The ACS Strong for Surgery program: Changing clinician and system behavior to optimize health before surgery


  • Discusses the early development and goals of the Strong for Surgery initiative, specifically raising patient awareness and changing surgical practice
  • Describes the RE-AIM framework and how it was used to evaluate the public health impact of Strong for Surgery
  • Outlines the transition of Strong for Surgery to a formal ACS Quality Program in 2016 and notable milestones of the initiative under College leadership

Health care systems around the world are struggling with rising costs and variations in the delivery of quality care. Medical care often is administered without sufficient evidence-based protocols, with U.S. patients receiving only about half of the preventive, acute, and chronic care recommended by current research and evidence-based guidelines.1 One-third of hospitalized patients may experience harm or an adverse event, often as a result of preventable errors.2,3 Infections and complications once were viewed as routine consequences of medical care; however, advances in perioperative medicine demonstrate that evidence-based strategies and interventions can significantly reduce the incidence and severity of these events. With nearly 40 percent of health care expenditures in the U.S. related to surgical interventions,4 opportunities exist to bring about true health care reform through the dissemination of effective evidence-based practices in surgical care.

In 2001, the National Academy of Science’s Institute of Medicine (now known as the National Academy of Medicine) released Crossing the Quality Chasm: A New Health System for the 21st Century, which focused on the divide between what is known about quality health care and the health care that people actually receive.5 The report emphasized that making incremental improvements in health care delivery is not enough to significantly improve outcomes and defined six pillars of health care quality: safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity.

Efforts are under way to build a web-based platform where multiple checklists/areas for optimization of a patient can be performed efficiently to generate individualized, patient-centered checklists with future goals of delivery via mobile apps and tracking within an electronic health record.

Surgery has made notable progress with the first pillar: safety.6 Although trends toward safer surgery are encouraging, wide variations in outcomes suggest further opportunities for improvement. In 2013, a further call to action was issued centered on maximum value for patients: achieving the best outcomes at the lowest cost.7

Most surgical quality initiatives undertaken by hospitals focus on the inpatient experience of surgical care—from the time the patient is admitted until discharge. Although these initiatives are important and meritorious, a patient’s risk of negative outcomes from surgery may be both predetermined and modifiable before entering the operating room. Therefore, the scope of surgical quality improvement (QI) efforts must expand to incorporate the preoperative setting by engaging surgeons in their clinics, and thus toward the realization of optimal surgical quality and perioperative care.

Preoperative, clinic-based QI initiatives face a unique set of challenges related to infrastructure, time constraints, professional overlap in the field, reimbursement issues, and conflicts with a fee-based culture (that is, more patients undergoing operations leads to greater remuneration). Ideally, QI programs should engage multidisciplinary stakeholders, educate the public, maximize value, improve efficiency in clinic workflow, and incorporate seamlessly into robust surveillance and data feedback platforms to initiate and sustain results after implementation.

In 2012, a novel public health initiative was piloted in the Pacific Northwest: Strong for Surgery, which aims to identify and improve evidence-based practices for elective surgical patients in the preoperative setting. After the 2012 pilot year, the program spread in the Pacific Northwest, until 2015 when it transitioned to the American College of Surgeons (ACS), officially becoming an ACS Quality Program in 2016. This article reviews the initial growth of the Strong for Surgery program, its impact on elective surgical patient outcomes, and plans for the years ahead.

The early years of Strong for Surgery

Building on the success of the Surgical Care and Outcomes Assessment Program (SCOAP), in May 2012, the team at the University of Washington Comparative Effectiveness Research Translation and Information Network (CERTAIN), Seattle, launched Strong for Surgery.8,9 This program is a platform that allows evidence-based interventions to be implemented in the preoperative time period, thus facilitating the optimization of patient health before elective operations. Strong for Surgery has two primary components: raising patient awareness and changing surgical practice.

The raising patient awareness component was achieved with the help of a public outreach campaign that included events, media reports, social media interactions, and the formation of strategic partnerships with regional specialty societies (see Figure 1). The campaign focused on four areas with robust evidence-based interventions intended to help optimize patient health before elective surgery: nutrition optimization, blood sugar control, medication reconciliation, and smoking cessation (see Table 1). A website ( was created to provide background information about the program, evidence from the literature for checklist components, and details on outreach events.

Figure 1. Road map for the Strong for Surgery awareness campaign

Figure 1. Road Map for the Strong for Surgery Awareness Campaign

Table 1. Initial Four Preoperative Modifiable Areas for Optimization of Health Before Elective Surgery

Table 1. Initial Four Preoperative Modifiable Areas for Optimization of Health Before Elective Surgery

Changing surgical practice was achieved when hospitals participating in the Strong for Surgery program entered into formalized agreements that led to site visits from trained surveyors who performed workflow mapping, assessed resources, and facilitated training of clinic staff. Implementation guides were developed to support these efforts (see Tables 2 and 3). Strong for Surgery change teams—composed of at least a surgeon champion, clinic nurse lead, nutritionist/dietitian, quality improvement database representative, and administrative support—were formed at participating sites. These team members were expected to participate in monthly stakeholder calls (see Figure 2).

Table 2. Strong for Surgery Design Principles

Table 2. Strong for Surgery Design Principles

Table 3. Principles of Workflow Mapping

Table 3. Principles of Workflow Mapping

Figure 2. Four Areas of Focus for Change Teams

Figure 2. Four Areas of Focus for Change Teams

Implementation occurred in three formal phases: explore, initiate action, and learn together (see Table 4).

Table 4. Phases of Implementation

Table 4. Phases of Implementation

In 2012, six sites representing a diverse spectrum of practice environments—academic medical center, large-volume private practice, medium-volume private practice, health maintenance organization, community hospital, and county hospital—pilot-tested the program (see Figure 3). Feedback from these sites led to the refined version of these checklists that was spread through the Strong for Surgery collaborative from 2013 onward. Funding in the early years of the initiative was achieved through grants from the University of Washington’s Patient Safety Innovations Program, the State of Washington’s Life Sciences Discovery Fund, Nestle HealthScience (nutrition optimization), Pacira Pharmaceuticals (opioid minimization), and Pfizer (smoking cessation). Strategic partnerships were developed with commercial industries rather than through the promotion of their products.

Figure 3. Strong for Surgery Pilot Sites: 2012

Figure 3. Strong for Surgery Pilot Sites: 2012


The Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework offers a comprehensive approach to considering five dimensions important for evaluating the potential public health impact of an intervention.10 The RE-AIM components are defined as follows:

  • Reach: The reach of the campaign was defined as the number of outreach events, strategic partnerships, and digital presence (Internet and social media) attained in years two and three following the pilot-testing year.
  • Effectiveness and adoption: Program adoption was measured as the percentage of health care professionals and their respective specialties that agreed to deliver the program. Effectiveness was assessed using process of care measures tracked in quarterly SCOAP reports for both nutritional interventions and blood sugar control—both specific targets of Strong for Surgery.
  • Implementation: Implementation was defined as uptake of the intervention and was measured in weekly electronic scorecard reports (number of checklists used divided by the number of eligible patients), observational site visits, and on-site interviews six and 12 months postintervention. Interview questions addressed familiarity with the implementation guide, feedback regarding sections that were the most and least helpful, actual use and implementation of the program, and barriers to adoption of the Strong for Surgery program. Focus interviews were conducted to assess whether the goals of implementation were reached and improvement in workflow was demonstrated.
  • Maintenance: Maintenance was defined as the degree to which the program is sustained within each institution at 12 months after implementation.


Six pilot sites tested the Strong for Surgery platform in 2012. Strong for Surgery was initiated at 11 SCOAP hospitals in year two (2013), and 21 SCOAP hospitals in year three (2014). The public awareness campaign was active, with 94 outreach events in two years (2013 and 2014), consisting of invited presentations at grand rounds at SCOAP sites, panel discussions and presentations at regional and national specialty society meetings in 10 states with a total of more than 4,000 U.S. attendees, and meetings with patient advocates. Strategic partnerships were formed with Washington State surgery, anesthesia, nutrition, patient safety, nursing, and QI organizations. Social media presence (Twitter accounts: @tomvarghesejr, @Strong4Surgery) grew during the two years, with 5,695 followers for the two Twitter accounts, 26,000 posts, and 159 followers on Facebook. The Strong for Surgery website received 16,227 hits over the two years, including 11,473 unique visits (that is, views that went beyond the home page with deep dives into content). Demand for the program came from well beyond the SCOAP collaborative, with 186 requests to participate from U.S. sites outside Washington State and from 13 countries around the world.

A total of 5,287 patients (median age 62 years) underwent elective colorectal surgery with anastomosis at SCOAP hospitals in 2013 and 2014. The Strong for Surgery intervention was used in 46.1 percent of SCOAP patients during the two-year study period, with 30.1 percent in 2013 and 62 percent in 2014. In the fourth quarter of 2014, Strong for Surgery hospitals provided for 83.2 percent (594/714) of elective colorectal procedures with anastomosis in SCOAP.

During on-site visits, leadership at Strong for Surgery hospitals indicated that they were familiar with and used the implementation guide. Predictors and barriers to successful Strong for Surgery implementation were identified based on site visits and focus interviews (see Tables 5 and 6). Baseline clinical and demographic characteristics were similar between patient groups that did and did not participate in the Strong for Surgery program (see Table 7).

Table 5. Site Characteristics that Favored Successful Strong for Surgery Implementation

Table 5. Site characteristics that favored successful Strong for Surgery Implementation

Table 6. Factors that Impaired Strong for Surgery Implementation

Table 6. Factors that impaired Strong for Surgery implementation

Table 7. Demographic and Clinical Characteristics by Assignment group

Table 7. Demographic and clinical characteristics by assignment group

Optimizing nutrition

Decreased albumin has been associated with significant increase in morbidity and mortality in the colorectal surgical patient population. In 2011, SCOAP data identified that 45 percent of all elective colorectal surgical patients had routine albumin measurements, and 15 percent of patients undergoing colon resection in Washington State had an albumin level of less than 3 grams per deciliter (g/dL) without documented attempt at nutritional intervention. The patients had reoperation rates of 5 to 12 percent and 30-day mortality rates of 3 to 14 percent. After the launch of Strong for Surgery, improvements were seen in all the nutritional process-of-care measures in both Strong for Surgery and nonparticipating hospitals. Albumin was measured in 70.45 percent of Strong for Surgery colorectal surgical patients and 56.7 percent of non-Strong for Surgery patients. Albumin levels less than 3.0 g/dL were identified in 5.6 percent of program patients, with 24.15 percent referred to a nutritionist or dietitian. In non-Strong for Surgery patients, albumin levels less than 3.0 g/dL were identified in 4.1 percent of the patients, with 48.8 percent referred to a nutritionist or dietitian. Although the referral rates were low, 88.9 percent of the Strong for Surgery patients and 59.2 percent of non-Strong for Surgery patients received oral nutritional supplementation.

To assess whether Strong for Surgery was effective only if a targeted intervention was performed (nutritional intervention), or if nutritional awareness by itself influenced other areas, blood sugar control was used as a comparator at those Strong for Surgery sites where only nutritional intervention was provided (see Table 8). In the first year of statewide dissemination (2013), we found a significant increase in testing of blood sugar in diabetics, as well as perioperative use of insulin for patients with high blood sugar levels at Strong for Surgery hospitals. However, this positive effect was short-lived as both metrics were no different than at non-Strong for Surgery hospitals in 2014, highlighting the importance of specific interventions for maintenance.

Table 8. Process of care

Table 8. Process of care

Because evidence-based immunonutrition was the most common nutritional intervention used in the program’s early years, measuring its use was taken as a surrogate for compliance with and maintenance of implementation efforts. At 12 months, 78 percent of participating Strong for Surgery sites were continuing to implement immunonutrition interventions (see Figure 4). Most sites followed a similar pattern of initially slow adoption, followed by a plateau phase for the first six months (fluctuation between 20 to 40 percent use), followed by rapid uptake and use. The tipping point toward rapid ascent was notably sooner (between a few weeks and a couple of months) at sites where surgeon champions and clinical practices were predominantly providers of colorectal surgery in contrast to mixed general surgery practices.

Figure 4. Length of time to adoption and uptake for evidence-based immunonutrition use at Strong for Surgery hospitals

Figure 4. Length of time to adoption and uptake for evidence-based immunonutrition use at Strong for Surgery hospitals

Transition to the ACS

For more than a century, the ACS has been at the forefront of improving the delivery of surgical care by implementing quality programs. The ACS has applied four key principles to consistently improve quality of care and increase value:

  • Set the standards
  • Build infrastructure
  • Collect robust data
  • Verify through a surveillance and feedback platform

From 2011 to 2015, the ACS conducted the Inspiring Quality tour, which was a series of community forums aimed at stimulating discussions about how QI programs in U.S. hospitals can reduce patient readmissions, prevent medical errors, improve patient outcomes, and reduce costs.11 These community forums brought together health care leaders and policy experts to describe best practices and key elements of surgical quality programs. The Strong for Surgery program was announced at the Seattle event in April 2012, at which point the ACS began closely monitoring the progress of the program. Discussions about transitioning the program to the College began in 2015, and in 2016, Strong for Surgery became a formal ACS Quality Program, with the College launching Strong for Surgery public awareness initiatives in 2017.12

The program has continued to grow under the leadership of the ACS. Notable achievements include the following:

  • When discussions were initiated with the ACS, Strong for Surgery was active at 50 sites. As of the end of 2018, the program was active at 230 clinical sites across the U.S., spanning the specialties of general, vascular, thoracic, bariatric, and spine surgery.
  • Most U.S. sites use Strong for Surgery in conjunction with enhanced recovery programs (see Figure 5).
  • From 2013 to 2015, the Strong for Surgery website had a total of 173,519 page views and 122,038 unique page views. A new ACS Strong for Surgery website launched in 2017.
  • From 2013 to 2015, 268 surgical care facilities outside of the Pacific Northwest, including 15 countries, submitted requests to participate in Strong for Surgery.

Figure 5. The role of Strong for Surgery and enhanced recovery programs in the five phases of perioperative care

Figure 5. The role of Strong for Surgery and enhanced recovery programs in the five phases of perioperative care

The number of adverse event rates (reintervention, infection, anastomotic leak +/- death) in elective colorectal surgical patients receiving immunonutriton declined from 9.5 percent to 7 percent, a difference that became even more pronounced after propensity score matching (11.6 percent to 7.2 percent), which translated to a decrease in length of stay from 6.9 days to 5.8 days.13

In an observational study of nearly 24,000 patients between the ages of 46 and 72 undergoing cervical (45.3 percent) or lumbar (54.7 percent) spine fusion procedures at 18 hospitals across Washington State between 2011 and 2016, the Strong for Surgery campaign led to a decrease in the proportion of patients who smoked at the time of surgery from 36 percent in 2011 to 12 percent in 2016. In addition, smoking cessation counseling increased from 6.14 percent in 2012 to 42 percent in 2016.14

At Christus St. Michael Health System, Texarkana, TX, use of Strong for Surgery improved glycemic control of patients with poorly controlled diabetes from 87.7 percent of patients on the day of surgery with blood sugar levels less than 200 mg/dL to 97.31 percent six months after implementation. Additionally, smoking cessation rates increased and the use of Strong for Surgery in conjunction with an enhanced recovery program led to a decrease in length of stay of 1.5 days and a reduction of costs by an average of $2,027.15

Future plans

In November 2018, four new checklists were released under the Strong for Surgery banner—delirium, prehabilitation, pain management, and patient directives (see Table 9). Similar to the first four areas for optimization, these additional components were selected because of the abundance of evidence in the literature and after receiving feedback from patient advocacy groups, health care leaders, and engaged stakeholders nationwide. Efforts are under way to build a web-based platform where multiple checklists/areas for optimization of a patient can be performed efficiently to generate individualized, patient-centered checklists with future goals of delivery via mobile apps and tracking within an electronic health record. Active collaborations are under way with the ACS Geriatric Surgery Verification Quality Improvement Program; Brigham and Women’s Center for Surgery and Public Health–Cambia Health Foundation, Boston, MA; and the American Society for Enhanced Recovery. These collaborations include ongoing discussions with leaders in the fields of anesthesia, nursing, patient advocacy groups, perioperative medicine, hospitalists, health systems, health policy, and insurance companies. The mission of the ACS Strong for Surgery program is simple: helping surgical care providers for any patient—in any part of the world electing to have surgery—answer the question, “Is our patient strong for surgery?”

Table 9. Second set of Strong for Surgery checklists addressing modifiable areas for preoperative optimization of health

Table 9. Second set of Strong for Surgery checklists addressing modifiable areas for preoperative optimization of health


The Strong for Surgery Collaborative represents the comprehensive work performed by engaged frontline health care teams dedicated to the highest ideals of patient care. We are indebted to the amazing commitment, countless hours, and ongoing efforts of all our partners who inspire quality by setting the highest standards in the pursuit of better outcomes for all.

And to all our patients past, present, and future: thank you for letting our teams be a part of your lives.


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