It is my pleasure to offer this annual report on the American College of Surgeons (ACS) activities. This account is presented as I near the end of my eighth year as Executive Director of the ACS and provides information on the major initiatives carried out by the ACS staff and volunteers from October 2016 to October 2017. It points to our accomplishments and to the areas in which we are striving to better meet the needs of surgeons and their patients.
Division of Advocacy and Health Policy
Renewed efforts to overturn the Affordable Care Act (ACA) have reemerged, ranging from efforts to eliminate only contentious portions of the law to more far-reaching repeals with no immediate replacement. ACS staff has reviewed these proposals to determine likely effects on surgeons and surgical patients, including potential changes to access to surgical care and in physician reimbursement. Taking into account expected ramifications of the proposed bills, the ACS revised its Statement on Health Care Reform and reiterated to Congress our priorities.
Another advocacy issue of considerable concern to ACS Fellows is the Centers for Medicare & Medicaid Services (CMS) efforts to implement the payment reforms in the Medicare Access and CHIP (Children’s Health Insurance Program) Reauthorization Act (MACRA) of 2015. Specifically, 2017 is the transition year for implementation of the Quality Payment Program’s (QPP’s) Merit-based Incentive Payment System (MIPS), and MIPS data collected in 2017 will be used to determine annual payment updates starting in 2019.
The ACS has been monitoring implementation of this payment system, and the Division of Advocacy and Health Policy (DAHP) staff has worked with consultants and stakeholders on a legislative proposal to grant additional flexibility to the Secretary of the U.S. Department of Health and Human Services (HHS) in implementing MIPS.
In collaboration with Division of Research and Optimal Patient Care (DROPC) staff and the Performance Measurement Committee, the DAHP has developed an updated 2017 version of the ACS Phases of Surgical Care Measure, which was approved as Qualified Clinical Data Registry (QCDR) measures for use in the ACS Surgeon Specific Registry (SSR). These measures will be available to SSR participants to satisfy the Quality component of MIPS.
One area of concern relates to a portion of the MIPS composite score Performance Threshold, which, beginning in 2019, will be based on the mean or median of the MIPS Final Scores from all MIPS eligible professionals from a prior period. As a result, approximately half of all Part B providers will be penalized. The ACS has written to HHS expressing concern about the policy, and DAHP staff has had in-person meetings with both CMS and the HHS Secretary.
In addition to MIPS, the QPP calls for the establishment of Alternative Payment Models (APMs). In the last year, DAHP staff has continued to address the lack of meaningful opportunities for surgeons to participate in APMs. In December 2016, the ACS submitted a surgical APM proposal to the Physician-focused Payment Model Technical Advisory Committee (PTAC). This proposal, the ACS-Brandeis Advanced APM (A-APM), was among the first two proposals that the PTAC recommended for CMS testing. The HHS Secretary reviewed the proposal and made recommendations for improvement. Efforts to develop the model continue, and the ACS is working with private insurers and potential APM entities that may implement the model once it is available.
The ACS, furthermore, has championed the development of patient-reported outcomes (PROs) as performance measures as part of the ACS Phases of Surgical Care Measure framework starting in 2018. As a starting point, the ACS seeks to use these PROs to confirm that, from the patient’s perspective, the surgeon provided value-based care. We envision these measures will be used for participation in the QPP as part of the SSR QCDR for MIPS reporting and as part of the ACS-Brandeis A-APM. The ACS has developed a framework for evaluating patient experiences of care during the surgical phases and linked those to PROs and PRO measures.
At press time, staff had analyzed the calendar year 2018 Medicare Physician Fee Schedule (MPFS), and identified 17 issues in the MPFS that may affect surgeons. These provisions pertain to reimbursement for physicians’ practice expenses, scope system equipment and costs, liability premiums, telehealth, values of certain Current Procedural Terminology codes, evaluation and management guidelines, and MACRA patient relationship categories and codes. (Details will be published in the January 2018 issue of the Bulletin.)
In addition, the ACS has engaged in numerous efforts to address potential changes to payment for global surgery services. As CMS collects data on global codes, the ACS has analyzed CMS policies and methodologies for data collection and provided several rounds of feedback.
As CMS seeks to develop episode-based payment models and measures to assess cost, the ACS has provided feedback via comment letters and requests for information, has attended meetings where episode-based cost measures are being developed, and has analyzed and commented on patient relationship codes that may be used to attribute costs to physicians starting in 2018.
Graduate medical education (GME) continues to be another issue of concern to ACS members. In anticipation of congressional efforts to reform GME financing and governance, the DAHP worked with a task force of experts to formulate principles and draft a discussion paper that was published in January.
DAHP staff has worked with congressional champions to revise and reintroduce legislation to study shortages of general surgeons and potentially designate surgical shortage areas. The Ensuring Access to General Surgery Act (S. 1351/H.R. 2906) was introduced in June in both the House and Senate.
The ACS worked to develop policy positions and materials to educate and advocate for surgeons who are experiencing problems with third-party payors. The DAHP also created a questionnaire on the ACS website that physicians can complete to receive assistance directly from DAHP staff on specific problems with commercial insurers.
With respect to state issues, the DAHP worked with the Brooklyn/Long Island Chapter to encourage New York surgeons to contact the governor to oppose a package of bills that would increase the medical liability statute of limitations for cases involving alleged misdiagnosis of cancer. This move would lead to increased medical liability insurance premiums and additional lawsuits. More than 35 surgeons responded by visiting the Surgery State Legislative Action Center (SSLAC) to send their letters.
Maintenance of Certification (MOC) legislation, S.B. 1148, was introduced earlier this year in Texas. Numerous e-mails were sent to Texas Fellows, and the College sent letters of opposition to every state senator and representative, resulting in amendments to S.B. 1148 that preserved the ability of hospitals to set MOC requirements.
Twelve chapters received state lobby day grants in 2017. The basic grant is up to $5,000. One grant in 2017 was raised to $15,000 and went to the Georgia Society of Surgery, which used the funds to cosponsor, with the Georgia Trauma Foundation, the first annual Georgia Trauma Day. The centerpiece of this program was Stop the Bleed®. Legislators allocated $1 million to place Stop the Bleed kits in all Georgia public schools.
The ACS addressed a number of scope-of-practice issues through activation of the SSLAC. In Florida, Georgia, Maryland, and North Carolina, SSLAC letters were sent addressing legislation regarding optometry’s scope of practices.
In Georgia, an out-of-network bill was defeated, thanks in part to Georgia surgeons responding to ACS Action Alerts to contact their legislators. State Affairs worked with the New Jersey Chapter to oppose out-of-network legislation in the state. The College weighed in on proposed regulations in Massachusetts requiring cancer counseling on every possible treatment option regardless of its relevance to the particular case, and in Alaska, the College joined with the American Society of Anesthesiologists and the Alaska Chapter to oppose draft rules permitting certified registered nurse anesthetists to practice independently.
The Commission on Cancer (CoC) Advocacy Committee held its annual planning meeting in February, developing a robust legislative agenda for 2017, followed by a day on Capitol Hill. The CoC also participated in two Capitol Hill visits in March and in June through One Voice Against Cancer.
On September 8, the College convened its first Virtual Hill Day in conjunction with the Cancer Programs Conference in an effort to build support for cancer research funding, a resolution highlighting College cancer programs, palliative care for cancer patients, and access to colorectal screening.
Leaders of the ACS and Committee on Trauma (COT) hosted a congressional briefing February 28 to highlight the Hartford Consensus and the Stop the Bleed training program. Throughout the briefing, lawmakers and congressional staff participated in simulations of how to treat severe bleeding injuries as an immediate responder.
The College continues to support COT advocacy priorities, including funding for trauma systems and trauma systems research funding with a goal of creating a nationwide trauma system. The Mission Zero Act (H.R.880/S.1022), which the ACS strongly supports, would create a grant program to assist civilian trauma centers partnering with military trauma professionals to establish a pathway to provide patients with the highest quality of trauma care in times of peace and war. The act moved through the House Energy and Commerce Committee this summer, and the College is lobbying for House floor consideration this fall.
In a related matter, the DAHP worked with the Military Health System Strategic Partnership ACS (MHSSPACS) to persuade Congress to include in the National Defense Authorization Act both a Joint Trauma System within the Defense Health Agency to promote continuous improvement of trauma care provided to members of the Armed Forces, and a Joint Trauma Education and Training Directorate to ensure military traumatologists maintain surgical readiness.
Other ACS advocacy initiatives centered on the interoperability of the electronic health record and participation in the National Academy of Medicine’s Physician Wellness program, which is poised to issue a report and action plan on physician burnout.
More than 300 surgeons and residents participated in the ACS Leadership & Advocacy Summit this May in Washington, DC. Participants met with lawmakers and congressional staff to educate them about ACS legislative priorities.
The ACS has played a leadership role in the Society for Academic Continuing Medical Education (SACME), which aims to advance the field of Continuing Medical Education (CME) and interprofessional education. Areas of focus for SACME have included leadership, scholarship, innovation, member engagement, and operational excellence.
The Division of Education has appointed a Steering Committee for Retraining and Retooling of Practicing Surgeons. The committee comprises leaders from across the surgical specialties and representatives from academic institutions, hospital systems, and the insurance industry. The committee’s present focus is on defining standards and establishing a national infrastructure to achieve optimal outcomes. The ACS-Accredited Education Institutes (ACS-AEIs) would be at the core of this infrastructure.
Training the Next Generation of Surgeons: Making It Stick, Making It Real, Making It Together, took place in June at the WWAMI Institute for Simulation in Healthcare (WISH), University of Washington, Seattle. The symposium focused on cutting-edge models of simulation-based surgical training and helped to define standards to enhance the value of simulation.
The Division of Education has appointed a Committee on Coaching the Next Generation, which is charged with engaging senior surgeons to share their expertise with the next generation of surgeons and participate in education and training programs. In addition, the Subcommittee on Simulation-based Teaching designed an Introduction to Simulation-based Teaching Course for senior surgeons, which was offered as a pilot program at the University of North Carolina at Chapel Hill.
The Future of General Surgery Training Committee builds on the work of the former Committee on Residency Training (“Fix the Five”). The new committee has identified 10 critical areas to improve general surgery training.
A total of 30 institutions have been approved to offer the ACS Program for Mastery in General Surgery, formerly known as the Transition to Practice (TTP) Program in General Surgery. A total of 16 TTP Associates were recruited for academic year 2017–2018. Experiences from the TTP Program have yielded invaluable information regarding individualized training in diverse locations with different mentors and strategies to provide sufficient autonomy to increase both competence and confidence.
The ACS remains a leader in the field of faculty development for surgeons. The Surgeons as Educators Course remains the flagship faculty development program. In the coming year, the Division of Education plans to create a comprehensive program for faculty development and support. This new program will address a spectrum of needs anchored to the four levels of professional development: teacher, master teacher, educator, and master educator.
The ACS Academy of Master Surgeon Educators launched at Clinical Congress. The goals of the academy are to recognize master surgeon educators, advance the science and practice of leading-edge surgical education and training, foster innovation and collaboration, support faculty development and recognition, and underscore the importance of surgical education and training.
Plans are under way to offer a Certificate Program for Surgeon Educators, which will involve workplace activities centered on translation of the science and practice of surgical education to real settings. An initial step in this process has involved a survey of graduates of the Surgeons as Educators Course to further identify gaps and opportunities.
The ACS Clinical Congress continues to offer a range of education and training opportunities to practicing surgeons, surgery residents, medical students, and members of surgical teams. The Clinical Congress 2017 program, which took place October 22−26 in San Diego, CA, included 24 Tracks, 118 Panel Sessions, 19 Didactic Courses, 12 Skills Courses, 45 Meet-the-Expert Sessions, and 21 Town Hall Meetings. In early 2017, 1,797 abstracts were submitted for the Clinical Congress—the highest number of abstract submissions in recent years. (Details regarding Clinical Congress 2017 will be published in the January 2018 Bulletin.)
After more than 45 years, the Surgical Education and Self-Assessment Program (SESAP®) remains the premier self-assessment and cognitive skills education program for practicing surgeons. SESAP 16, released in October 2016, comprises 850 questions and critiques that can be used to earn up to 90 Category 1 CME Self-Assessment Credits.
Selected Readings in General Surgery (SRGS®) celebrated its 10th anniversary in January. SRGS continues to publish evidence-based reviews of the medical literature, and the cycle of topics is designed to cover the field of general surgery in 48 months. SRGS offers the opportunity to earn 80 Self-Assessment Credits per year. The SRGS package contains an overview of the literature, a concise review of 10 recently published articles accompanied by an expert commentary for each article, and an editorial on health care. A posttest of 20 multiple-choice questions is available.
This year, the ACS also launched ACS Case Reviews in Surgery, which is published six times per year. Each issue features 10 peer-reviewed case reports from an array of surgical specialties.
Evidence-Based Decisions in Surgery includes concise, focused modules derived from practice guidelines. A total of 60 modules are available. A new educational model is being designed and will include discussions of key articles based on the review of evidence.
The Committee on Ethics released Ethical Issues in Surgical Care at Clinical Congress 2017. This book covers key topics and defines the field of ethics in surgery as it has evolved in the last 10 years. Topics address the broad areas of the surgeon-patient relationship, the surgeon and the surgical profession, and the surgeon and society.
Key activities of the Surgical Patient Education Program include development of Home Skills Kits; Education for Better Recovery; Informed Surgical Prep brochures and e-Learning materials; and a new Professional Training Program to ensure a well-trained patient education workforce. The Home Skills Kits are the centerpiece of this program, which focuses on supporting successful transitions to home care. Kits focus on colostomy/ileostomy, urostomy, feeding tubes, central lines, and surgical wounds; kits in development center on tracheostomy and anticoagulation therapy.
A new Patient Education Program on surgery and opioids and managing pain during surgery is in development. A Statement on the Opioid Abuse Epidemic was prepared by the DAHP in collaboration with the Patient Education Program of the Division of Education and was approved by the Board of Regents in June.
There are currently 95 ACS-AEIs, 14 of which are outside the U.S. Further refinement of the accreditation model has continued, and a new Maintenance of Accreditation model that involves assessment of outcomes and review of robust annual reports with longer accreditation cycles is being phased in. The 10th Annual ACS-AEI Consortium Meeting, now the Annual ACS Surgical Simulation Conference, took place March 17–18, attracting 237 attendees.
The number of ACS Members using the MyCME program to request transfer of their CME Credits to the American Board of Surgery (ABS) has steadily increased. In 2016, 3,974 individual members sent 5,885 records to the ABS.
Steps are being taken to support surgeons seeking to meet requirements for MOC and re-licensure and, more recently, to meet educational requirements of the ACS Clinical Accreditation and Verification Programs. The focus on Self-Assessment Credits for MOC continues to steer the design of many programs. A complete list of requirements by state has been compiled and is available online at facs.org/education/cme/state-mandates. Additional content is being developed to address regulatory mandates and those identified for CME Credit.
Continuous Quality Improvement (CQI)
The CQI programs within DROPC have continued to grow and respond to surgeons’ evolving needs. The ACS National Surgical Quality Improvement Program (ACS NSQIP®) has 805 participating hospitals, with 698 in ACS NSQIP Adult and 107 in ACS NSQIP Pediatric. Another 65 hospitals are in various stages of the onboarding process. A steady 10 percent of ACS NSQIP hospitals are international, although there is interest in expansion in Australia, Asia, the Middle East, and South America.
Enrollment in ACS NSQIP Pediatric has increased by 16 sites since October 2016. This interest from the pediatric community is likely attributable to the launch of the Children’s Surgery Verification (CSV) Quality Improvement program in January 2017.
ACS NSQIP collaboratives are a popular means of engagement, enabling sites to share outcomes and best practices and work on quality improvement (QI) in organized groups. More than 50 collaboratives have been established and more are in development. The Department of Defense has the largest collaborative, with 42 enrolled hospitals and four more in the onboarding process. In addition, the first international regional collaborative, the ACS NSQIP Middle East Collaborative, has been established, comprising hospitals from the United Arab Emirates, Jordan, Lebanon, and Saudi Arabia.
The new ACS Quality and Safety Conference, formerly the ACS NSQIP Annual Conference, took place in July in New York, NY. The conference boasted a record-breaking attendance. For details about the conference, see the October Bulletin.
As ACS NSQIP prepares to move to a new data portal hosted by QuintilesIMS, some programmatic changes are being made to better meet hospital needs, including the introduction of the ACS NSQIP Participant Portal, which will help streamline hospital enrollment and participation. Interested hospitals will be able to learn about ACS NSQIP, apply to join ACS NSQIP, and track the application process. Existing ACS NSQIP sites will be able to update hospital information, hospital contacts and registry users, and ACS NSQIP sampling.
An updated ACS NSQIP Surgical Risk Calculator was released in July. This version adds predictions of several postoperative complications and uses a new recalibration process that improves accuracy.
Nearly 125 sites have shown interest in CSV Quality Improvement Program accreditation. The program officially launched in January, and five pilot centers have been verified as Level I children’s surgery centers. The first non-pilot site visits occurred this summer and 16 sites are going through the verification process.
A total of 847 centers participate in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP), 762 of which are fully accredited. From October 2014 through August 2017, 867 site visits were completed. A total of 68 surgeon surveyors are expected to perform approximately 250 site visits in 2017.
MBSAQIP’s national enhanced recovery initiative, Employing New Enhanced Recovery Goals to Bariatric SurgerY (ENERGY) has been fully deployed to 36 U.S. centers and is set to conclude in the fall 2018. The overarching goal of ENERGY is to enhance patient experience through improved pain management, fewer opioid side effects, decreased readmissions, and quicker return to normal activity.
The ACS Quality Data Platform Project is in the midst of a three-year implementation plan through a partnership with QuintilesIMS to migrate all existing ACS clinical databases into a single platform. The new platform will incorporate both financial data and PROs to give participating hospitals insights into the value of care they provide as well as the quality of that care as judged by patients. Patient-reported outcomes are being piloted within ACS NSQIP and the MBSAQIP.
The new SSR, which launched on the new QuintilesIMS platform in April, continues to evolve as a means for individual surgeons to log and track and meet regulatory requirements, such as MIPS and MOC Parts 3 and 4.
With the CMS reimbursement programs and policies becoming increasingly centered on individual provider measures data, the College has sought to provide its members with an array of options to participate in MIPS and other CMS payment programs. The following reporting options are available through the SSR for surgeons who participate in the 2017 MIPS reporting cycle:
- General Surgery Specialty Measures Set for general surgeons (MIPS-Qualified Registry)
- ACS Surgical Phases of Care Measures Set (MIPS-Qualified Clinical Data Registry)
Participation in either set of measures also allows for the inclusion of reporting Improvement Activities to CMS.
New Surgical Phases of Care Measures were developed to be inclusive of multiple subspecialties, thereby easing the burden of complying with the requirements for physicians. ACS Clinical Scholars used the College’s new quality manual, Optimal Resources for Surgical Quality and Safety, and other CQI programs, including the Coalition for Quality in Geriatric Surgery Project, to align the measures.
Strong for Surgery is a joint program of the ACS and the University of Washington, Seattle. The ACS administers and promotes this program as a quality initiative aimed at identifying and evaluating evidence-based practices to optimize the health of patients before surgery. Strong for Surgery provides hospitals with checklists to screen patients for potential risk factors that can lead to surgical complications, and the program offers appropriate interventions to ensure better surgical outcomes. The checklists target four areas known to be highly influential determinants of surgical outcomes: nutrition, glycemic control, medication management, and smoking cessation.
The Coalition for Quality in Geriatric Surgery Project (CQGS), funded by the John A. Hartford Foundation, completed its second year in development. The four-year project aims to improve care of older patients though a standards and verification program. The CQGS published its first manuscript in the Annals of Surgery, “Hospital standards to promote optimal surgical care of the older adult.” This paper was the culmination of a two‐year study performed as a modified RAND‐University of California, Los Angeles, appropriateness methodology study.
The CQGS also conducted its second Patient and Family Advisory Council (PFAC) meeting at Oregon Health & Science University (OHSU), Portland, in March with older adults who underwent surgery or who had a family member undergo surgery at OHSU. The information and patient perspectives gleaned from the OHSU PFAC group informed the development of the beta standards, data registry measures, and structure of the quality program. Additionally, the CQGS published the model for building and disseminating the geriatric surgery program, “Improving quality in geriatric surgery: A blueprint from the American College of Surgeons,” in the December 2016 Bulletin.
The Agency for Healthcare Research and Quality (AHRQ) Safety Program for Improving Surgical Care and Recovery (ISCR) is a collaborative program between the ACS and Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality to enhance the recovery of the surgical patient. The ISCR is a five-year funded project that seeks to meaningfully improve clinical outcomes by supporting hospitals in the implementation of evidence-based enhanced recovery pathways that promote the delivery of evidence-based perioperative care and reduce variability. ISCR will comprise five anticipated cohorts, each lasting 12 months—colorectal, orthopaedic, gynecology, emergency general surgery, and bariatric—and is open to all hospitals in the U.S., Puerto Rico, and the District of Columbia.
The pilot Residents Leading Quality Course course took place preceding the official start of Clinical Congress 2016 in Washington, DC. The course introduced surgery residents and fellows to the basics of QI, including the identification of a problem, data review, QI models and techniques, and patient and provider engagement strategies.
The College released Optimal Resources for Surgical Quality and Safety at the ACS Quality and Safety Conference in July 2017. “The red book” is intended to be a trusted resource for surgical leaders seeking to improve patient care in their institutions, departments, and practices. It introduces key concepts in quality, safety, and reliability and explores the essential elements that all hospitals should have in place for patient-centered care, to help health care institutions perform better evaluation and achievement of quality processes and outcomes at the facility/departmental level. Exploratory work is under way to evaluate the feasibility of developing adjunctive or integrated resources/standards within the manual, as well as a Surgical Quality Verification Program.
The Surgical Research Committee selected the recipient of the 2017 Jacobson Promising Investigator Award (JPIA) and sponsored the 2016 Health Services Research Methods (HSRM) Course, December 8–10, 2016. Previously the Outcomes Research Course, the HSRM course was redesigned in 2016 for clinical and health services researchers with varying degrees of experience in the field. In addition to didactic lectures and skills-based labs tailored to individual interests, participants had one-on-one consultations with leading experts focused on their specific research questions.
The ACS Clinical Scholars in Residence Program features four Clinical Scholars who are working on CQI activities, one with support from the CQGS, two with support from the AHRQ ISCR, and one with a focus on PRO measures.
The ACS was awarded a three-year R01 from the National Institute on Minority Health and Health Disparities. L. D. Britt, MD, MPH, DSc(Hon), FACS, FCCM, FRCSEng(Hon), FRCSEd(Hon), FWACS(Hon), FRCSI(Hon), FCS(SA)(Hon), FRCSGlasg(Hon), will serve as the principal investigator on this award. The project period is September 1, 2017, through May 30, 2020, with overall funding expected to exceed $2.36 million. The four participating sub-award sites are Eastern Virginia Medical School, Norfolk; Brigham and Women’s Hospital, Boston, MA; University of California, Los Angeles; and the National Quality Forum. The overall aim of this project is to determine robust surgical disparities-sensitive metrics across the continuum of care that can be used to develop targeted interventions aimed at eradicating disparities.
A total of 1,486 programs have CoC accreditation, and 460 cancer programs were due for survey in 2017. In all, 42 new cancer programs applied for accreditation in 2017, whereas 35 programs have withdrawn or had their accreditation discontinued. A total of 42 cancer programs surveyed between January 1 and December 31, 2016, received the 2016 Outstanding Achievement Award. Results for the January−June 2017 survey period were announced in September. The annual accreditation fee is $9,000. In 2018, the CoC will introduce a tiered fee structure.
The CoC is evaluating future options for the Oncology Medical Home (OMH) accreditation program, and the National Accreditation Program for Rectal Cancer (NAPRC) manual is undergoing final revision. Launch will proceed when the manual is released.
Four workgroups are developing revised content for the CoC Cancer Program Standards: Ensuring Patient-Centered Care (2016 Edition), including cancer program goals, prevention and early detection activities, QI activities, and survivorship care plan requirements. The Accreditation Committee brought final changes to the CoC Executive Committee in October.
The National Cancer Database (NCDB) completed a successful call for data in the first quarter of 2017. More than 10.2 million cancer patient records were submitted to the NCDB in January, 1.43 million of which were for new cases diagnosed in 2015, representing approximately 70 percent of all newly diagnosed cases in the U.S. The NCDB released the 2017 NCDB Data Quality Tools this fall. The NCDB curates 35.2 million records from diagnosis years 1985–2015.
Rapid Quality Reporting System (RQRS) participation has grown to 1,342 programs—more than 90 percent of CoC-accredited facilities. As of 2017, participation is required for all CoC-accredited programs. February 2018 deliverables from the Quintiles project for the NCDB will include a new file uploader and submission reports, and a Rapid Cancer Reporting System. These enhancements will simplify the data submission process, decrease the time between diagnosis and NCDB receipt of an initial record of disease, and will integrate a QI platform for data-driven quality measures for 1,500 CoC hospitals.
Targeted efforts are under way to increase participation in ACS Clinical Research Program (ACS CRP) committees and dissemination of materials from the Operative Standards for Cancer Surgery. A total of 1,050 hard copies and 50 e-books of Operative Standards for Cancer Surgery Volume I have sold to date. In addition, Controversies in Surgical Oncology, a series of 10 articles based on Operative Standards for Cancer Surgery Volume I, has been published in Annals of Surgical Oncology. Operative Standards for Cancer Surgery Volume II is set for publication in July 2018.
The ACS CRP Cancer Care Delivery Research group is engaged in ongoing activities related to two projects centered on optimizing the effectiveness of routine posttreatment surveillance in prostate cancer and the comparison of operative to medical endocrine therapy for low-risk ductal carcinoma in situ. Activities related to three projects on posttreatment surveillance for breast, colorectal, and lung cancer have been completed.
The Dissemination & Implementation Committee surveyed members of the ACS and National Accreditation Program for Breast Centers (NAPBC) to determine the following: how physicians enroll patients in clinical trials, the facets of implementation of standards, and preferences for dissemination. The CRP Education Committee are collaborating with the Society of Surgical Oncology (SSO) Research Committee to cosponsor a session, Clinical Trials for Surgeons: Hurdles and Opportunities, at the SSO annual meeting in March 2018.
Educational Cancer Programs include the 2017 ACS Cancer Programs Conference: Creating a Culture of Quality, which took place September 8–9. This program provided integrated education, including content from all areas of the Cancer Programs department.
More than 400 individuals across 18 expert panels and several disease-specific groups were involved in the development of content for the American Joint Committee on Cancer (AJCC) Cancer Staging Manual, Eighth Edition, published in October 2016. More than 21,000 copies of the book have been sold. The guidelines in the eighth edition go into effect January 1, 2018.
More than 600 U.S. centers are accredited by the NAPBC. Reaccreditation rates for 2017 remain at more than 95 percent, and there are three accredited international centers: Abu Dhabi, UAE; South Africa; and Toronto, ON. Centers in Lebanon, Venezuela, and Australia have applied for accreditation.
The NAPBC continues to work with the Cancer Programs leadership team to identify opportunities for increased collaboration between the CoC and NAPBC. NAPBC participated in the 2017 Cancer Quality Conference in September, and plans are under way to integrate NAPBC content into the DROPC Quality and Patient Safety Conference in July 2018.
Finally, Cancer Programs revised the weekly e-newsletter, The Brief, to include news, updates, and information that will be relevant to all areas within Cancer Programs. The newsletter was renamed The Cancer Programs Brief and is disseminated to more than 25,000 cancer center personnel.
The COT, a sponsor of a recent report from the National Academies on Science, Engineering, and Medicine (NASEM), strongly supports the findings and 11 recommendations in A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths after Injury. In collaboration with military partners and the National Highway Traffic Safety Administration (NHTSA), the COT held a conference, attended by 170 trauma care professionals, in April to advance the NASEM recommendations.
Four core workgroups have formed in the areas of governance/framework for a national trauma care system; research funding and direction; data linkage, integration, and outcome measures; and military/civilian trauma workforce. Along with these four areas of focus, the COT is working to develop a coalition of stakeholders from other organizations and specialties with the shared goal of achieving zero preventable deaths. NHTSA has offered the COT additional funding to develop a policy statement on data linkage across the trauma care continuum in support of NASEM report recommendations.
The COT Injury Prevention and Control Committee (IPCC) is advocating for a public health/trauma system approach to firearm injury prevention; that is, implementing evidence-based firearm violence prevention programs through its network of trauma centers. These institutions are working toward a consensus approach to reduce firearm injuries and deaths. Following a survey of COT members and a Town Hall, the IPCC developed a paper outlining COT members’ views and opportunities to improve firearm injury prevention, which was accepted for publication in the Journal of Trauma and for presentation at an American Association for the Surgery of Trauma session. Additionally, the IPCC’s work on firearm injury prevention was featured in the October Bulletin.
The IPCC also developed a position statement on the significance of lithium battery injuries, promoting safety regarding manufacturing, safe storage, and reporting and tracking injuries. In addition, the committee prepared a position statement outlining the risk of motor vehicle crashes due to driving under the influence of opioids.
More than 700 centers participate in the Trauma Quality Improvement Program (TQIP®). This past year has seen the most growth in TQIP’s Level III program, and 15 state/regional/system TQIP collaboratives have been established.
The 2017 TQIP Scientific Meeting and Training took place November 11–13 in Chicago. The conference included tracks for all members of the trauma team and sessions tailored to Level III centers and TQIP collaboratives. There are 486 ACS-Verified Trauma Centers.
The verification program has embarked on a new process for the ongoing review and revision of trauma care standards detailed in Resources for Optimal Care of the Injured Patient. Workgroups have been established to review and provide recommendations for each chapter.
Performance improvement and patient safety efforts have focused on the development of best practice guidelines for patient imaging. The expert panel for this project includes pediatric and adult trauma surgeons as well as radiologists. The guidelines will cover imaging across injury types, for special populations, and will be a resource on performance improvement for imaging.
The 10th edition of the Advanced Trauma Life Support® (ATLS®) program is the most transformational iteration in the 40-year history of ATLS. Significant changes to the format and delivery of education are as follows:
- Traditional lectures have been replaced with interactive discussions to foster engagement.
- The skills stations are now taught through unfolding case scenarios that allow students to apply learned skills to real-life situations.
- Incorporation of a hybrid course option, mATLS, which allows students to complete interactive modules online before attending the in-person skills day.
- The addition of a faculty and coordinator online toolkit, which provides easy-to-use/downloadable tip sheets and instructional videos.
The ACS has 81,244 members, 65,080 of whom are Fellows (57,590 U.S; 1,310 Canadian; 6,180 International). Of these Fellows, 8,727 are senior status and 18,658 are retired (both dues-exempt). The ACS has 2,703 Associate Fellows, 10,529 Resident Members, 2,424 Medical Student Members, and 518 Affiliate Members.
This year’s Initiate class totals 1,827, including 1,221 U.S., 24 Canadian, and 582 international new Fellows representing 68 countries. Among the Initiates, 448 are women, 1,379 are men. Class size has continued to rise for the last 16 years and is at its highest point since 2001. Almost 900 Initiates attended this year’s Convocation.
The ACS has engaged in the following recruitment and retention activities:
- Release of the Physician Well-Being Index—a validated screening tool that helps members better understand their overall well-being and identify areas of risk
- Outreach to Fellows who are in jeopardy of losing their Fellowship because their dues are in arrears
- Outreach to surgeons who became Fellows in 2012, 2013, and 2014 whose membership has lapsed
- Outreach to nonmember registrants of ACS meetings and courses and nonmember purchasers of ACS products
- Discount membership offers to participants in select ACS meetings
- Created contact lists of surgeon interest groups (SIGs) at medical schools, created and promoted a toolkit focused on the student membership for SIGs to use, established an online Community for Medical Student members, created a new web page of resources for medical students, and started a medical student newsletter
- Surveyed new Fellows to determine areas for improvement in the application process and customer service and to determine why they chose to become Fellows
- Developed a new online orientation program for new Fellows
- Surveyed all dues-paying Fellows and Associate Fellows
- Expanded the member engagement events at this year’s Clinical Congress to include the reunion class recognition effort and wellness activities, including yoga, a spin class, and running tours
The College continues to add chapters and expand the range of services available to them. Examples are as follows:
- The Bangladesh and Kuwait Chapters were chartered in June.
- The first Chapter Officer Leadership Program occurred in May 2017.
- Quarterly domestic and international chapter newsletters were launched in January.
Members of the Chapter Activities Domestic Workgroup continued to establish a process to capture the health of ACS chapters and revised the Chapter Guidebook and the Chapter Meeting Toolkit. These documents have been combined into one online resource.
The Chapter Activities International Workgroup continues to advocate for all ACS international chapters by assisting them in implementing and promoting ACS programs. Chapters in Lebanon, Jordan, Chile, and Greece successfully offered the General Surgery Review Course to surgeons in their respective regions. The workgroup is working to enable more international chapters to conduct similar courses and to present ATLS and other trauma courses.
The Advocacy and Health Policy Pillar of the Board of Governors (B/G) and its workgroups continue to focus on legislative and regulatory issues. The Health Policy and Advocacy Workgroup produced a white paper on out-of-network billing. The Grassroots Advocacy Engagement Workgroup focused on enhancing bidirectional communication between the ACS leadership and Fellows regarding important legislative and regulatory issues.
The Communications Pillar continues to focus on bidirectional communication between Fellows and the Regents. This mission is accomplished through the Newsletter and Survey Workgroups. The Newsletter Workgroup continues to produce The Cutting Edge e-newsletter, which will move to a biannual publication to be distributed before the Clinical Congress and the Leadership & Advocacy Summit.
The Survey Workgroup published the results of the 2016 Board of Governors Annual Survey in several College venues over the past year, including the Bulletin. The Workgroup has completed the 2017 Board of Governors Annual Survey. This year’s survey focused on the Stop the Bleed campaign, the opioid crisis, work-related injuries/surgical ergonomics, and advanced practice providers in surgery.
The Education Pillar and its three workgroups continue to collaborate with the Division of Education on several projects. The Patient Education Workgroup has developed a presentation for Governors to provide communication back to their chapters or societies and is working with the Young Fellows Association (YFA) and the Patient Education Committee to improve awareness of the College’s patient education resources. After seeking input from the Association of Program Directors in Surgery and the Association for Surgical Education, the members of the Surgical Training Workgroup finalized a standardized letter of recommendation for applicants to surgery training programs, which is available on the ACS website.
The Member Services Pillar continues to strengthen both domestic and international chapters by updating resources, creating a chapter performance metric, and surveying the chapters about their activities and needs.
The Surgical Volunteerism and Humanitarian Awards Workgroup received a historically high number of nominations—54 versus 44 in 2016. The workgroup selected five recipients, who were honored at the B/G dinner at Clinical Congress 2017. The workgroup will continue to collaborate with the military Governors and the MHSSPACS to better define the criteria for a military award and to reach out to the Excelsior Surgical Society for nominations.
The Quality Pillar has three workgroups. The Best Practices Workgroup continues to participate in the Evidence-Based Decisions in Surgery Program module review and is developing a standard template and timeline for annual guidelines development, as well as a new guideline on perioperative anticoagulation management. The Physician Competency and Health Workgroup has three subcommittees focused on ergonomics, disruptive surgeons, and wellness. The Surgical Care Delivery Workgroup updated ACS Statements on the Rationale for Emergency Surgical Call and the Development and Use of Proprietary Guidelines for Accountable Patient-Centered Care, which the Regents approved in June.
Since last October, seven Advisory Councils have issued newsletters. The Advisory Councils also have engaged in the following activities:
- Assisted with review of expert witness testimony for the Central Judiciary Committee
- Nominated members for boards and specialty review committees
- Developed an ACS Statement on The Use of General Anesthetics and Sedation Drugs in Children and Pregnant Women
- Recommended members to represent the ACS on specialty guidelines writing and review panels
- Asked specialty colleagues to encourage their residents and junior colleagues to join the ACS
- Communicated with non-ACS member specialty program directors to encourage enrollment
The YFA is launching a speakers’ bureau and paired 15 mentors/mentees for the YFA Annual Mentoring Program. The Resident and Associate Society (RAS-ACS) is collaborating with the YFA and the ABS to develop a podcast series for resident learning. The RAS-ACS also engaged in the following activities:
- Offered 18 webinars for Associate Fellows
- Established a subcommittee to identify resources and engagement opportunities for Associate Fellows
- Developed a survey on opioid education and prescribing methods by residents
- Contributed articles on the opioid epidemic to the August RAS issue of the Bulletin
Operation Giving Back (OGB) continues to encourage surgeon volunteerism in underserved domestic and international regions. A new OGB website launched in October 2016 with a unique feature that lists volunteer opportunities offered by partner organizations. To date, 31 opportunities have been posted, 51 partners have enrolled, 257 volunteers have signed up, and 68 volunteers have signed up for the disaster registry.
The MHSSPACS contract with the DoD has been extended through 2022. MHSSPACS and the COT are visiting the major military treatment facilities (MTFs) that are charged with achieving Level 1 or Level 2 trauma center status within their region. MHSSPACS has formed an ACS NSQIP Collaborative for MTFs. The MHSSPACS Quality co-chairs have created their own Quality Committee and have visited three MTFs to support their patient safety initiatives. Data from these centers already indicate that MTF QI initiatives have proven beneficial.
The Excelsior Surgical Society has been resurrected and is now a formal society within the ACS. The Society has elected officers, developed a charter, and convenes a full-day meeting at the ACS Clinical Congress.
Due to the efforts of the subcommittees of the International Relations Committee, a total of 21 international scholars and travelers were invited to Clinical Congress 2017, and two international scholars participated in the 2017 Quality & Safety Conference.
In spring 2017, the first ACS/American Society of Breast Surgeons (ASBrS) International Scholar attended the annual meeting of the ASBrS and the ACS NAPBC. A request for a new cosponsored scholarship program, the ACS/American Association for the Surgery of Trauma International Scholarship, was presented to the Board of Regents in October.
The Central Judiciary Committee (CJC) has addressed issues of unprofessional conduct in the care and treatment of patients, expert witness testimony that does not meet ACS standards and guidelines, impaired physicians, state medical licensure issues, negligence and incompetence, failure to maintain adequate and accurate medical records, and inappropriate use of social media.
The Women in Surgery Committee (WiSC) and its four subcommittees continue to generate resources for women members of the College. WiSC wrote the ACS Statement on Gender Salary Equity, which the Board of Regents approved in June, and selected the recipient of the second Mary Edwards Walker Inspiring Women in Surgery Award. This is the fifth year of the Mentorship Program, and in 2017–2018 26 pairs of mentors and mentees will participate.
The Committee on Diversity Issues’ new web page will address why diversity is important and will include needs assessment tools and articles and resources to address cultural competency at work, implicit bias, and development of diverse surgical teams.
More than 450 surgeons and residents participated in the ACS Leadership Summit May 6–7. The Leadership portion of the Leadership & Advocacy Summit included a series of presentations that provided practical take-home tips on how to be a better leader. For details, see the August issue of the Bulletin. The 2018 Leadership & Advocacy Summit is scheduled for May 19−22, 2018, in Washington, DC.
The ACS website remains a vibrant source of information for members of the College, other members of the surgical team, and the general public, providing content on College programs, initiatives, and surgical news. Moreover, the functionality of the site undergoes continual improvements. Key enhancements in 2017 include:
- Search by Zip feature for Find a Surgeon is more precise (within 10 miles of a specified zip code)
- Usability updates to My Profile, including clearer indications for members’ mailing address preferences and security settings for each section of the surgeon’s profile, and easier editing features for a member’s subspecialties and conditions/procedures
- Enhanced Clinical Congress page
- Improved ability for users to share ACS news releases on social media
The web team in the Division of Integrated Communications collaborated with staff in several College divisions, including information technology, to bring other new dynamic content online for many of the programs described in this report, including the AHRQ Safety Program for ISCR, Strong for Surgery, Resources in Surgical Education articles, ACS Case Reviews in Surgery, surgeon well-being, and CSV. From August 1, 2016, through July 31, 2017, the ACS website had nearly 9.5 million page views.
The College’s bleedingcontrol.org website had 262,710 page views between August 1, 2016, and July 31, 2017. The Twitter site, @bleedingcontrol, has nearly 2,200 followers, and we have tweeted nearly 1,000 times since the site launched approximately one year ago.
ACS media relations outreach efforts are focused on highlighting original research studies promoting surgical advances and innovation. In Washington, DC, the focus is on building media awareness of our positions and opinions on health care policy issues at the federal and state levels. Noteworthy media mentions of the College and its activities included coverage by U.S. News & World Report, Reuters Health, New York Times, NBC News, USA Today, and National Public Radio.
The Bulletin successfully transitioned from a mostly print publication to an online publication in January 2017. At press time, the Bulletin team was gearing up to survey readers on their impressions of the transition as part of a strategic planning process to ensure that the Bulletin remains one of the College’s most widely read and trusted publications.
In November 2016, the Journal of the American College of Surgeons (JACS) successfully implemented a direct login process for ACS members to facilitate ease of access to full-text articles online. With implementation of this direct login process, JACS has begun the process of transitioning to an electronic-only journal.
The College’s social media presence continues to grow. The 115 ACS Communities continue to attract a range of members. In three years, the communities have become home to more than 4,631 unique contributors who have posted more than 53,279 messages in approximately 8,996 discussion threads. Furthermore, the ACS continues to see upward trajectories on our Facebook, Twitter, and LinkedIn sites.
Over the last year, ACS partnered with Weber Shandwick on several campaigns and activities. For the third year, the Weber Shandwick team worked with the ACS Program Committee to develop the Clinical Congress Daily Highlights e-newsletter. In 2016, the newsletter was distributed twice daily to all ACS Fellows, including those off-site. The newsletter also received three newsletter and writing awards from the Public Relations Society of America.
In 2016, Weber Shandwick began working with the ACS COT to develop a messaging platform and campaign that would draw attention to the urgent need to fill the gaps in the nation’s trauma system and respond to the NASEM report. This work is expected to continue over the next year in support of the COT’s effort to develop a National Trauma Action Plan and support key legislation, including the Mission Zero Act. In addition, this spring, the team launched a trauma story series, Putting the Pieces Together: A National Effort to Complete the U.S. Trauma System, to draw attention to gaps in the system and proposed solutions.
The ACS Foundation experienced a 35 percent increase in total contributions over the previous year while maintaining its low cost-per-dollar-raised.
Under the leadership of a new Chair, Mary H. McGrath, MD, MPH, FACS, the ACS Foundation is offering new initiatives to broaden its outreach to Fellows. One example is National Doctors’ Day, which in its second year nearly tripled total contributions from donors giving in honor of their mentors. A generous donor also provided a Challenge Grant match opportunity at Clinical Congress 2016, raising $100,000 for the ACS Greatest Needs Fund. The Chair and Foundation staff are working with each ACS division to offer more defined giving opportunities to donors.
Philanthropic funding continues to sponsor ATLS training in underdeveloped countries; provide mentorship opportunities to trauma surgeons; bring new skills courses to Clinical Congress; make breakthrough research possible with scholarship and fellowship awards; and support advocacy efforts in patient safety.
None of the efforts described in this report would be possible without the tremendous work carried out by the College’s Facilities and Finance, IT, Human Resources, Convention and Meetings, and Performance Improvement teams. These support areas provide the backbone of all College endeavors, along with all of the ACS volunteers and division staff. Because of their dedication and hard work, the College continues to lead the way in ensuring all surgical patients have access to high-quality care.