Looking forward – April 2019

David B. Hoyt, MD, FACSA number of American College of Surgeons (ACS) leaders have been working on standards for verifying and accrediting hospitals on the basis of surgical quality and patient safety. These standards are drawn from the principles outlined in Optimal Resources for Surgical Quality and Safety, also known as the Red Book. As part of this process, ACS Past-President J. David Richardson, MD, FACS; Clifford Y. Ko, MD, MS, MSHS, Director, ACS Division of Research and Optimal Patient Care; and I have been conducting site visits at hospitals throughout the country that have agreed to pilot test the program.

What the participating hospitals have learned

The article on page 16 of this issue of the Bulletin highlights how two hospitals in Kentucky—one an academic medical center, the other a community hospital seeking to improve outcomes—prepared for their site visits and what they learned from this experience. Both hospitals report that they gained insights into what steps they could take to improve quality and safety in their institutions.

Briefly, the health care professionals at the academic medical center realized early on that the institution needed a more consistent process for reviewing their cases and better coordination of all services involved in delivering surgical care. By looking at care delivery from a multidisciplinary perspective, the hospital was able to improve engagement from all stakeholders and to integrate them more effectively into the institution’s quality improvement culture. The medical center also developed a more effective process for using data to open discussions with outliers.

The community hospital found that although it had effective processes for managing outliers, it had inconsistent methods of case review to benchmark the performance among all surgeons. Several services had metrics for measuring performance against national standards, but several did not. Loop closure was often inconsistent, with no specific individual or group consistently responsible for follow-up. The hospital leaders also recognized the need for more coordinated communication across all specialties and services, as well as more resources devoted to quality improvement.

What we have learned

Just as these institutions have learned a great deal about next steps in improving quality and safety, we have learned a lot about the value of the Red Book and what we can do to make it and the resultant standards and verification process more meaningful to the full range of health care institutions.

First, we have been informed which chapters of the Red Book are the most relevant to quality improvement leaders in hospitals. More specifically, they find the information pertaining to the following areas of greatest practicality:

  • The surgeon’s responsibility and leadership during the five phases of care: preoperative evaluation and preparation, immediate preoperative readiness, intraoperative, postoperative, and postdischarge
  • The value and responsibilities of the Surgical Quality Officer
  • The importance of standard case review and peer review processes
  • Establishment of an operational infrastructure to ensure quality, safety, and reliability
  • Development of rigorous credentialing and privileging protocols to ensure that staff surgeons are competent in the provision of optimal care
  • Application of the principles of high reliability with a supportive infrastructure
  • Disease management and multidisciplinary care
  • Surveillance and use of the data to improve outcomes

Next steps

On these site visits, we have learned that some hospitals are performing some of these activities well, but no hospital does all of them well.

As many individuals involved in quality improvement have said, it’s a journey, not a destination. Based on the experiences of the pilot sites, the College will continue to develop standards for verifying and accrediting health care centers that provide surgical care and to develop a second edition of the Red Book. We ask that surgeon champions continue to work with their hospital leadership to institute policies and practices that will lead to the provision of better quality and safer patient care and to consider having an ACS site visit.

The ACS also is looking to bring its other accreditation and verification programs in trauma, cancer, and bariatric surgery under the Red Book umbrella. In other words, the ACS is practicing what it preaches: Better coordination of activities and more inclusive teams that lead to better quality.

If we perform surgery using the concepts of integrated practice units and work together as teams with a focus on using data to address outliers, we will achieve the College’s core mission: To improve the care of the surgical patient and to safeguard standards of care in an optimal and ethical practice environment.


If you have comments or suggestions about this or other issues, please send them to Dr. Hoyt at lookingforward@facs.org.

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