Making quality stick: Optimal Resources for Surgical Quality and Safety: The SQSC and credentialing and privileging processes ensure sustainability of standards

Optimal Resources for Surgical Quality and SafetyEditor’s note: In July, the American College of Surgeons (ACS) released Optimal Resources for Surgical Quality and Safety—a new manual that is intended to serve as a trusted resource for surgical leaders seeking to improve patient care in their institutions and make quality stick. Each month, the Bulletin will highlight some of the salient points made throughout “the red book.”


To ensure that they have the right infrastructure in place and competent health care professionals on staff, hospitals should have a Surgical Quality and Safety Committee (SQSC) and standardized credentialing and privileging processes in place.

The SQSC should be chaired or co-chaired by the Surgical Quality Officer described in the November issue of the Bulletin. This committee oversees myriad activities depending on local characteristics and factors. Specific SQSC responsibilities listed in the quality manual include the following:

  • Monitor surgical mortality and adverse event rates
  • Address clinical practice variations
  • Establish quality and safety standards, guidelines, and surgery-related policies
  • Monitor primary data and data reports to identify consistent, cross-cutting surgical issues
  • Use other sources of information, including direct observation, to evaluate quality, safety, and reliability
  • Develop, align, and implement corrective action plans
  • Monitor compliance with regulations
  • Foster, lead, and implement culture improvement activities

While the SQSC focuses on the institutional infrastructure, the credentialing and privileging processes ensure that the surgeons who practice in health care institutions are trained and competent to provide safe, reliable care. The credentialing process uses objective criteria, such as board certification, to determine whether a health care professional has the education, experience, and skills needed to practice in the institution. Through the privileging process, institutions designate the specific surgical procedures that a surgeon may perform. The manual outlines the criteria that should be evaluated in the credentialing and privileging processes and the intervals at which a surgeon’s privileges should be evaluated. It also defines which individuals and committees should lead the credentialing and privileging processes.

Be sure to read next month’s overview of the quality manual, which will focus on creating a culture of safety and high reliability and describe the infrastructure needed to create and sustain this environment. Optimal Resources for Surgical Quality and Safety is available for $44.95 per copy for orders of nine copies or fewer and $39.95 for orders of 10 or more copies in the ACS online store.

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