Physicians in ancient Egypt determined what types of practices yielded predictable responses in an effort to establish standards of care. The Edwin Smith Papyrus (1501 BC) is the first known written surgical quality standard for diagnosis and treatment of a variety of trauma conditions.1
At a 1916 Board of Regents meeting, American College of Surgeons (ACS) Founder Franklin H. Martin, MD, FACS, said that surgery was face to face with grave problems, such as discrepancies in the standards of hospital efficiency at even the nation’s most prestigious hospitals. To determine the severity of these variations, Dr. Martin called upon Ernest Amory Codman, MD, FACS, to develop a hospital assessment program based on Dr. Codman’s groundbreaking concepts of outcomes assessment.
The ACS Hospital Standardization Program of 1918 evolved into what is now known as The Joint Commission. It has served as a model for the College’s other quality improvement programs, including the work carried out through the Commission on Cancer (CoC), the Committee on Trauma (COT), the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP®), the National Accreditation Program for Breast Centers (NAPBC®), the ACS National Surgical Quality Improvement Program (ACS NSQIP®), ACS NSQIP Pediatric, the National Accreditation Program for Rectal Cancer (NAPRC®), and several others under development. Institution of these programs and their field-specific quality standards informed the development of the Optimal Resources for Surgical Quality and Safety (the Red Book), bringing their standards together on behalf of surgery overall.2
What we have done
The ACS leadership has asserted that health care reform should be patient-centered, physician-led, quality-driven, and efficiency-based. We recognized that the College needed to follow a set of clearly defined values to serve as our moral compass as we navigate the changing tides of health care delivery.
These values, which apply to all efforts by ACS staff and volunteers, are as follows:
- Professionalism, defined as demonstrating accountability, honesty, responsibility, loyalty, and respect
- Excellence, defined as exceeding internal and external standards
- Innovation, which means thinking creatively and addressing future challenges and constantly searching for better, more efficient ways to provide quality health care
- Introspection, which involves looking within to attain self-awareness and to achieve self-improvement
- Inclusion, which we define as listening to and involving other stakeholders and applying our collective intelligence to solve problems
With these values in mind, the ACS has developed a four-step process for achieving quality improvement. These steps have become our guiding principles for developing quality programs over the last 10 years:
- Set the standards. Identify and set the highest clinical standards based on the collection of outcomes data, other scientific evidence, and expert consensus that can be customized to each patient’s condition so that surgeons and health care professionals can offer the right care, at the right time, in the right setting. These standards are published and updated regularly.
- Build the right infrastructure. To provide the highest quality care, surgical facilities must have in place appropriate and adequate staffing levels, a reasonable mix of specialists, and the right equipment. Recently, checklists and health information technology, such as the electronic health record, have become integral components of this infrastructure. The right infrastructure is determined by the clinical standards set in the beginning.
- Collect robust data. Dr. Codman proposed that medical and surgical decisions should be based on clinical data drawn from medical charts that track patients after discharge from the hospital. These outcomes data should be risk-adjusted and collected in nationally benchmarked registries to allow institutions to compare their care with that provided at other health care facilities. Each institution’s performance feedback should also be measured against the standards they are committed to achieving.
- Verify processes and infrastructure. Allow an external authority to periodically ensure that the right systems are in place, outcomes are being measured and benchmarked, and hospitals and providers are proactively responding to these findings with quality improvement. This final principle provides assurance to the public that the hospital or health care facility performs at the level of the standards.
ACS Quality Programs
The ACS has implemented increasingly sophisticated continuous quality improvement (CQI) programs that have been proven to be effective in delivering optimal, cost-effective care to the surgical patient. Examples include:
- The CoC, founded in 1922 in collaboration with the American Cancer Society and other professional organizations, improves survival and quality of life for cancer patients through standard-setting, prevention, research, education, and monitoring of comprehensive treatment strategies. CoC-accredited institutions report their outcomes to the National Cancer Database and can benchmark their performance in real time.
- The COT, established in 1950, evolved from the Committee on Treatment of Fractures and improves all phases of care for the injured patient. The COT issues guidelines for injury prevention, sets protocols for provision of safe and effective trauma care, and establishes standards for trauma center verification. The COT manages the National Trauma Data Bank® (NTDB®)—the largest aggregation of U.S. trauma registry data—and established the Trauma Quality Improvement Program (TQIP®) to provide risk-adjusted benchmarking for trauma patient outcomes.
- The ACS brought the Department of Veterans Affairs National Surgical Quality Improvement Program into the private sector in 2004 as ACS NSQIP. This program uses nationally validated, risk-adjusted outcomes to measure and enhance the quality of surgical care. The ACS collaborated with the American Pediatric Surgical Association to develop ACS NSQIP Pediatric, which enables children’s hospitals to collect highly reliable clinical data points and compare their surgical outcomes with other institutions.
- The NAPBC launched in 2005 and is dedicated to improving the care of patients with breast disease.
- The ACS program for Accredited Education Institutes, initiated in 2008, developed a network of regional educational institutes that is guided by standards and metrics.
- The ACS administers the MBSAQIP in partnership with the American Society of Metabolic and Bariatric Surgery (ASMBS). This initiative is the product of a 2012 agreement to combine the verification activities of the ACS Bariatric Surgery Center Network Accreditation Program, established in 2005, with those of the ASMBS surgery centers. These programs require the maintenance of certain physical and human resources, reporting of patient outcomes to the ACS Bariatric Surgery Database, and ongoing peer evaluation to remain accredited.
There is considerable evidence that these programs are effective and enable the College to carry out its mission of providing surgeons with the tools, measures, and standards needed to deliver optimal care to their patients. One study concluded that ACS NSQIP-participating hospitals have successfully used the program to prevent complications and save lives at each institution.3 Another study indicated that patients who receive care at the more than 300 COT-approved trauma centers have mortality rates that are 25 percent lower than patients treated at undesignated hospitals.4 Specific to bariatric and metabolic surgery, two studies that examined more than 1 million patients found significant decreases in cost, complications, mortality, and failure to rescue at bariatric centers that were MBSAQIP-accredited.5,6
What we have learned
Quality is measurable, and data analysis reveals scientifically valid protocols for improving care. When health care professionals and institutions follow and maintain these standards, patient care improves and costs go down. It’s that simple. These principles incorporate the following six essential elements for success in surgery going forward:
- The future of medicine is dependent on quality, and the ACS registries and databases described previously have proven to be effective instruments for achieving quality goals.
- Quality is measurable, and a number of representatives from surgical institutions are effectively using ACS NSQIP and other quality improvement programs to arrive at best practices. Implementation of high-reliability systems of care that use quality data allow hospitals to significantly reduce the rate of complications.
- High-quality data are essential to provide surgeons and surgical teams with risk-adjusted, verified, clinical data they can trust for tracking the results of quality initiatives and benchmarking against a national standard. A recent study showed that claims data yielded a high percentage of false positives for complications. Also, correlation when ranking hospitals based on clinical versus claims data was poor, underscoring the importance of knowing the source of the data when making clinical decisions.7
- A supportive culture for evidence-based care delivered by high-performance teams results in better patient outcomes.
- National and state-level collaborative efforts have enabled insurers, health care professionals, medical institutions, and government agencies to share data and work together to improve quality of care and create a learning health care system.
- Continuous surgical quality improvement requires surgeon leadership within our institutions and in the halls of government as well. Federal agencies, members of Congress, and policymakers want feedback and are interested in learning how quality improvement initiatives reduce spending and improve care.
The next step in quality
Based on a legacy of 100 years of improving quality for our patients, the ACS released Optimal Resources for Surgical Quality and Safety in 2017,2 with the goal of defining the common standards and elements needed to achieve quality across all surgical specialties and provide a framework for the previously mentioned programs. This work defines the basic commitment, leadership, standard elements, and review process that a hospital should have in place to achieve quality. It covers all phases of surgical care, from initial decision making and preoperative optimization and preparation through operation and postoperative and postdischarge care. Expectations and metrics have been defined and data collection tools enabled. All other programs will complement optimal care delivery for common risks (for example, elderly patients) or for the traditional condition-based programs (such as cancer, trauma, bariatric/metabolic, and so on). In general, this effort will bring the best practices of each health care professional involved in surgical patient care together and create a true learning system.
A story in metabolic surgery
We rarely celebrate our accomplishments and often forget the tremendous progress that has occurred in our understanding of surgical diseases and how they can be best treated. Our awareness of the causes of morbid obesity is an example of an area of significant improvement in recent decades. Two pioneers in metabolic and bariatric surgery—Henry Buchwald, MD, PhD, FACS, FRCS(Hon), and Walter J. Pories, MD, FACS—convened a Metabolic Surgery Symposium, August 9−10, 2017, in Chicago, IL. Dr. Buchwald is renowned for his research into type 2 diabetes and its reduction through bariatric surgery, and Dr. Pories was the first to describe the full and durable remission of type 2 diabetes following gastric bypass. The symposium comprised a group of outstanding leaders in the field of metabolic and bariatric surgery and showed how our understanding of morbid obesity and its treatment have evolved.
Bariatric surgery has proven to be the most effective means of addressing morbid obesity and its comorbidities, including type 2 diabetes mellitus, hypertension, dyslipidemia, cardiovascular disease, stroke, sleep apnea, gallbladder disease, hyperuricemia and gout, and osteoarthritis. It helps people improve their self-image and self-confidence, thereby reducing the risk of depression and anxiety. These benefits can be further manifested by providing bariatric and metabolic surgery to obese patients as a form of prehabilitation before other procedures, such as joint replacement or transplant, to enhance the outcomes of those procedures.
Perhaps most importantly, bariatric surgery is safe, has durable outcomes, and is acceptable to patients who are presented with the option. Numerous studies have shown that bariatric operations can be performed as safely and with outcomes that are equal to or better than operations performed to treat gastroesophageal reflux disease. In the last 15 years, mortality and complications have been dramatically reduced through laparoscopic techniques, fellowship training, accreditation programs with performance data, and the overall dedication of the leaders in metabolic and bariatric surgery.8
Optimal outcomes result when bariatric procedures are required to be performed in facilities that are accredited for maintaining the appropriate resources. The ACS and ASMBS combined their respective national bariatric surgery accreditation programs into a unified program several years ago to achieve one national accreditation standard for bariatric surgery centers, the MBSAQIP. The MBSAQIP works to advance safe, high-quality care for bariatric surgical patients through the accreditation of bariatric surgical centers. A bariatric surgical center achieves accreditation following a rigorous review process, during which the center proves that it can maintain certain physical resources, human resources, and standards of practice. All accredited centers report their outcomes to the MBSAQIP database.
The ACS is doing the right thing in helping metabolic and bariatric surgeons to mobilize and provide quality surgical services to Americans in need of care for morbid obesity and metabolic diseases. It’s the right thing for the profession, and it’s the right thing for patients.9
This work was supported by the ACS. The authors declare that they have no relevant conflict of interest.
We are grateful to the ACS for their generous sponsorship of the Metabolic Surgery Symposium and associated journal publication development. We thank Jane N. Buchwald, chief scientific research writer, Medwrite Medical Communications, Maiden Rock, WI, for manuscript editing and publication coordination. And we thank Patrick Beebe and Donna Coulombe, ACS Executive Services, for their expert organization of the Metabolic Surgery Symposium.
- U.S. National Library of Medicine. An ancient medical treasure at your fingertips. Available at: www.nlm.nih.gov/pubs/techbull/ma10/ma10_hmd_reprint_papyrus.html. Accessed April 11, 2019.
- Hoyt DB, Ko C (eds). Optimal Resources for Surgical Quality and Safety. Chicago, IL: American College of Surgeons; 2017.
- Hall BI, Hamilton BH, Richards K, et al. Does surgical quality improve in the American College of Surgeons National Surgical Quality Improvement Program? An evaluation of all participating hospitals. Ann Surg. 2009;250(3):363-376.
- MacKenzi EJ, Rivara FP, Jurkovich GJ, et al. A national evaluation of the effect of trauma-center care on mortality. N Engl J Med. 2006;354(4):366-378.
- Azagury D, Morton J. Bariatric surgery outcomes in U.S. accredited vs non-accredited centers: A systematic review. J Am Coll Surg. 2016;223(3):469-477.
- Morton JM, Garg T, Nguyen N. Does hospital accreditation impact bariatric surgery safety? Ann Surg. 2014;260(3):504-509.
- Lawson, EH, Louie R, Zingmond DS, et al. Using both clinical registry and administrative claims data to measure risk-adjusted surgical outcomes. Ann Surg. 2016;263(1):50-57.
- Nguyen NT, Nguyen B, Smith B, Reavis KM, Elliott C, Hohmann S. Proposal for a bariatric mortality risk classification system for patients undergoing bariatric surgery. Surg Obes Relat Dis. 2013;9(2):239-246.
- Hoyt DB. Looking forward. Bull Am Coll Surg. 2017;102(10):10-11. Available at: bulletin.facs.org/2017/10/looking-forward-october-2017/. Accessed May 16, 2019.