Nearly 2,000 representatives from sites participating in ACS quality programs attended the American College of Surgeons (ACS) 2018 Quality and Safety Conference July 21–24 in Orlando, FL. Attendees included surgical team members, clinical registrars, and allied and administrative health care professionals dedicated to improving the quality of surgical care and patient safety. The theme of the conference, Partnering for Improvement, was evident in its 10 preconference sessions, 13 general sessions, 41 breakout sessions, and 20 abstract sessions.
Partnering is about “sharing with each other the knowledge, trust, and actions to achieve your overarching common goal, and for all of us, that’s quality, safety, and great care,” Clifford Y. Ko, MD, MS, MSHS, Director, ACS Division of Research and Optimal Patient Care, noted. Conferences like this one remain valuable in an era when so much information is available at one’s fingertips. “We need to be able to interact with people in front of a poster or after a session and have real-life discussions,” Dr. Ko said.
Update on ACS Quality Programs
“This is the very first time that all of the Quality Improvement Programs of the American College of Surgeons have come together under one roof” at a conference, Dr. Ko said.
Avery B. Nathens, MD, PhD, FACS, Medical Director, Trauma Quality Improvement Program (TQIP®), said the TQIP program was born of the ACS Trauma Center Verification Program. The College has accredited more than 500 trauma centers, and over the years, surveyors have observed variations in trauma center quality. TQIP provides trauma centers with contextual data and best practice guidelines to reduce these disparities. Hence, efforts are under way to integrate the verification program with TQIP, whereby trauma centers would need to “verify efforts to meet TQIP standards,” Dr. Nathens said.
Keith T. Oldham, MD, FACS, Chair of the Children’s Surgery Verification (CSV) Committee, noted that the CSV Program is “literally and figuratively in its infancy.” The program was founded on the principle that “every child who needs operative care should receive care in an environment that has optimal resources” for treating pediatric illnesses and injuries, Dr. Oldham said. CSV launched in early 2017, verifying pediatric care centers, using a tiered system based on multispecialty standards, annual case volume, data collection, and quality improvement (QI)activities that measure a facility’s ability to access the optimal resources necessary to provide the best care based on the needs of pediatric surgical patients.
Jason Liu, MD, ACS Clinical Scholar-in-Residence, provided an update on Patient-Reported Outcomes (PROs) Pilot in the ACS National Surgical Quality Improvement Program (ACS NSQIP®) Adult. Dr. Liu said measuring PROs is important to ensure that the care provided is “truly patient-centered and that outcomes match patients’ definition of quality.” Matthew Hutter, MD, MPH, FACS, associate professor in surgery, Harvard Medical School, Boston, MA, added that patient-centered care also involves reviewing patient-reported outcome measures (PROMs). PROMs tell you what matters most to patients after the surgical care experience.
Through the John A. Hartford Foundation-sponsored Coalition for Quality in Geriatric Surgery (CQGS), “we have the blueprint for taking care of the frail older adult,” said Thomas Robinson, MD, FACS, professor, surgery-gastrointestinal, trauma, and endocrine surgery, and director, minimally invasive surgery (MIS) Center, University of Colorado-Denver, Aurora. The CQGS beta standards target four areas: goals of care and decision making, cognition screening and delirium, maintenance of function and mobility, and nutrition and hydration optimization, and are being beta-tested at volunteer sites. The ACS expects to release final standards and launch a geriatric surgery verification program in 2019.
Stacy A. Brethauer, MD, FACS, associate professor of surgery, Cleveland Clinic Lerner College of Medicine, OH, provided an update on the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP). He reported that centers that participated in the MBSAQIP Decreasing Readmissions through Opportunities Provided (DROP) project experienced a “significant 30-day readmission decline”—12 percent over time and a 27 percent in the last quarter as DROP has been implemented. In addition, MBSAQIP has an Employing New Enhanced Recovery Goals for Bariatric Surgery (ENERGY) program aimed at decreasing variability and improving value.
Using data to standardize care
ACS Regent Fabrizio Michelassi, MD, FACS, Lewis Atterbury Stimson Professor of Surgery and chairman, department of surgery, Weill Cornell Medicine; surgeon-in-chief, New York-Presbyterian/Weill Cornell Medical Center, New York, NY, explained how a well-articulated, updated dashboard for displaying case information and relative outcomes—such as the one that ACS NSQIP offers—is vital for instructing QI efforts. “Our surgical department feels comfortable basing our QI decisions on [data in the NSQIP dashboard],” Dr. Michelassi said.
High-performing hospitals can provide the model for implementing ACS NSQIP-based QI activities, added Leigh A. Neumayer, MD, MS, FACS, professor and chair, department of surgery, University of Arizona, Tucson, and Chair, ACS Board of Regents. Nonetheless, “if you’re in that high category and your hospital is performing really well, I would tell you to continuously look at other systems and providers and find opportunities to improve,” Dr. Neumayer said.
ACS NSQIP allows hospitals to compare patient data to see what works for improving outcomes, and then apply that knowledge across the health care system through standardized care. Part of the challenge in standardizing care is translating evidence-based guidelines into codified standards.
“How do we take clinical practice guidelines and turn them into standardized care pathways?” asked Lillian Kao, MD, MS, FACS, professor of surgery, The University of Texas Health Science Center at Houston (UTHealth), and chief, division of acute care surgery, McGovern Medical School at UTHealth. Using her experience implementing an Enhanced Recovery after Surgery (ERAS) program, Dr. Kao said you need to define your goals and metrics; select a team lead; gather the rest of the multidisciplinary team; adopt, adapt, or create the guidelines; and then secure stakeholder buy-in.
Bruce L. Hall, MD, PhD, MBA, FACS, chief quality offer, BJC Healthcare, Washington University, St. Louis, MO, and ACS NSQIP Consulting Director, suggested that monitoring and standardizing resources use can have an enormous effect on the cost of health care because as surgeons, “No service we deliver is delivered without the use of resources.” Dr. Hall said that after implementing responsible resource stewardship practices, the systems could significantly reduce supply costs by hundreds of millions of dollars over an extended period.
Susan Gearhart, MD, director of quality and safety, Johns Hopkins Bayview Medical Center, Baltimore, MD, said the QI team at that institution comprises a core group—leaders who develop and execute QI projects—and a collaborative group of “individuals from different specialties that help develop clinical pathways and analyze the metrics that serve as indicators of your success.” It’s important to engage with members of both groups to achieve QI.
By partnering with all members of the team, surgeons could contribute to the sustainability and ongoing success of QI, according to Kevin Schuster, MD, MPH, associate professor of surgery, Yale School of Medicine, New Haven, CT. “We were fortunate enough to have nurses on the floor who came to us and said they wanted to be a part of this project, and they’re the ones who are actually leading the project from the floor on a day-in, day-out basis,” Dr. Schuster said.
Rocco Ricciardi, MD, MPH, chief, colon and rectal surgery, Massachusetts General Hospital, Boston, cautioned against “reactive QI”—launching projects in response to an unexpected result on an ACS NSQIP report but which may not lead to long-term improvements. “All continuous quality improvement programs should be considered in the broader context of your organization’s mission and strategic initiatives,” he said.
Although hospital QI projects may seem insular, achieving success may require partnering with health care professionals outside your institution. Virginia Shaffer, MD, FACS, associate professor, Emory University, Atlanta, GA, described a project aimed at reducing readmissions from ileostomies. “We needed a partner, someone to help fill in the gap between discharge and first post-op appointment—someone to alert us to potential problems and a way to address them quickly.” Those partners included pharmacies, social workers, and a home health agency, among others.
Improving system-level outcomes for each patient takes time, effort, and resilience, according to David B. Hoyt, MD, FACS, ACS Executive Director, and keynote speaker Rolf Benirschke, exemplifies the ability to bounce back. Mr. Benirschke, a retired National Football League kicker for the San Diego Chargers (1977–1987), continued to play at a high level after surviving complications from ulcerative colitis.
He described collapsing on a cross-country team flight while battling his condition and subsequently undergoing two emergency operations within six days. After the resection and anastomosis of his small intestine, he questioned the quality of his life with two ostomy bags attached to his body. “I was scared to death. I was angry, I was confused—I thought my life was over, that I had no reason to live,” Mr. Benirschke said.
However, the nurses who worked with Mr. Benirschke during his initial eight-week hospital stay helped him to understand how other patients overcame their own suffering and struggles, enabling him to conquer his “dragons of doubt.” He worked with his care team and the San Diego Chargers to return to playing and went on to have a successful career.
This experience led Mr. Benirschke to become an advocate for patient engagement, noting that the health care professional-patient connection is paramount for successful outcomes. “You can educate us all day long in the head, but if you don’t touch our hearts, you’ve missed it,” he said.
Partnering with patients
“Patient-centered care means thinking about the patient as a person,” said Ronnie Rosenthal, MD, FACS, professor of surgery, Yale School of Medicine, New Haven, CT, and surgeon-in-chief, VA Connecticut Healthcare System.
The Institute of Medicine (now the National Academy of Medicine) defines patient-centered care as, “Providing care that is respectful of, and responsive to, individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions,” said Marcia McGory Russell, MD, FACS, a general and colorectal surgeon at Ronald Reagan UCLA Medical Center. It is important to remember that the patient is a member of the surgical care team, Dr. Russell said. Her institution has a Patient as Partner program, which emphasizes clear and open communication with patients about what to expect throughout the course of surgical care. “If you want patients to be compliant, you need to be very clear about what you want,” she said.
Margaret “Gretchen” Schwarze, MD, MPP, FACS, associate professor and Endowed Professor, Morgridge Professorship in Vascular Surgery, division of vascular surgery, University of Wisconsin-Madison, said, “There are lots of tools to help with shared decision making.” She suggested using the NURSE method of approaching this process: “name the problem, understand the patient’s perspective, respect the patient’s wishes, support the patient, and explore options.”
Using the red book
“The surgical ecosystem is changing,” said Joe H. “Pat” Patton, MD, FACS, a general, trauma, and surgical critical care surgeon, Henry Ford Health System, and associate professor of surgery, Wayne State University School of Medicine, Detroit, MI. “The rules have changed, and we have to change with them.” In response to these transformations, the ACS developed Optimal Resources for Surgical Quality and Safety, also known as the “red book.”
“Regardless of where you work, you have to have a system in place” to ensure quality of care and patient safety across the continuum of surgical care, said Rachel Kelz, MD, MSCE, MBA, FACS, professor of surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia. “The red book has given us a new language” to describe quality and safety from preoperative evaluation and preparation to postdischarge.
The red book underscores the importance of team-based care in today’s health care environment, offering insights into team building and emphasizing the value of mentoring and coaching, Dr. Hall added. In addition, the manual offers best practices for reducing surgical site infections (SSIs) and outlines the infrastructure that should be in place to deliver better, safer care.
Benjamin C. Dubois, MD, FACS, a general surgeon, Christus Health, Texarkana, TX, described how his team has used the red book to champion a surgical quality and safety program at his institution. They formed a “book club,” where the team met monthly to discuss key concepts in the manual. Through this process, the group developed a surgical safety checklist; reviewed its operating room (OR) policies; implemented Choosing Wisely protocols to reduce unnecessary medical tests, treatments, and procedures; and produced a surgeon scorecard. “The key to success is to communicate,” Dr. Dubois said. “You can do this. It will take time. Remember, quality is a journey, not a destination.”
Communication, culture, and emotional intelligence
The goal of communication is to “share ideas and affect the listener’s worldview,” added Lewis J. Kaplan, MD, FACS, FCCM, FCCP, professor of surgery, department of surgery, the Hospital of the University of Pennsylvania and the Veteran’s Administration Medical Center, Philadelphia. The speaker should focus on one major idea and give the listener a reason to care. Engage the listener’s curiosity or demonstrate how the story will bridge a knowledge gap. Use body language that conveys interest, openness, honesty, confidence, and credibility, Dr. Kaplan said.
Kimberly McKinley, MSN, RN, patient services manager, Vancouver Coastal Health, and Quality Lead and Surgical Data Specialist, British Columbia Patient Safety and Quality Council, said good storytellers bring data to life. “Data give a very small piece of the picture. The narrative answers the listener’s ‘so what?’ questions,” Ms. McKinley said. “Public narrative is the art of translating values into action,” Ms. McKinley added.
Shared values help the speaker and the audience to connect and provide the foundation for the institutional culture. Psychologist Michael Rosen, PhD, Johns Hopkins University School of Medicine, said although safety culture emanates from hospital leadership, surgical staff need to act as a “real team” to propagate it. Real teams have shared values and goals that are concrete and specific, and “there is some acknowledged form of interdependence,” Dr. Rosen said.
One tool commonly used to improve communication in surgical teams and promote a culture of safety in the OR is the surgical checklist. E. Patchen Dellinger, MD, FACS, professor of surgery, University of Washington, Seattle, explained how surgical checklists contribute to effective teamwork, which reduces delays, SSIs, and other complications. However, “It’s only if the checklist promotes communication and teamwork that it’s going to make a difference,” Dr. Dellinger said.
Underpinning any discussion of teamwork, culture, and leadership are the tenets of emotional intelligence (EI). Michelle R. McGovern, Director, ACS Human Resources and Operations, described how EI affects the workplace, noting those individuals with high EI “adapt more readily to new cultures, new workplaces, and are more sensitive to the needs of their coworkers.”
Ronald M. Stewart, MD, FACS, professor and chair, department of surgery, University of Texas Health Science Center, San Antonio, and Medical Director, ACS Trauma Programs, said, “Any time I’m dealing with a surgeon, I have to realize they are emotionally invested in that care. Emotional intelligence allows emotional management,” he said, adding that managing one’s emotions and understanding another’s improves the workplace environment and a surgeon’s ability to lead.
From consultation to recovery
The red book, mentioned previously, describes the surgeon’s and the surgical team’s responsibilities at each stage of surgical care.
Dr. Patton focused on the preoperative evaluation and preparation phase, specifically on determining whether a patient is an appropriate candidate for surgery. “Why does appropriateness matter?” he asked. Possible consequences of operations that are performed without consideration of these factors include worse outcomes, more disparities in care, and “choices that may be incongruent with patient wishes,” Dr. Patton said.
The surgeon also is responsible for developing a plan to ensure the right operation is performed in the right place, by the right provider, and on the right patient, Dr. Patton noted. Surgeons can use the ACS NSQIP Surgical Risk Calculator to discuss risks and benefits with patients. “It’s important to use it before the patient leaves the office,” he added.
Mark R. Katlic, MD, MMM, FACS, chief, department of surgery; surgeon-in-chief, Sinai Hospital; and director, Sinai Center for Geriatric Surgery, Baltimore, MD, provided details on preoperative risk assessment for frail, older patients. “Many different geriatric patient evaluations exist,” but they often are difficult to use, he said. To meet these challenges, his institution developed the Sinai Abbreviated Geriatric Evaluation (SAGE)—a simple geriatric screening tool that has proven to perform as well as more complex assessments.
To help surgeons prepare patients for surgery, the College offers the Strong for Surgery program, said Thomas K. Varghese, Jr., MD, FACS, chief value officer, Huntsman Cancer Institute, head of the section of general thoracic surgery, and program director, cardiothoracic surgery fellowship, University of Utah; and associate professor, department of surgery, University of Utah School of Medicine, Salt Lake City. Strong for Surgery empowers hospitals and clinics to integrate checklists into the preoperative phase of care to screen patients for potential risk factors and to provide appropriate interventions to ensure better surgical outcomes. At present, the checklists target four areas: nutrition, glycemic control, medication management, and smoking cessation. Efforts were under way to add checklists for prehabilitation, advance directives, shared decision making, and delirium, Dr. Varghese said.
Dr. Hoyt spoke about the immediate preoperative readiness phase, which begins 24 to 48 hours before an operation. Specific activities performed during this stage that affect patient safety and outcomes include skin preparation, bowel preparation, site marking, antibiotic selection, perioperative use of medications to avoid contraindications, anesthetic selection, and use of prophylaxis, he said.
“The intraoperative phase of surgical care begins when the patient enters the operating room and ends when the patient exits the OR,” said Timothy D. Jackson, MD, FACS, assistant professor of surgery, University of Toronto, ON. “Team training can improve OR performance,” Dr. Jackson said, citing the Agency for Healthcare Research and Quality’s (AHRQ) Strategies and Tools to Enhance Performance and Patient Safety (also known as TeamSTEPPS) curriculum and crew resource management programs as training options.
Jose L. Pascual-Lopez, MD, FACS, a general and critical care surgeon, Hospitals of the University of Pennsylvania and Penn Presbyterian Medical Center, Philadelphia, focused on the postoperative and postdischarge phases of surgical care. “Continuity of care is vital,” he said. “Two out of three sentinel events result from communications problems during handoffs” after an operation, he said. To avert this problem, surgical teams can apply the I-PASS (illness severity, patient summary, action list, situation awareness and contingency plans, and synthesis by receiver) method.
“Only 85 percent of patients feel prepared for the postdischarge phase,” Dr. Pascual-Lopez added. “Optimal follow-up begins before surgery” with a plan for what the patient can expect in recovery and identification of at-risk groups.
Despite the surgical team’s best efforts, something may happen that could lead to an SSI or other complication. “What do you do when things go wrong?” asked Sandra L. Wong, MD, MS, FACS, chair and professor of surgery, Geisel School of Medicine, and professor, The Dartmouth Institute, Hanover, NH. “What gets you to recognize a potential complication?” Dr. Wong outlined the “elements of rescue” after a postoperative complication, including timely recognition of complications and appropriate action by all members of the team.
Addressing adverse events
According to Oscar D. Guillamondegui, MD, MPH, FACS, professor of surgery; trauma medical director; and vice-chair of quality, section of surgical sciences, Vanderbilt Medical Center, Nashville, TN, when a sentinel event that results in an adverse outcome occurs, a member of the patient care team has an obligation to report it in a timely manner. At Vanderbilt, clinicians are encouraged to report sentinel events within five days of discovery. He outlined the guiding principles of reporting these situations as follows: maintain humility, describe your certainty that a sentinel event occurred, engage other clinicians with appropriate expertise, reduce inflammation, avoid speculation on the cause, and convey the facts of the case.
Once an adverse event has been reported, the department chair or surgical quality officer should “bring all parties to the table” to discuss what occurred. The purpose is not to point fingers but to ensure everyone can speak freely “without fear of retribution or shame,” Dr. Guillamondegui said. The next step is to create a performance improvement action plan, he said.
Jean Donovan, RN, MSN, department of surgery, Inova Fairfax Hospital, Falls Church, VA, described the case review process at her institution. Depending on the case under review, the case review committee may involve clinicians from a single specialty or a multidisciplinary team. She offered an example of how this process was used to develop a QI program that included the introduction of a gastrointestinal bleed algorithm that led to a reduction in SSIs.
Also discussed at the meeting was the peer review process. Key players in this process include the surgical quality officer and legal counsel. Tools used in the process include the ACS NSQIP Surgical Risk Calculator, clinical guidelines and codes of conduct, and the operative report to determine whether an individual applied best practices. The final report from the peer review committee provides recommendations on steps that the clinician can take to improve outcomes, such as reeducation and retooling of skills.
The opioid epidemic continues to be a topic of concern for surgeons and surgical quality teams. Michael Englesbe, MD, FACS, professor of surgery, University of Michigan, Ann Arbor, spoke about his experiences in Michigan, where hospitals found that reducing the amount of pills in a prescription not only reduced the number of pills a patient took to manage pain, but also limited community access to opioids.
Jonah Stulberg, MD, PhD, MPH, FACS, assistant professor of surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, spoke about a comprehensive solution to the opioid epidemic that he and the Illinois Surgical Quality Improvement Collaborative are developing called MOPIS, or Minimizing Opioid Prescribing in Surgery. The first step in the initiative echoes Dr. Englesbe’s recommendation of decreasing the numbers of pills, but “the reality is that we need to integrate better ideals of pain management into the continuum of care,” Dr. Stulberg said, suggesting that to fully address the issue, surgeons need to begin looking at setting pain management expectations, implementing risk screening for patients at high risk of abuse, optimizing patient function, and monitoring and improving outcomes in real time.
The 2019 ACS Quality and Safety Conference will take place July 19–22 in Washington, DC.