; Ronnie Rosenthal, MD, FACS, professor of surgery, Yale School of Medicine, and surgeon-in-chief, [Veterans Affairs] Connecticut Healthcare System, West Haven; and Julia Berian, MD, an ACS Clinical Scholar in Residence and a surgery resident at the University of Chicago, IL. The core team also includes five experienced surgeons in elder patient care, a geriatrician, and a gerontology nurse.

The College also continues its involvement with Washington State’s Strong for Surgery initiative. This program uses evidence-based checklists that surgeons and other health care professionals can use in the perioperative setting to assist in patient screening, preparation, and education in an effort to improve clinical outcomes. This effort is currently being led by David R. Flum, MD, FACS, professor of surgery and director of the Surgical Outcomes Research Center, department of surgery, University of Washington Medical Center, Seattle, and medical director of the Surgical Care and Outcomes Assessment Program Comparative Effectiveness Research Translation Network, which created the Strong for Surgery programs.

At the other end of the patient spectrum, the Children’s Surgery Verification Program continues to develop, with a focus on improving care for pediatric patients. The ACS Task Force for Children’s Surgery developed the first draft of Optimal Resource Standards with support from the Society of Pediatric Anesthesia and the American Pediatric Surgical Association. The program is set to formally launch next spring.

The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program’s Decreasing Readmissions through Opportunities Provided project got under way this spring. At press time, more than 120 centers were participating in this interventional effort to decrease 30-day postoperative readmissions.

Furthermore, the College continues to make progress in developing the quality manual for surgical quality officers to use in ensuring that the surgeons on their teams have the training, tools, and resources needed to safely and effectively provide surgical care. The manual will be published in 2016.

In addition, the College maintains strong ties with The Joint Commission. As ACS Past-President and current member of The Joint Commission’s Board of Commissioners Carlos A. Pellegrini, MD, FACS, FRCSI(Hon), FRCS(Hon), FRCSEd(Hon), notes later in this issue, The Joint Commission’s Targeted Solutions Toolkit seeks to safeguard patients from preventable harm, specifically wrong site surgery, through the use of standardized practices across the perioperative phase of care.

Ongoing collaboration

It is deeply satisfying to work with other representatives of the operating team to ensure that patients receive safe, high-quality care. This type of collaboration lays the groundwork for more coordinated and collaborative care in and out of the hospital setting. Together, we truly can develop a high-reliability health care system.

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