In 2017, the American College of Surgeons (ACS) published Optimal Resources for Surgical Quality and Safety, which was co-edited by David B. Hoyt, MD, FACS, ACS Executive Director, and Clifford Y. Ko, MD, MS, MSHS, FACS, Director, ACS Division of Research and Optimal Patient Care. Commonly referred to as the Red Book, this manual was intended to serve as a guide for the development of quality and safety programs in U.S. hospitals.* It shares many common features with the optimal resource documents used in other ACS-recognized programs, including the well-established ACS Committee on Trauma Verification, Review, and Consultation Program.
Optimal Resources for Surgical Quality and Safety focuses on surgeon involvement in the five phases of care: (1) the preoperative preparatory phase; (2) the immediate preoperative readiness period; (3) the intraoperative phase; (4) the postoperative period; and (5) the postdischarge phase of care. Additional quality improvement recommendations include: appointing a surgical quality officer, who has the responsibility and authority to affect surgical quality improvement efforts in the institution; implementing a method for case review of outcomes with appropriate peer review; and ensuring broad institutional involvement. Additionally, the Red Book recommends that the hospital have an effective structure for privileging and credentialing surgical care professionals. In a high-volume hospital, benchmarking performance against recognized databases is a laudable goal. The aim of these efforts is to aid in the provision of infrastructure development to support hospitals in the creation of a culture focused on safety and high reliability.
After the release of the Red Book, a small committee of College Fellows convened to develop standards based on the principles outlined in the manual. The objective was to provide a mechanism by which hospitals could focus on their surgical quality efforts in an organized fashion. The ultimate goal of these standards was to develop a verification process that would encourage participation by a large number of hospitals with diverse characteristics; that is, both academic centers and community hospitals, including not only large private urban institutions, but smaller facilities in rural or suburban settings as well.
The authors of this article were involved in the initial planning phases of the verification program, in part because they represent different types of institutions. Dr. Smith is the quality officer at a 350-bed academic institution with a safety net role as a major part of its mission; Dr. Chipman is a designated surgical quality officer at a 500-bed, private tertiary hospital; and Dr. Richardson has held leadership positions within the College, including as ACS President (2015–2016), and has participated in various ACS quality efforts, in addition to having general knowledge about rural and community hospital care. The authors affirmed their commitment to this quality improvement process by engaging their institutional leadership with a plan for developing a hospital quality and safety program that generally conformed with the principles outlined in the manual and being among the first hospitals to undergo a verification site visit.
University of Louisville Hospital
The 350-bed University of Louisville Hospital, KY, provides trauma care for a broad catchment area of more than 2 million people and serves as a safety net hospital for urgent and elective surgery for the service area. The hospital has a long history of being an ACS-verified Level I trauma center. The hospital also has an accredited breast program, cancer program, and comprehensive stroke center. The hospital is an ACS National Surgical Quality Improvement Program (ACS NSQIP®) participant. As a training institution, every surgical discipline has a morbidity and mortality (M&M) conference as required for accreditation, although the intensity of these reviews appeared to vary somewhat. Moreover, a fair assessment of these efforts might characterize them as “disciplinary silos,” in that they resulted in few coordinated efforts to improve quality, with the exception of a robust performance improvement process in the trauma program.
As the University of Louisville Hospital began this initiative, it was clear the surgical specialties needed better coordination of existing reviews under the aegis of the quality officer and better processes to involve nonsurgical disciplines, such as anesthesia, various medical services, and the emergency department. Examples of multidisciplinary coordination included efforts to manage conditions, such as gastrointestinal bleeding where more effective protocols were implemented, or the coordination of the ordering of anticoagulants in a postoperative patient with atrial fibrillation.
Many benefits were observed as the department of surgery initiated the upgraded quality program. Participation increased among the specialty surgical services, and they became much better integrated into the quality culture of the hospital. The process required tremendous coordination and emphasis on teamwork, especially in our preoperative assessment phase, requiring collaboration with the anesthesia department. An increased emphasis was placed on the use of data to decrease variability in care and improve clinical effectiveness.
The process of preparing for the site visit energized the staff—physicians and nonphysicians alike. We were proud of our review of problems in a traditional M&M format, but we were impressed that the structure of the Red Book process forced a discipline of review that may have previously been lacking. This process, though resource- and labor-intensive, allowed the quality program to move beyond the M&M conference.
The process provided several tangible benefits that could be considered self-serving, but were an offset to the time and resources required for the process. The opportunity to query the site visitors about their experiences and best practices regarding quality metrics was highly beneficial. The possibility for external validation of the merits of our quality and safety program was no small achievement for our safety net hospital, as quality issues had been raised previously when the hospital was part of another health care system. Although the University of Louisville Hospital does not have an active marketing program, the prestige of potential verification by the ACS for our safety initiative would lend credence to the importance of quality to the institution.
Baptist Health Louisville
Baptist Health Louisville, KY, is a 500-bed private hospital that is part of a large health care network in Kentucky and southern Indiana. It has an open medical staff of nearly 500, with a mixture of employed and private practice physicians. The hospital provides extensive tertiary surgical care with busy orthopaedic, cardiothoracic, and general surgical services. The institution participates in several quality databases, including an accredited program in bariatric surgery, the Society of Thoracic Surgery outcomes dashboard, and the ACS Commission on Cancer National Cancer Database. However, Baptist Health Louisville does not participate in a general surgical database.
The hospital has a surgeon who reviews potential quality issues, which emanate from queries from many sources. This surgeon then reviews the cases and refers them to a surgical patient care committee (PCC), which appropriately adjudicates the concerns raised. The PCC is a large, active group with specialty representation from all surgical disciplines. The PCC chair is a surgeon elected by the committee, and the leadership rotates annually. After chart review of myriad cases (including some with suboptimal outcomes), it appeared the process for detecting and managing outliers was robust, and it was evident that disciplinary actions were taken as required.
As the surgical quality leaders in the hospital evaluated their process in preparation for the site visit, they made several observations. Although they were appropriately proud of their processes and ability to manage outliers, they had inconsistent methods of case review, which may have impaired their ability to raise the level of performance of all surgeons. In addition, several services had metrics for comparing their performance to national standards, but several did not. Loop closure was often performed when problems were identified; however, this process was frequently fragmented, without a person or group consistently responsible for the follow-up action. The hospital leaders recognized the need for a better means of communication, not only in problem areas, but also a system for raising awareness among the medical staff of problems or corrective actions that occurred. Participation in the quality and safety site visit appeared to energize the medical staff in this private hospital, as it did in the academic center five miles away.
Two disparate hospitals in Louisville were proud to have been among the four initial institutions to have an ACS quality and safety site visit. As an observer during both visits, Dr. Richardson was struck by several common themes. The nonphysician leadership at both hospitals enthusiastically endorsed the process. In addition to any promotional value that might accrue from a positive verification visit, they were clearly committed to enhancing the culture of safety and quality. Leaders at both institutions appropriately believed the process for detecting outliers was in place, but embraced potential improvements in the ability to deliver consistent, excellent care across the board. The term “high reliability” can be a cliché, but there seemed to be a genuine desire to have a continuous improvement process in place to achieve that goal.
From a surgical staff perspective, it was rewarding to encounter more than 20 surgeons in each institution representing all disciplines sitting in a room after hours discussing quality. Clearly, the key is to maintain the commitment to improving quality and safety daily, but the surgeons in both hospitals appeared to realize this process is iterative and requires constant attention. Another positive common feature was the enthusiasm the entire process generated in the nonphysician professionals who deal with various aspects of the five phases of care, as well as the quality programs themselves. The experience provided other unstated value to both hospitals.
Both hospitals clearly embraced this endeavor, but undertaking a quality and safety site visit and the processes required for a positive outcome requires commitment across the institution. The process requires an enormous time commitment, even in a hospital with the appropriate elements in place. The expense of establishing an effective quality and safety program is real, particularly in a large facility. It also requires surgeon buy-in to have their results scrutinized. Merely having a committed surgical quality officer trying to lead a nonparticipatory surgical staff will offer little or nothing. The ACS has been the clear leader in the field of surgical quality, and our two institutions seek to be at the forefront of this new effort and demonstrate their willingness to embrace these quality efforts across the broad spectrum of surgical care.
After decades of experience with myriad ACS quality programs, Dr. Richardson is committed to the belief that not only are quality and safety initiatives inherently important, but that they may act as a talisman to confer protection from forces that may desire to impose “quality” standards without an understanding of what that term truly entails. The site visitors recognized the learning-curve nature of the Red Book process, and those from our two hospitals were grateful to be included in the formative stages of this evolutionary program.
*Hoyt DB, Ko CY (eds). Optimal Resources for Surgical Quality and Safety. Chicago, IL. American College of Surgeons; 2017.