The Bulletin by the American College of Surgeons Fri, 17 Oct 2014 18:07:58 +0000 en-US hourly 1 Looking forward – October 2014 Wed, 01 Oct 2014 05:59:18 +0000

Many American College of Surgeons (ACS) members and staff were deeply saddened to learn that the College’s former Executive Director, Thomas R. Russell, MD, FACS, died August 4 after a four-year battle with cancer. Tom was a very personable, optimistic, and dedicated leader, and he accomplished a great deal in the 10 years in which he served as Executive Director.

Overcoming challenges

He assumed that role in January 2000—a time of considerable strife within the organization. Furthermore, the Institute of Medicine was set to release the seminal report To Err Is Human: Building a Safer Health System, which brought to light the number of complications and deaths resulting from medical and surgical error. It was clearly a time for a leader with a bold vision, integrity, and compassion.

Dr. Russell fit the bill and led the College through a decade of change that centered largely on refocusing the organization on its core mission of promoting quality, establishing standards of care, and putting the patient first. He began by implementing a strategic planning process, which resulted in the reorganization of the College into four core divisions: Education, Research and Optimal Patient Care, Advocacy and Health Policy, and Member Services—now the pillars of this organization.

Key accomplishments

Dr. Russell

Dr. Russell

Perhaps one of Dr. Russell’s most significant accomplishments was bringing the Veterans Affairs (VA) National Surgical Quality Improvement Program into the private sector as ACS NSQIP®. This program launched in 2004 and is now credited with helping nearly 550 hospitals discover systemic problems and understand the steps they need to take to achieve better outcomes, reduce costs, and save lives. He also was a driving force in the creation of the Clinical Scholars in Residence Program, which provides surgical residents with opportunities to work on-site on the College’s quality improvement programs to develop innovative solutions to problems in patient care.

Dr. Russell also led the charge to enhance the College’s educational programming, including a redesign of the Clinical Congress to help surgeons meet new and evolving Maintenance of Certification requirements. In addition, the College began offering more hands-on educational opportunities, including simulated training in new technology and procedures at the ACS Accredited Education Institutes.

Under Tom’s direction, the College also established the ACS Foundation in 2005 to better support its scholarship programs. This expansion of the College’s former Development Program led to a proliferation in the number of types of educational opportunities that the College provides to residents and surgeon researchers.

Dr. Russell sought out ways to help improve the College’s visibility and influence in the health policy arena. Soon after he became Executive Director of the College, it became clear that the sustainable growth rate formula used to calculate Medicare payment was terribly flawed and could result in payment cuts that were untenable to many surgeons and, therefore, had the potential to jeopardize patient access to care. To provide surgeons with a more powerful voice in Washington, DC, the Board of Governors’ Committee on Socioeconomic Issues suggested that the College establish a political action committee (PAC). Tom and the Regents approved the concept and played a pivotal role in the development of the ACS Professional Association and its SurgeonsPAC.

In addition, Dr. Russell sought to expand the ACS Division of Advocacy and Health Policy. To physically accommodate this growth, a larger facility that was closer to Capitol Hill was constructed at 20 F Street, NW, in Washington, DC.

His legacy

Most of all, Tom was a bridge builder. He had a gift for connecting with all surgeons and ACS staff. Dr. Russell traveled extensively as Executive Director, reaching out to ACS members through the chapters and to other members of the operating room team, including anesthesiologists, nurses, and technicians.

Tom treated everyone with kindness, respect, and affection. Those health care professionals and ACS staff who had the pleasure of knowing him clearly felt the same way about him, as evidenced by the many e-mails we received from members and comments from the staff upon the announcement of his death.

He was a devoted and loving husband and father, and I know he so was pleased that both his daughters, like he and his wife, Nona Chiampi Russell, MD, a pathologist, had chosen careers in medicine. Katie will soon embark on a fellowship in pediatric surgery, and Jackie is a veterinary medicine student.

More details about Tom’s life and career can be found in an In Memoriam, but I wanted to use this column to speak as his successor and to highlight what I see as his greatest accomplishments. He left the College well-positioned to face the challenges of this decade and with a hard-working staff that is committed to helping the members provide optimal care. I believe Tom was happy with the progress the College was making in fulfilling his vision, and I intend to ensure that we continue to move in that direction.

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Lessons in collaboration: New York surgeons look back at Superstorm Sandy Wed, 01 Oct 2014 05:58:14 +0000

flood waters

Flood waters inside the Bellevue Hospital basement.

bucket brigade

Bucket brigade passing fuel at Bellevue Hospital.

flood waters

Flood waters outside Metropolitan Hospital.

Flood waters in the Metropolitan Hospital kitchen.

Flood waters in the Metropolitan Hospital kitchen.

The damage that Superstorm Sandy inflicted on lower Manhattan, NY, in late October 2012 resulted in an unusual merger by necessity of two of the city’s hospitals: Bellevue Hospital Center and Metropolitan Hospital Center. Guided by lessons learned from the September 11, 2001, attacks and the response of the now-defunct St. Vincent’s Hospital in Manhattan, surgeons and surgical residents at Bellevue and Metropolitan led a synchronized effort to ensure adequate care for patients in both hospitals. Bellevue—located at the south end of Manhattan and founded in 1736—is the oldest continuously operating hospital in the U.S. and one of the premier public medical centers in the world. Metropolitan, founded in 1857, is its smaller counterpart to the north. To mark the second anniversary of the storm, this article recounts the events that took place at each hospital, as well as their collaborative efforts to provide safe care to their patients in a disaster situation.

Sandy hits

Superstorm Sandy began as a tropical wave in the North Atlantic on October 19, 2012. On October 24, Sandy became a Category 1 hurricane in the waters just south of Jamaica. After its sustained winds increased to more than 90 mph that night, National Hurricane Center officials reclassified the storm as a Category 2 hurricane. Shortly after midnight on October 25, Sandy’s winds rose to 110 mph, and by dawn, the eye had passed over the eastern parts of Jamaica and Cuba.

Between October 25 and October 28, Sandy continued northward but declined in intensity and was reclassified as a Category 1 hurricane, then later as a tropical storm. But after passing over the Bahamas and traveling parallel to the coastline of the southern U.S., the storm had again grown, now into a Category 3 hurricane. On October 29, the storm curved westward toward the Mid-Atlantic states and by 8:00 pm made landfall near Atlantic City, NJ, with maximum sustained winds of 100 mph.

Winds circulating around the low-pressure centers of a cold air mass and of Hurricane Sandy began to mix. This interaction pulled part of the cold air mass to the south of the hurricane and turned the jet stream, separating the two systems westward and subsequently drawing Sandy sharply toward the New Jersey coast. After the cold air had wrapped around and mixed with the warm air of the hurricane, both systems merged and effectively transformed the hurricane into a sprawling post-tropical storm.*

Lights out at Bellevue

On October 29, all of southern Manhattan lost power by 9:00 pm, due to a Con Edison power substation explosion. This incident caused the lights in Bellevue to flicker, but its power was quickly restored by a backup generator. As a result, the overhead lights and red outlets worked in the intensive care unit (ICU), recovery room, operating room (OR), and hallways, but the patient rooms and emergency department (ED) went dark and all the elevators were out of service.

Outside, Superstorm Sandy’s wind and rain continued to rage, and the storm surge, which arrived at high tide, rose to an unprecedented 14 feet in New York City. Within an hour, Bellevue’s basement and sub-basement were filled with water from Manhattan’s East River, located just east of the hospital. The retaining wall was quickly overwhelmed. The generator was running on fuel reserves, and the transfer pump was completely inundated with saltwater. Once the cement barriers were breached, the fuel pumps ceased to function, leaving the generator to rely only on its existing fuel stores.

Just before these events, at approximately 11:00 pm, the Bellevue ICU staff met to discuss the situation—Bellevue had just hours of fuel left to power its generators. Physicians and nurses were asked to make lists of critical patients, define the organ systems that were failing them, and itemize the resources they needed. Once flashlights were distributed, critical patients were moved into adjacent ICU rooms where power was still being maintained. Intravenous drips were set to manual and charts were made of their dilutions and rate. Collectively, hospital staff braced for the worst. Communication systems were marginal, with intermittent cell phone service and the in-house phone system working only to call other Bellevue numbers. Communication within Bellevue and between other hospitals, including Metropolitan, became problematic.

At 3:00 am the morning of October 30, the City of New York delivered a diesel fuel tanker to Bellevue. Because the basement and sub-basement were flooded, there were no operational pumps to move the fuel to the 13th floor generator room. Social workers, nurses, medical students, radiology technicians, physicians, and secretaries passed open buckets of diesel fuel up a packed and sweltering stairwell in a human assembly line to keep the generators working.

A Bellevue hospital administrator was able to initiate a 9-1-1 call to request fuel delivery and patient assistance. The call was routed to the closest fire station. The individual who took the call, in turn, passed it on to a fireman who was on active duty in the U.S. Army National Guard, which responded quickly and arrived with a small team to take over the vital task of moving fuel up to the auxiliary generators.

As Sandy finally passed, the sun rose and the flood waters receded, revealing the devastating damage to Bellevue. With no power, running water, or a fresh supply of oxygen, it became clear that Bellevue needed to evacuate the 736 inpatients in the 21-story hospital. As Metropolitan had sustained less damage from the storm, it was well-positioned to help.

On October 30, the critically ill inpatients, ED patients, and dialysis-dependent patients left first, carried downstairs on backboards by medical students and residents. Handwritten discharge summaries and lists of medications were paper-clipped to patients’ gowns as they were carried away by ambulance. At the bottom of the stairwell, triage attendants in red jackets with clipboards took down the names of the patients and the receiving hospitals.

With no “official” evacuation order in place yet, the process of discharging patients that first day was slow. The policy of a “shelter in place” remained in effect while administrators focused on keeping the hospital open and restoring services. Because Bellevue was in its network—the New York City Health and Hospital Corporation (HHC)—Metropolitan Hospital Center issued an “open-door policy” for all Bellevue patients even before the formal evacuation was announced. In fact, it was clear that the administrative process had not caught up to the disaster, which would become a lesson learned for future events.

On October 31, 539 patients were still awaiting triage, including hundreds of psychiatric patients and 80 prisoners. The medical teams were told to triage and discharge any patients remotely ready to leave. As a result, 224 patients were sent home or to shelters without medication because the hospital pharmacy was closed and all clinics were closed to follow-up visits. The remaining patients could not be safely discharged and required transfer to other hospitals. Each medical and surgical team created a list of patients with diagnoses, specific inpatient requirements, bed type, and priority status. These lists were submitted to the hospital incident command center—now a guarded, fortified room bustling with activity. With the Manhattan VA NY Hospital and New York University Hospital already evacuated, Bellevue was the last hospital open in the Zone A flood territory.

More than 36 hours after the power went out, a large-scale evacuation began at Bellevue to move the remaining patients in one dramatic, chaotic day. A vertical hospital evacuation of this magnitude had never been attempted; its success was uncertain.

Metropolitan’s experience

Although northern Manhattan was likely to be less affected than the area along the East River, the Metropolitan administration alerted all staff in advance of Sandy’s landfall and activated the incident command center in anticipation of what was to come. All elective surgeries were cancelled and patients were notified and appropriately rescheduled. Patients who were not critically ill were discharged, and those inpatients who needed care were informed of the impending disaster. By 8:00 pm on October 29, it was fairly certain that upper Manhattan would be hit. All units were placed on alert, and in preparation for the impending storm, all data were backed up, orders and lists were printed, and flashlights and other battery-powered equipment, including cell phones, were charged.

At approximately 9:00 pm on the night of the storm, a partial power outage occurred due to flooding of some of the generators near the East River, although some portions of the hospital were spared. Because no patients were on ventilator support, a quick check of the surgical ICU (SICU) rooms provided assurance that all was quiet and stable. Fortunately, the power outage spared some elevators and the post-anesthesia care unit (PACU), which was located a floor above the SICU. In contrast to the situation in the SICU, across the hall in the medical ICU (MICU), five patients were on ventilator support and in critical condition. The ventilator batteries had kicked in and their respiratory status was stable. Oxygen cylinders were quickly switched with backup at the patients’ bedside. It was imperative that these patients be transported to another unit with enough power to keep the respirators working. The PACU had power, so it was the obvious choice. Two residents from the surgical service who were most familiar with PACU and the nurses quickly rallied both medical and surgical residents and ICU nurses and identified the four MICU patients who needed to be moved first.

Surprisingly, the initial chaos faded as staff began the job of moving patients. Two teams were created—one that would ready patients for transfer and another that would physically move the patients. Each team had a medical and surgical resident, a nurse for intravenous administration, and a respiratory therapist to manage airways. A portable ventilator was used during transfer, with all settings documented before transport. This information was relayed to the PACU team on patient arrival. The PACU team consisted of a nurse and a medical resident. Five patients on ventilator support were transported to the PACU, along with two non-critical adult patients and one pediatric patient. Once in the PACU, these patients’ primary teams took charge of their care. As the elevators were all being used to transfer patients, simultaneous transport of ICU beds, drips, and personnel was challenging, but teamwork made it happen.

In compliance with the disaster preparedness plan, orders and medication lists had already been printed before the temporary outage, and handwritten paper orders were initiated because the electronic health record (EHR) system was unavailable even on the floors that had power. All of this activity occurred as the storm hit Manhattan and as Bellevue was on the threshold of losing power throughout the facility. Metropolitan staff knew that if the hospital maintained power, then they would be receiving many of the Bellevue patients.

As the East River flooding progressed through the night on October 29, the surge inundated First Avenue at 96th and 97th streets and flooded a residence hall and a parking lot filled with vehicles belonging to nurses, residents, and faculty. Metropolitan staff became concerned that the hospital’s generators would be flooded. Fortunately, work performed by Metropolitan’s engineering department and Con Edison protected the hospital’s power supply against this flooding, and the power was back to full capacity as the storm subsided overnight.

Even though the area east of Metropolitan Hospital was flooded, the ED—which is on the ground floor—was unaffected. It is located approximately 50 feet above sea level, which kept that area of the hospital out of harm’s way, and all the patients who arrived before Sandy were accommodated in the ED overnight.

At approximately 4:00 am on October 30, the storm and the floodwaters started to recede. The worst was over, but we now had to face the storm’s aftermath. The parts of Metropolitan affected by the outage slowly regained power, allowing the hospital to return to somewhat normal function within hours.

Metropolitan started preparing for the arrival of Bellevue patients at 6:00 am. Even during the worst parts of the storm, we were in limited communication with our Bellevue counterparts and knew that, if we remained functioning, we would be responsible for many of their patients. The following day, the ambulance bay next to the ED was converted into a triage center and clinic run by medicine and surgery residents, along with medical students, to help the ED decant all of the additional Bellevue outpatients seeking continuity of care. This triage bay was constructed over a period of 24 hours after the storm and served at least 600 patients, allowing the ER to deal with more urgent and critically ill patients.

Evacuation and transfer

Meanwhile, plans were being developed at Bellevue for its evacuation. Patient handoffs were accomplished over the phone between the residents at both institutions, with the chiefs of surgery providing oversight. As a result of ongoing phone calls between the chiefs, select Metropolitan surgeons were granted temporary access to the Bellevue EHR system while hospital employees, especially physicians and nurses, were getting credentialed to work at Metropolitan. Records were transferred to Metropolitan and printed, and it was agreed that 24 of the sickest surgical patients would be transferred to Metropolitan on October 31.

The National Guard provided support for carrying out the evacuation plan. What ensued on October 31 was an organized pandemonium of telephone calls, ambulances, and emergency medical technicians (EMTs), evacuation sleds by the dozens, and approximately 250 men and women in uniform joining medical students, residents, and faculty in an effort to carry patients down as many as 20 flights of stairs. Complicating the process was the simultaneous evacuation of several other HHC facilities, including Coney Island Hospital and Coler-Goldwater Specialty Hospital and Nursing Facility, which decreased the number of available beds. However, Metropolitan had prepared for this possibility.

The command centers at Bellevue, HHC Central Office, and Metropolitan were in constant contact by telephone as these transfers became reality. Conference calls at 8:00 am and 5:00 pm were equivalent to physician rounds and ensured continuity of care and that all facilities were effectively communicating their needs and what they could offer. Despite the chaos and confusion, this process worked, and patients were transferred vertically without any real disruption in care. Throughout this entire process, the chiefs of surgery at Bellevue and Metropolitan were in contact at least three or four times at all hours, and even managed neurosurgery, otolaryngology, and urology services.

It is important to note that EMTs and ambulances arrived from across the East Coast to help move patients, and this extra transportation helped in getting patients evacuated expeditiously.

As the storm subsided, the prisoners at Bellevue were triaged back to Riker’s Island or transferred to the HHC hospitals with an additional temporary male prison unit that was set up at Harlem Hospital. A total of 38 pediatric patients were transferred, the youngest just two days old. Those pediatric patients who did not require hospital care were sent home, while those who did require care were sent to Kings County Hospital Center in Brooklyn. Another 38 patients were triaged from inpatient rehabilitation. The psychiatry department transferred the most patients, a total of 331, who were sent to several HHC hospitals, although most were sent to Metropolitan. The influx of patients to Metropolitan increased the demands on staff. It became clear that staff from Bellevue would need to be deployed to meet this need. Bellevue surgeons and residents were immediately credentialed. Whereas none of the Bellevue surgeons had clinical and operative privileges at Metropolitan, their credentialing paperwork was expedited by the Metropolitan administration. This process usually takes many weeks, and instead was accomplished in hours. This emergency credentialing process had never occurred before in New York City.

Over a 24-hour period on Halloween Day, patients left Bellevue Hospital, an average of one every 3.4 minutes. New York City had not seen this type of medical and surgical challenge since September 11, 2001.

As patients were transferred to Metropolitan, the entire clinical staff of the hospital, under the direction on the chief executive officer and the chiefs of medicine, surgery, emergency medicine, and psychiatry, orchestrated efforts to ensure continuity of care for all of the patients coming from Bellevue while maintaining the same level of care for the patients already housed in the hospital. Medical students, residents, and faculty reviewed transfer notes, and ordered labs and radiologic studies as needed.

During this catastrophe, Bellevue staff attempted to call patient families to alert them to the transfer, but without working computers, reliable phone service, or a functional interpreter system, the task of giving appropriate information regarding transferred patients was impossible and was ultimately given to the medical director’s office to be completed when power returned.

By the evening of November 1, with a Nor’easter blowing in, only two patients remained at Bellevue and neither could be moved safely down the stairs. One had a ventricular assist device and was too critical to move, and the other was morbidly obese. As a result, the decision was made to wait for the Bellevue basement to be pumped out and for restoration of elevator power and service, so that both patients could be moved three days later. These two patients were given extra staff to maintain their safety.

The aftermath

Metropolitan’s admitting department was informed of the transfers, and the patients were admitted to either the SICU or to the eighth floor of the main hospital. The eighth floor at Metropolitan had three inpatient units—A, B, and C. Preceding Sandy, 8B was the only open and active unit, and 8C was used only for respiratory isolation cases. The 8A unit was opened within 12 hours of Sandy to receive all surgical patients from Bellevue. The Metropolitan staff worked day and night to prepare the floors and the rooms, ensure EHR access, and stock supplies in 8A. Many of the patients had critical surgery at Bellevue and were in postoperative recovery in surgical wards but required transfer because they were not ready for discharge. Additional inpatient wards were reopened and Metropolitan’s operating census was close to 100 percent of capacity.

Some of the other patients were nonoperative under the care of the surgery team. The most complicated of these cases included a patient with a partial colectomy and a concomitant liver resection, a patient with duodenal perforation secondary to a motor vehicle accident, and a patient who had a reversal of an ileostomy secondary to treatment of inflammatory bowel disease. These patients were at various stages of recovery at Bellevue, which made the handoffs to Metropolitan extremely important.

With the sudden increase in patient volume, resources were bolstered by the integration of evacuated physicians, nurses, and technicians—especially those health care professionals with operating room experience. Many urgent cases had already been booked by Bellevue surgeons, and these patients were rescheduled and underwent their operations at Metropolitan in the immediate aftermath of the storm. When the famous Bellevue ED reopened, several months before the rest of the hospital, patients seen in the Bellevue ER who required immediate surgery were transferred to Metropolitan and operated on by Bellevue and Metropolitan surgeons.

The remainder of the week was spent assessing Bellevue’s infrastructure, patient care, and resident education needs. In the coming months, Bellevue’s electrical systems were rebuilt, plumbing lines were flushed, and all mechanical devices located in the basements were replaced. The basement and the sub-basement were emptied of infested river waters, the generators were reconfigured, and the entire infrastructure thoroughly cleaned. HHC President Alan Aviles stated that a total of $810 million would be needed to repair the damage to the city’s public hospital facilities, most of which was to be spent at Bellevue—the hospital most affected by the storm.

Over the next few days, many of the patients transferred were discharged with disposition plans because this handoff system was successful. Moreover, several patients who needed surgery underwent their operations as Metropolitan added two ORs for teams of Bellevue surgeons, with the two chiefs of surgery and the two departments of anesthesia organizing the effort.

Within two weeks, Bellevue’s operating teams were using assigned block times in the Metropolitan OR and in the outpatient clinics at Metropolitan. General surgeons and subspecialists from surgical oncology, plastic surgery, urology, neurosurgery, vascular surgery, and otolaryngology were quickly credentialed and performed procedures in two to three operating rooms, five days per week, specifically dedicated to Bellevue patients and entirely staffed by their own surgery, anesthesiology, and nursing teams. Within 10 days of Superstorm Sandy, two separate surgical teams—one from Bellevue and one from Metropolitan—worked in tandem within the expanded Metropolitan perioperative service and departments of surgery. This type of cooperation has never been reported secondary to an emergency event in New York City.

Grand reopening

The Bellevue ER was fully functional within four weeks, and other areas of the facility reopened on February 7, 2013—99 days after it was evacuated. There were balloons, banners, press releases, and smiles all around. Six months after Superstorm Sandy, the hospital had returned to its centuries-old tradition of caring for New York City’s injured and disenfranchised. Now fully operational, the hospital continues to address what went right and what went wrong regarding the preparation, evacuation, and recovery efforts in the wake of Superstorm Sandy.

Since its founding in 1736, Bellevue had never been without patients until Sandy shuttered her doors on November 3, 2012. Against overwhelming odds, the largest-ever vertical evacuation of a hospital was successfully accomplished because two hospitals came together to accomplish what was necessary in order to provide continuous care to patients.

Even in dire circumstances, the staffs of both institutions were resourceful, adaptable, and persistent, working in tandem toward a common goal. Cited by some as a “once in a hundred years” event, Sandy has proven that there is no such thing as over-preparation. The time to ready for the next storm event is now, as we repair, rebuild, and upgrade our infrastructure. More importantly, these lessons have resulted in improvements in HHC hospitals, especially Bellevue, to protect vital hospital infrastructure and be better equipped to treat patients when disaster strikes again.

*National Weather Service: Hurricane Sandy. Accessed August 26, 2014.

Blake ES, Kimberlain TB, Berg RJ, Cangialosi JP, Beven JL II. Tropical Cyclone Report: Hurricane Sandy (AL182012), 22–29 October 2012. National Hurricane Center, 12 February 2013. Accessed August 29, 2014.

New York City Health and Hospitals Corporation, Office of Communications and Marketing. Press release. January 8, 2013. Accessed September 8, 2014.

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State lobby days build bridges Wed, 01 Oct 2014 05:57:09 +0000

The American College of Surgeons (ACS) Chapter Lobby Day Grant Program began in 2010 and continues to provide chapters with the support they need to engage their membership in grassroots advocacy at the state level. Participating chapters are eligible to receive up to $5,000 in grant funds from the College and are required to match every $2 received. Participation has been wide-ranging, with more than 20 chapters hosting a state lobby day since the inception of the program.

Lobby day events help raise the profile of chapters in their respective states and educate state legislators on matters of importance to surgeons. Issues discussed at lobby days in 2014 ranged from trauma funding, to scope of practice, to telemedicine. In addition, these meetings enable chapters to build relationships—perhaps the most critical component of grassroots advocacy—with legislators, members of the judicial branch, and other health policy stakeholders.

2014 ACS Lobby Day Grant Program awardees

Brooklyn-Long Island
New York
North Carolina
Northern California
South Texas
Washington State

This article summarizes the 2014 ACS chapter lobby days, provides an overview of current advocacy issues in each state, and highlights how some chapters organize their day at the state capitol program.


The Alabama Chapter of the ACS hosted its lobby day on February 20 in conjunction with the Medical Association of the State of Alabama. The event began in the morning with breakfast and training across the street from the state capitol. Attendees heard from political pundit and former Alabama state legislator Steve Flowers (R) on lobbying and politics and received tips on effective advocacy from David Mowery of the Mowery Consulting Group. Participants then attended a hearing of the Senate Committee on Health and participated in a working lunch where a question-and-answer session was held with state Sen. Greg Reed (R) and state Rep. Jim McClendon (R). The afternoon was spent meeting with legislators, during which surgeon attendees focused their discussion on the statewide trauma system, trauma care, and funding. The legislators were receptive to the issues and expressed an interest in working with the surgeons and maintaining contact. The surgeons met with a total of 15 legislators.


The Connecticut Chapter of the ACS, in conjunction with the Connecticut State Medical Society, sponsored a lobby day in Hartford on March 20. Several ACS Fellows attended and advocated on current legislation, including bills pertaining to scope-of-practice expansion for advanced practice registered nurses (APRNs) and the establishment of a legislative definition of surgery. The day began with a breakfast reception for legislators and staff that was attended by members of both political parties. Following the reception, the group listened to remarks from a Connecticut State Medical Society lobbyist and transitioned into meetings with individual legislators. Chapter leadership attended meetings with Donald Williams, Jr. (D), President pro tempore of the Senate, and Brendan Sharkey (D), Speaker of the House of Representatives.


The Florida Chapter of the ACS hosted its White Coat Wednesday in March. The event coincided with the State Committee on Trauma meeting and drew nearly 20 participants. The event began with a dinner on March 4 that included a presentation from Chris Nuland, Chapter Lobbyist, who updated attendees on the current composition of the Florida legislature and provided background on the key health care legislation that would be discussed in their meetings. White Coat Wednesday kicked off with a breakfast reception that provided an opportunity for attendees to interact with their legislators in a less formal manner. Participants then headed over to the state capitol where they met with their legislators. The main topics covered in these meetings included licensing issues related to telemedicine and scope of practice.


The Indiana Chapter of the ACS hosted its annual Day at the Capitol on January 27. The event began with a series of speakers in the morning, including Rep. Ed DeLaney (D) who described how to be an effective advocate in the Indiana legislature. Other topics included a review of the current legislative issues by Michael Rinebold, a lobbyist from the Indiana State Medical Association; a review of the challenges to Indiana’s medical liability damages cap from consultants Libby Goodknight and Krieg DeVault; a review of the status of Indiana politics by T.K. Wall, a local reporter; and an overview of how to successfully interact with elected officials from Tory Castor, vice-president of government affairs at Indiana University Health. The group discussed the following bills in their meetings with their legislators: S.B. 222, Student Athlete Concussions; S.B. 50, Minors and Tanning Devices; and H.B. 1097, Immunity for Providing Volunteer Health Care Services.

The Day at the Capitol was well attended, with more than 20 surgeons meeting with their legislators.


The Kansas Chapter of the ACS, in conjunction with the Kansas Medical Society, hosted a state lobby day in Topeka on January 22. The event included in-depth briefings on state and federal advocacy, the current legislative environment in Kansas, and medical liability. In addition to the briefings, several legislators attended the meeting with the goal of speaking with attendees, including Robert P. Moser, MD, Secretary of the Kansas Department of Health and Environment, and legislators who serve on the Senate Public Health Committee, and the House Health and Welfare Committee. After the briefings, members met with their state legislators and voiced their views on scope-of-practice expansion legislation for APRNs and podiatrists, tanning bed restrictions, and medical liability rate increases. The tanning legislation, banning use by people younger than 18 years old, was heavily advocated for by Joshua Mammen, MD, FACS. Dr. Mammen worked with his local legislator to get this bill introduced in the state House of Representatives. The bill did not pass, but thanks to Dr. Mammen’s advocacy, the groundwork has been set for the bill to be re-introduced in 2015.

Brooklyn-Long Island and New York

The New York Chapters of the ACS, Brooklyn-Long Island and New York, in conjunction with the New York State Medical Society and several other state specialty organizations, hosted a lobby day in Albany on May 20. The event included various legislative and advocacy presentations, followed by meetings with legislators. Fellows lobbied against allied health scope-of-practice expansion and medical liability rate increases, and for truth-in-advertising legislation.


The Tennessee Chapter hosted its lobby day at the capitol in Nashville on March 12 in conjunction with the Tennessee Medical Association. More than 200 physicians attended the event, with surgery well-represented by the chapter. Participants attended a meeting of the Senate Health and Welfare Committee and heard from Gov. Bill Haslam (R), who welcomed them to the Capitol and encouraged attendees to remain involved in the advocacy process. Meetings with legislators were held throughout the day, and the chapter’s participants focused their discussions on the work of the Tennessee Surgical Quality Collaborative (TSQC) and on the initiatives of the medical association. Surgeons had the opportunity to meet with all members of the House and Senate Health Committees, who reportedly found the work of the TSQC impressive.


The Virginia Chapter of the ACS, in conjunction with several other surgical medical societies, hosted a lobby day in Richmond on February 12. The day began with a briefing and an advocacy presentation from one of the lobbyists for the Medical Society of Virginia. After the briefing, Fellows headed to the capitol for meetings with their state legislators. These meetings were productive and covered a variety of legislative topics, including Medicaid expansion, various scope-of-practice issues, and cancer prevention and treatment.


The Washington Chapter participated in its first lobby day on February 10 by having an organized presence at the Washington State Medical Association’s (WSMA) Annual Legislative Summit. Beginning with a chapter council meeting the evening before the lobby day, leadership of the chapter had the opportunity to share in policy briefings with their WSMA colleagues, receive helpful tips for meeting with state legislators, and enjoy the political camaraderie of a lobby day. Priority issues included:

  • Legislation addressing notification concerns regarding the 90-day grace period for patients who fall behind on their health insurance premiums, which became law March 27
  • Requirements that insurers that cover a clinical service on a face-to-face basis must also cover the same service when it is provided using video technology; that bill died in the Senate
  • Prohibition of the use of tanning devices by children and teens under age 18, which became law March 27
  • Expansion of the list of tests a medical assistant phlebotomist may perform, which became law March 28

Most state legislatures have finished their legislative business for the year, and lawmakers have shifted their focus to re-election efforts and the 2015 legislative sessions. At this time, it is imperative that chapters begin to plan for the upcoming sessions by creating an advocacy strategy. The lobby day program is one of the best tools that the ACS offers, and the State Affairs team is available to assist with planning a lobby day or helping chapters with other grassroots advocacy initiatives. Contact the State Affairs team at with questions or concerns.

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The ACS NSQIP Geriatric Surgery Pilot Project: Improving care for older surgical patients Wed, 01 Oct 2014 05:56:07 +0000

More than one-third of all inpatient operations in the U.S. involve patients ages 65 and older.1 In 2010, the cost of hospitalization with an operating room (OR) principal procedure for this patient population was $72 billion.2 Because surgical care for older adults is common and consumes enormous amounts of resources, understanding the relevant outcomes and their key determinants for geriatric patients is vital.

The American College of Surgeons (ACS) National Surgical Quality Improvement Program (ACS NSQIP®) is the preeminent outcomes-based program designed to measure and improve the quality of surgical care in the U.S. ACS NSQIP was developed with the goal of providing risk-adjusted surgical outcomes data for adults. In 2010, ACS NSQIP introduced the first National Quality Forum (NQF)-endorsed measure to track surgical outcomes in patients greater than 65 years of age. The geriatric measure uses standard ACS NSQIP risk variables to track traditional patient- and procedure-adjusted surgical outcomes, such as postoperative complications and 30-day mortality. Although this measure has proven to be a significant step forward in improving care in this vulnerable population, recent literature suggests that standard risk factors and traditional outcomes may not provide a complete enough picture through which to focus improvement strategies targeting older surgical patients.

At the 2011 ACS NSQIP National Conference in Boston, MA, David B. Hoyt, MD, FACS, Executive Director of the College, moderated a plenary session to emphasize the need to “achieve optimum surgical care” in a variety of specific areas, including geriatrics. It was clear from the audience response that many hospital systems from across the U.S. and Canada shared the challenge of understanding what constitutes “optimum” outcomes in older patients and how to achieve these results.

Development of the pilot project

With the obvious need for more data, ACS NSQIP and the ACS Geriatric Surgery Task Force worked together to determine how these data could be collected and analyzed by forming a ACS NSQIP Geriatric Surgery Pilot Project. The pilot project is predicated upon two goals: (1) to determine if the inclusion of geriatric-specific preoperative variables and outcome measures in the existing ACS NSQIP models will add to our ability to more accurately predict relevant outcomes, and (2) to provide a platform for introducing new interventions designed to improve these outcomes.

Participant hospitals were recruited from among task force member institutions and at a follow-up geriatric breakout session at the 2013 ACS NSQIP National Conference in San Diego, CA. Representatives of 23 hospitals, including academic centers and community-based systems from the U.S. and Canada, participated in the meeting.

Choosing the variables

Candidate variables were reviewed by task force members and ACS NSQIP staff primarily for relevance and for ease of extraction from the medical record. To be relevant, the new preoperative variable set needed to address characteristics unique to the older adult. In contrast to younger adults (<65 years old) in whom surgical risk is estimated by summing comorbid conditions, the presence of frailty is rapidly emerging as a primary factor that defines increased risk in the older surgical patient.3,4

Frailty is defined as “a biologic syndrome of decreased reserve and resistance to stressors, resulting from cumulative declines across multiple physiologic systems…causing vulnerability to adverse outcomes.”5 Although there are many different ways of identifying a frail individual, most characteristics of frailty are not routinely assessed in clinical practice. Consideration was given to those variables that could best describe the frail state, such as evidence of impaired cognition, functional dependence, and reduced mobility.

The new outcome variables are needed in order to capture the outcomes that are common and important to older patients, including postoperative delirium and functional decline. Postoperative delirium occurs in approximately one-half of older patients undergoing major operations and is associated with increased rates of all other major complications, a need for institutional discharge, and death. Interventions to decrease postoperative delirium do exist, and efforts are under way to establish evidence-based guidelines. To date, however, delirium is not routinely recognized as a surgical complication in older adults and, therefore, is not tracked.

Functional decline following surgery is often more of a concern to the older surgical patient than the risk of mortality, but because it is rarely measured, there is a lack of data allowing surgeons to counsel older patients on its risks. In addition, ACS NSQIP currently lacks a robust method for identifying patients who are undergoing surgery for palliative intent, for whom the risk may not be well captured by traditional variables (palliative care is a more common primary objective in geriatric surgery compared with surgery on younger patients). The outcome variables for the ACS NSQIP Geriatric Surgery Pilot Project were chosen to specifically identify changes in postoperative cognition, functional decline, and a need for transition to palliative care.

Once appropriate variables were selected, the Clinical Support team from ACS NSQIP developed strict definitions of these variables, in a manner consistent with all of the other variables in the program. The variables and definitions were then reviewed a final time by task force members before commencement of data collection.

Current status of the pilot project

The ACS NSQIP Geriatric Surgery Pilot Project includes 23 hospitals, and features 14 new variables specifically chosen for their relevance to geriatric surgical patients (see table). ACS NSQIP staff members including Matt Fordham, Project Coordinator, ACS NSQIP; James Wadzinski, ACS NSQIP Director of Operations; Melissa Latus, ACS NSQIP Clinical Support Services Manager; and Amy Hart, ACS NSQIP Product Operations Manager, have provided invaluable assistance to making the pilot project a success, as well as Sanjay Mohanty, MD, one of the ACS Clinical Scholars in Residence (2013–2015), who is analyzing the data. Data collection began on January 1, 2014, and an interim analysis of the project’s efforts was presented at the ACS NSQIP National Conference in New York, NY, in July. Both the viability of data collection and the ability of these new variables to provide additional insight into the care of geriatric patients will be assessed.

New Variables Collected by the ACS NSQIP Geriatric Pilot Project

Preoperative variables

Intent of variable (definition)
Origin from home with support To determine baseline functional status (lives alone at home, lives with support in home, origin status not from home)
Use of mobility aid To quantify baseline mobility (uses a walking aid—yes/no)
History of prior falls To define the presence of a geriatric syndrome prior to admission (prior fall—yes/no)
History of dementia To determine baseline cognition (history of dementia—yes/no)
Competency status on admission To define significant cognitive impairment (consent signed by patient or by surrogate—yes/no)
Palliative care on admission To identify patients admitted from palliative care or hospice (from palliative care/hospice—yes/no)

Postoperative occurrences

Intent of variable (definition)
Postoperative pressure ulcer To define the presence of a geriatric syndrome at discharge (a pressure ulcer is present at discharge; did it occur during the hospital stay—yes/no)
Postoperative delirium To define the presence of a geriatric syndrome during the hospital stay (delirium is present if there are one or more episodes of acute confusion during hospitalization—yes/no)
Do not resuscitate (DNR) order during hospitalization To capture changes in DNR status during the hospital stay (was there a new DNR order during hospitalization—yes/no)
Palliative care consult To understand treatment goals of patients with short life expectancy (palliative care consult obtained during hospitalization or patient made comfort care—yes/no)
Discharge functional health status To determine functional status at discharge (ability to perform activities of daily living at discharge—independent/partially dependent/dependent)
Fall risk on discharge To quantify mobility at discharge (define fall risk at time of discharge—high/low)
Need of mobility aid on discharge To understand a patient’s mobility at discharge (new use of mobility aid walker/cane at time of discharge—yes/no)
Discharge with/without services To capture care needs at discharge (home alone with self-care, home alone with skilled care, home with support and self-care, home with support and skilled care)

The ultimate goal of this pilot project is to evaluate specific geriatric variables for incorporation into the ACS NSQIP set of essential variables collected by all participating hospitals. These variables may then be used to measure the effectiveness of interventions designed to mitigate geriatric-specific surgical risks and improve outcomes.


  1. Hall MJ, DeFrances CJ, Williams SN, et al. National Hospital Discharge Survey: 2007 summary. National Health Statistics Reports. U.S. Department of Health and Human Services. October 26, 2010. Accessed February 12, 2014.
  2. U.S. Department of Health and Human Services. Health. United States, 2012. Accessed February 12, 2014.
  3. Robinson TN, Eiseman B, Wallace JI, et al. Redefining geriatric preoperative assessment using frailty, disability, and co-morbidity. Ann Surg. 2009;250(3):449-455.
  4. Makary MA, Segev DL, Pronovost PJ, et al. Frailty as a predictor of surgical outcomes in older patients. J Am Coll Surg. 2010;210(6):901-908.
  5. Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: Evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001;56(3):M146-156.
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Past recipients of the ACS/Pfizer Surgical Volunteerism and Humanitarian Awards: Where are they now? Wed, 01 Oct 2014 05:55:26 +0000

Dr. Price

Dr. Price (center, front row) in Mongolia.

Dr. Price

Dr. Price receiving the Presidential Friendship Medal.

Dr. Ellis

Dr. Ellis addresses the health care needs of a patient at OCMC.

Neurosurgery in Western Kenya

A recent Ruben J. Williams Foundation mission trip to rural Western Kenya: two neurosurgical teams, from Moi University and Johns Hopkins, operating together to treat a young child with an extra-axial tumor.

Neurosurgery in Western Kenya

A recent Ruben J. Williams Foundation mission trip to rural Western Kenya: two neurosurgical teams, from Moi University and Johns Hopkins, operating together to treat a young child with an extra-axial tumor.

Dr. Hayanga

Dr. Hayanga

Dr. Kingham

Dr. Kingham and Martin Weiser, MD, FACS, participating as faculty in courses on the management of colorectal cancer and starting a minimally invasive surgery program at Obafemi Awolowon University Hospital in Ile-Ife, Nigeria, 2013.

Dr. Kingham

Dr. Kingham

Dr. Kingham

Dr. Kingham and Martin Weiser, MD, FACS, participating as faculty in courses on the management of colorectal cancer and starting a minimally invasive surgery program at Obafemi Awolowo University Hospital in Ile-Ife, Nigeria, 2013.

Dr. Kingham

Dr. Kingham and Martin Weiser, MD, FACS, participating as faculty in courses on the management of colorectal cancer and starting a minimally invasive surgery program at Obafemi Awolowo University Hospital in Ile-Ife, Nigeria, 2013.

Dr. White

Dr. White with residents in front of the computed tomography building at Tenwek Hospital.

Dr. White

Dr. White with a patient.

Every year, the ACS/Pfizer Surgical Volunteerism and Humanitarian Awards recognize and celebrate ACS Fellows and members whose altruism, vision, leadership, and dedication provide models to emulate and whose contributions have made a lasting difference. Since the initiative began in 2003, 38 individuals have won awards, including four this year. The Bulletin will be providing periodic updates on some of the past recipients of these awards and their accomplishments since they were honored. This article is the first installment in that series.

Raymond R. Price, MD, FACS
2012 International Volunteer Award

Raymond R. Price, MD, FACS, a general surgeon at Intermountain Medical Center in Murray, UT, received the Surgical Volunteerism Award in 2012 for his international outreach efforts to improve surgical care in Mongolia and other countries. Since receiving the award, Dr. Price has continued to improve access to surgical care and anesthesia in Mongolia through the Dr. W.C. Swanson Family Foundation, based in Ogden, UT, where he continues to serve as the director of medical programs.

Dr. Price implemented a two-week, hands-on basic laparoscopic cholecystectomy course in Darkhan, Mongolia, taught by members of the foundation and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), of which he is a member. With the help of those two organizations, Dr. Price also taught an advanced laparoscopic course to professors at the Health Sciences University of Mongolia (HSUM) in Ulaanbaatar that covered colectomy, Nissen fundoplication, adrenalectomy, splenectomy, and ventral and inguinal hernia.

In addition, Dr. Price held meetings with the World Health Organization (WHO) and other Mongolian health organizations. These interactions led to the signing of a memorandum of understanding between the ACS Committee on Trauma (COT) and the Health Development Department of Mongolia to teach the Advanced Trauma Life Support® (ATLS®) course to all of the physicians in that country. For his volunteer efforts in Mongolia over the previous nine years, Dr. Price received the Presidential Friendship Medal, the highest honor given to a foreigner. In addition to his work in Mongolia, Dr. Price has accomplished the following:

  • Organized a national e-mail campaign to support a World Health Assembly resolution highlighting the importance of surgery and anesthesia for basic health care
  • Spoke at and participated in the fifth biennial meeting of the WHO Global Initiative for Emergency and Essential Surgical Care, where he was appointed vice-chair of the group
  • Co-authored a global surgery chapter in the 10th edition of Schwartz’s Principles of Surgery, which was published this year, and also co-authored a trauma chapter in the Disease Control Priorities 3rd edition, which is currently open for public comment and is expected to be published early next year by the World Bank
  • Reported on global surgery volunteer work and its public health components at the American Public Health Association, the Academic Surgical Congress, and at a United Nations side meeting called Empowering Women and Children through Essential Surgery, where attendees discussed emergency and essential surgical care for mothers and children
  • Continues to expand the Center for Global Surgery at the University of Utah, Salt Lake City, with fellow, resident, and student projects

George F. Ellis III, MD, FACS
2005 Domestic Volunteer Award

George F. Ellis III, MD, FACS, a urological surgeon at Orlando Regional Medical Center, FL, received the Surgical Volunteerism Award in 2005 for his contributions to medically underserved residents in Orange County, FL. Since then, Dr. Ellis has continued to volunteer at the Orange County Medical Clinic (OCMC), a facility that provides medical care to uninsured patients. Dr. Ellis says it has been an enlightening experience, and the most essential element has been to help patients in need of health care services and to practice medicine without the interference of health insurance plans.

The OCMC is part of Primary Care Access Network (PCAN), a collaborative among local government, health care centers, agencies, and hospitals that Dr. Ellis founded in 2000. Dr. Ellis is keeping PCAN’s activities consistent with the U.S. Department of Health and Human Services (HHS) Health Resources and Services Administration’s goal of providing 100 percent access to care with zero percent disparity. The OCMC also has an outpatient clinic, where Dr. Ellis discusses cases with the residents who are providing the care. In addition to these efforts, Dr. Ellis has accomplished the following:

  • Began developing plans for his newest initiative, the Florida Health Fund, which will be a charitable foundation to provide education and further assist people who are in need of health care services
  • Inspired both of his sons to do volunteer work of their own; his oldest son, a budding fiction author, leads a writers’ club, and his younger son does clean-up and maintenance for a municipal park system north of Orlando

Awori J. Hayanga, MD, MPH
2009 Resident Volunteer Award

Awori J. Hayanga, MD, MPH, an Associate Fellow and cardiothoracic surgeon at Spectrum Health DeVos Heart & Lung Transplant in Grand Rapids, MI, received the inaugural Surgical Volunteerism Award for resident service in 2009 for his founding role and ongoing work with the Ruben J. Williams Foundation, based in Seattle, WA, which fosters networks of academic medical institutions in sub-Saharan Africa, Europe, and the U.S. Over the last five years, the foundation has conducted four annual trips to Kenya and engaged the local surgical community in more than 100 hours of continuing medical education. The trips brought together surgeons, nurses, anesthesiologists, technicians, and volunteers to provide care to more than 200 local patients. Postoperative follow-up was facilitated through audio-visual applications in real time, which allowed ongoing remote surgical collaboration. Kenyan residents had one-on-one time with visiting professors and participated in case presentations and research talks. Dr. Hayanga said these mentoring initiatives have led to several Kenyans being accepted into surgical residency and fellowship training positions in the U.S. and South Africa. In 2011, the foundation began a new initiative to support five physician graduate scholars from resource-poor countries currently enrolled at the Johns Hopkins School of Public Health, Baltimore, MD.

The foundation has also accomplished the following:

  • Extended its focus beyond health care delivery to include health policy and economics, as these three areas of health care have become interdependent, especially in limited-resource environments
  • Procured and donated more than $250,000 in operating equipment and supplies to Mukurweini District Hospital and the Moi Teaching and Referral Hospital in Eldoret, Kenya, with the assistance of visiting teams from Vanderbilt University, Nashville, TN, and Johns Hopkins
  • Organized lectures by the following distinguished surgeons: ACS President-Elect Andrew L. Warshaw, MD, FACS, FRCSEd(Hon), former surgeon-in-chief and chairman, department of surgery, Massachusetts General Hospital, and the W. Gerald Austen Professor of Surgery at Harvard Medical School, Boston; Michael Mulholland, MD, FACS, the Frederick A. Coller Distinguished Professor of Surgery and Chair, department of surgery, University of Michigan, Ann Arbor; and Russell G. Robertson, MD, chair, Council on Graduate Medical Education and the special advisor to Congress and the HHS with regard to physician supply and distribution
  • Expanded its board of directors, appointed a full-time chief executive officer, and sought to expand delivery of care to the entire region over the next five years

T. Peter Kingham, MD, FACS
2010 Resident Volunteer Award

T. Peter Kingham, MD, FACS, a general surgeon at Memorial Sloan Kettering Cancer Center (MSKCC) in New York, NY, received the Surgical Volunteerism Award in 2010 for outreach during residency for his work as a co-founder and president of Surgeons OverSeas (SOS), an organization that improves surgical care in developing countries, most notably Sierra Leone. Since receiving the award, Dr. Kingham has formed a colorectal cancer consortium called the African Colorectal Cancer Group (ARGO) with his Nigerian colleague and SOS member, Isaac Alatise, MD. The consortium comprises MSKCC in New York, NY, and Obafemi Awolowo University Teaching Hospital, Federal Medical Centre Owo, Lautech Teaching Hospital, and University of Ilorin Teaching Hospital in Nigeria. The consortium is sponsoring two prospective studies—one to create a database and biobank, and one related to colonoscopy—with the goal of improving the care of patients with colorectal cancer. Dr. Kingham said they hope this infrastructure can be applied to patients with other types of cancer in the future.

In addition to these efforts, Dr. Kingham has accomplished the following:

  • Completed his surgical oncology fellowship at MSKCC and joined the faculty as a member of the hepatopancreatobiliary surgery service
  • Continued to serve as president of SOS
  • Continued to work with SOS co-founder Adam Kushner, MD, MPH, FACS, to document the burden of surgical disease in low- and middle-income countries, and published this research in The Lancet*

Russell E. White, MD, MPH, FACS, FCS (EASC)
2012 Surgical Humanitarian Award

Russell E. White, MD, MPH, FACS, FCS (EASC), a general surgeon at Tenwek Hospital in Bomet, Kenya, received the Surgical Humanitarian Award in 2012 for his efforts to improve surgical care in Bomet. Dr. White currently directs the surgical residency training program at Tenwek Hospital, where the program has expanded to include a full residency in orthopaedic surgery. Dr. White is proud to say that his residents are scoring among the highest in the region on their written and oral examinations.

He serves as the country director for the College of Surgeons of East, Central, and Southern Africa, which is the certifying body for 11 countries in the region. He is also the educational coordinator for all the training programs in general surgery in Kenya. This year, Dr. White will coordinate the writing of the certifying exam for all the general surgery candidates, and will also direct all the oral and clinical exams for those health care professionals completing their training.

In addition to these efforts, Dr. White is involved in the following:

  • Contributing time and expertise to research programs for all of the hospital’s residents
  • Working on several ongoing clinical trials involving epidemiology, diagnosis, and treatment of esophageal cancer, which is the most common malignancy in Kenya
  • Expanding the cardiac surgery program at Tenwek Hospital, which is the only center outside the capital that offers cardiac surgical services
  • Looking into beginning a fellowship training program in cardiothoracic surgery, which would be the only program of its type in the region

*Groen R, Samai M, Steward KA, et al. Untreated surgical conditions in Sierra Leone: A cluster randomised, cross-sectional, countrywide survey. The Lancet. 2012;380(9847):1082-1087.

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The YFA Essay Contest: Introduction Wed, 01 Oct 2014 05:54:02 +0000

Earlier this year, the Young Fellows Association (YFA) of the American College of Surgeons (ACS) announced its first essay contest. The YFA was inspired to present the essay contest and to have as its theme “The Promise of a Profession” based on the comments that Carlos A. Pellegrini, MD, FACS, FRCSI(Hon), made during his Presidential Address at the 2013 Clinical Congress in Washington, DC, and to address the challenges we, as young surgeons, face.

Today’s challenges

It is often said that the only constant in life is change. Young Fellows must deal with shifting practice expectations, including the ongoing shift from private practice to hospital and health system employment, a large training debt burden combined with declining reimbursement, and the Affordable Care Act’s expansion of access to health care services, along with new standards of care. Many surgeons wonder how our profession will survive all of this change.

In addition to these challenges, the training model for surgery has changed, largely due to the 80-hour workweek. Overall, this shift offers residents a more balanced work and private life, but it has also raised questions about whether new graduates are adequately prepared to face the realities of practice. Has surgical expertise suffered because of the 80-hour workweek? Has reduced time in a hospital setting led to a “failure to launch,” as some new graduates struggle in their first job? And does the system in which they work similarly struggle with the best way to integrate the individual who has trained under this new paradigm, especially since most health care institutions and surgical practices have largely been passive in their support of new associates?

The contest

In his Presidential Address, Dr. Pellegrini gave an inspiring talk about what the College has stood for during its history, and he charged new Fellows to create their future amid so much change, using the College as a guiding compass. This year’s essay contest, sponsored by the YFA Communications Committee, is the response of the young surgeons to Dr. Pellegrini’s address. It is this group’s desire to answer back to his charge and give voice to the promise of a profession.

With this in mind, the YFA opened a competition for all Fellows “young at heart” to write a one-page essay about what inspires them and what they view as the promise of the profession. The committee evaluated the winning essay out of the six submitted using a numeric scale in several categories, including technical knowledge, language, and writing style. The essay with the highest score is the winner of this year’s contest, and we are excited to share this essay with the College membership at large. The message of this winning essay underscores the fact that although much of the profession is changing, our dedication to our patients and our commitment to our colleagues remains very much the same.

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First YFA Essay Contest winner: The promise of a profession lies within us Wed, 01 Oct 2014 05:53:22 +0000

Challenges to our surgical profession are numerous. These demands include the need to adjust practices to comply with the Affordable Care Act, increased legal and regulatory requirements, new financial stresses, modifications in training requirements, and documentation of patient encounters through electronic health records.

Waning morale

These challenges have taken a personal toll on many surgeons. A 2008 survey of American College of Surgeons (ACS) members reported 40 percent of us feel burned-out, and nearly one-third screened positive for depression (n=7,905).1 More recently, a 2013 Medscape survey of 24,000 physicians in 25 medical specialties indicated that less than half (47 percent) of general surgeons agreed with the statement, “Yes, I would choose the same specialty.” This figure was a decrease from 60 percent in 2011.2 With these beliefs, how can one convey the promise of this profession to the next generation, let alone to ourselves? Where does the promise of our profession ultimately lie?

To answer these questions, I recall the advice from my research mentor, Suyu Shu, PhD, while at the Cleveland Clinic, OH: “When things are difficult and unclear, go back to fundamental principles.” Heeding this advice brought my attention to the College’s guidelines for the training of general surgeons and surgical specialists (see figure).31939 January Bulletin - Selection of applicants for graduate training for surgery

These guidelines list “character” as the first criterion of surgical trainee selection, stating, “Character embraces ethics, conscientiousness, judgment, industry, and all other elements which make up the background of a surgeon.” Most people would agree with this criterion, but there is a big gap between knowing about character and living it out. Eliminating this gap takes leadership.

Exhibiting leadership, character

Surgeons are seen as leaders. At the most basic level, patients identify us as the leader of the health care team focused on their surgical care. We are trained to efficiently gather information, analyze data, and make decisions. We are also wired to fix problems, which helps us to develop innovative approaches to address health care issues. Many of us are actively involved in finding viable solutions to the challenges facing our profession through service on local, regional, and national positions and committees. Our elected ACS leadership is actively involved with the federal government on key issues currently under deliberation.

The promise of the profession takes more than being a leader; it takes being a leader with “evidence of high character.” Indeed, we have all witnessed, experienced, or exhibited examples of poor leadership—abusive and degrading comments, disrespectful interactions, refusal to cooperate with other physicians, and arrogant behavior. A report on disruptive behavior by physicians revealed 21 percent of respondents (n=828) could directly attribute an adverse clinical outcome to a lapse in character.4 These data show what we all intuitively know—that lapses in behavior can and will negatively affect patient care.

For those of us involved in training fellows, residents, and medical students, consider the impact of our behavior on the next generation. They have to see not only how we operate, but also that our interactions with colleagues and patients, as well as our approach to challenges, are grounded in the quality of our character. This behavior includes how we hold one another accountable for lapses in character, just as we hold each other accountable for decisions that affect clinical patient care. We must have the same passion in imparting character attributes as we do for imparting surgical wisdom to our trainees.

As surgeon leaders, we need to strive to be better. I was delighted to see Carlos A. Pellegrini, MD, FACS, FRCSI(Hon), deliver his ACS Presidential Address, The Surgeon of the Future: Anchoring Innovation and Science with Moral Values, at the 2013 Clinical Congress, in Washington, DC. Moral values and actions reflect one’s character.

Notably, the ACS holds an annual Surgeons As Leaders training course that includes character-building in its curriculum. At our institution, we have implemented a program called Leadership Lived Out that explicitly trains tomorrow’s leaders on a foundation of virtuous character traits.

Each of us has challenges that we must address. In some cases, these concerns are best addressed collectively, while other challenges can only be met on an individual basis. In all cases, each of us must face and overcome these impediments by ceaselessly striving to exude high character in all that we do. The first critical step is to examine the quality of our own character in the behavior we exhibit with our colleagues, the health care teams we lead, the trainees we mentor, and most importantly, the patients to whom we provide care. We must do so because the promise of our profession ultimately lies within each of us.


  1. Shanafelt TD, Balch CM, Bechamps GJ, et al. Burnout and career satisfaction among American surgeons. Ann Surg. 2009;250(3):463-471.
  2. Medscape. Medscape Surgeon Compensation Report: 2012 Results. 2013. (Login required). Accessed August 25, 2014.
  3. MacEachern MT. Criteria for graduate training for surgery and a manual of graduate training for surgery: General surgery and the surgical specialties. Bull Am Coll Surg. 1939;24(1):6-11.
  4. QuantiaMD, American College of Physician Executives. Disruptive physician behavior. May 15, 2011. Accessed August 18, 2014.
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Adverse behaviors and their effect on credentialing and licensure Wed, 01 Oct 2014 05:52:50 +0000

Editor’s note: The following is the fourth in a series of excerpts from Being Well and Staying Competent: Challenges for the Surgeon, a guidebook issued in 2013 by what is now the Physician Competency and Health Workgroup of the Board of Governors Quality Pillar. The complete document is posted in the General Surgery Community. Log-in is required.

“I’ve been reported to the state medical board for alcohol/substance abuse. What do I do?”

“I have been reported for anger, sexual harassment, or disruptive physician behavior. What do I do?”

“I had my privileges restricted by my credentialing body. What are my options?”

“My license has been restricted/revoked. What are my rights?”

“I have completed a treatment program. How do I restore my license/privileges?”

“What do I disclose to the hospital, my colleagues, and my patients?”

These are some of the questions posed by our colleagues who have engaged in some form of adverse behavior, which led to the loss of their credentials and/or restriction of their medical license. Loss of credentials and licensure takes a toll on physicians and their patients. As professionals, we have made a significant investment in our education and careers, and it can be difficult to find another career that is as financially and professionally rewarding as surgery. For society, loss of licensed health care professionals can result in reduced access to the talents and care that surgeons provide. The goal of this article is to define the terms used among the licensing and regulatory bodies, as well as the credentialing committees, and outline steps for individuals to reinstate themselves as fully productive members of the medical community.


Illness generally is defined as the presence of a disease, whereas impairment is a functional classification and implies that the person is affected by a disease that renders him or her unable to perform specific activities. Regulatory and credentialing bodies often use these terms synonymously; however, mental and physical illness, as well as substance abuse, can eventually lead to impairment if left untreated. As surgeons, we strive to recognize and treat surgical illness in our patients early, before they face significant impairment in their ability to function. Surgeons should look at their own issues in the same way.

Disruptive physician behavior, as defined by the American Medical Association, is a style of interaction with physicians, hospital personnel, patients, family members, or other individuals that interferes with patient care. More specifically, the physician’s behavior intimidates and demeans others, potentially resulting in a negative impact on patient care. It is not a diagnosis, but could reflect underlying personality disorders, substance-related disorders, or psychiatric illness.*

Another area of potential impairment for physicians is addiction. Addiction is a compulsive activity or a psychological dependence on a certain behavior, which can eventually consume the attention of the individual to the exclusion of the other aspects of an individual’s life and, thereby, create impairment. Addiction may include substance abuse disorder, as defined by the American Psychiatric Association’s Diagnostic and Statistical Manual of Disorders, Fourth Edition, or addictive illness.

Related bodies

The Federation of State Medical Boards (FSMB) is a national body that leads the licensing community by promoting excellence in medical practice, licensure, and regulation. The FSMB also functions as a resource and voice on behalf of the state medical boards in their protection of the public’s well-being. Another organization involved in supporting physician behavior is the Federation of State Physician Health Programs, which, as its name suggests, is an association of physician health programs (PHP) with knowledge and expertise specifically related to matters of physician health. These programs do not diagnose and treat physicians, but rather coordinate and monitor intervention, evaluation, and the treatment and the continuing care of an impaired physician, as well as those with potentially impairing illness. The PHPs have a primary commitment to uphold the mission of their state medical and osteopathic boards in order to protect the public.

The state medical board’s primary goal is to protect the public through the issuance of professional licenses, as well as the use of disciplinary action for those health care professionals who violate the state medical practice act. There are approximately 70 state medical boards, including 13 osteopathic boards; several states have dual boards. Unfortunately, many physicians finish their training with specialty certificates only to realize that it is not possible to practice medicine without meeting a certain standard in the state where he or she practices.

The issuance of a license attests to meeting a minimal standard of education and training. The United States Medical Licensing Examination (USMLE) is the product of a collaborative effort between the National Board of Medical Examiners, the FSMB, and the individual state licensing boards to develop uniform standards across the U.S. and Canada for the issuance of an initial license. In addition to the examination, other data are taken into consideration before the license is granted. For example, each state has its own rules and regulations regarding medical practice. The overall purpose of these guidelines is to protect the public through licensure, discipline, and assurance of a minimal level of education to issue a license. Many states now require additional education beyond medical school before a license is issued.

A large portion of a state medical board’s activity centers on measuring competency, particularly in the areas of illness and impairment, and restricting licenses and mandating treatment programs for those health care professionals who are demonstrating signs of impairment or illness. This is frequently done through the PHPs that work in conjunction with the state medical board and the state medical societies; however, PHPs should be insulated as much as possible from any political pressures and conflicting interests with the professional organizations.

Hospital credentialing

Credentialing is usually done at the local hospital or health care facility where the the physician seeks to practice. The FSMB has developed a centralized credentialing bank that stores an individual’s college, medical degree, initial licensure, USMLE scores, and basic demographic information. This database helps to facilitate new licensure applications as physicians move from state to state and into different positions and, at the same time, protects the public from exposure to physicians who are under investigation in another jurisdiction. The local hospitals and health care facilities issue credentials depending on the individual’s training and upon the needs and standards they have established. An unrestricted license is usually mandatory; however, for individuals who have had their licenses restricted, each individual credentialing body has to establish the rules and regulations under which their practitioner is going to operate in the facility. It is imperative that each individual, depending on the jurisdiction in which he or she practices, be familiar with the state medical practice act and the unique rules and policies regarding that legislation.

Next steps

Although most physicians want to help their colleague reinstate his or her license, there has to be an appropriate balance between the goals of protecting the public and the safety of their health care versus the recovery of the ill physician. From a practical standpoint, if a health care professional is subject to a formal complaint, either with their local credentialing body or the state board, it is important that they undergo self-examination of their illness or addictive behavior. Initially, these individuals should obtain the assistance of their treating physician, as well as colleagues who may assist them in their recovery. However, if a formal hearing, locally or statewide, is initiated, then it is imperative that these physicians obtain legal counsel from a lawyer who is familiar with administrative health laws, as the rules of evidence in these hearings are different than in a criminal court proceeding.

It is necessary that individuals who are facing disciplinary action act with complete transparency before the hospital administrative body or the state regulatory agency in the hearing. Documentation of efforts to correct the illness or the impairment in a forthright manner is essential to a favorable decision by these authorities.

In many cases, if a patient has not been adversely affected by the individual’s behavior, then the PHP can work in conjunction with the state regulatory agency in terms of monitoring appropriate intervention, evaluating the condition, and recommending treatment and the ongoing care for the impaired physician. If anger or disruptive behavior is an issue, programs are available to assist individuals in managing these problems. Ongoing monitoring and continuing reports to the appropriate authority will be mandatory. If a medical license is encumbered, specific restrictive conditions need to be fulfilled in order to achieve full reinstatement of an unencumbered license. Again, an experienced health care lawyer should be secured to assist in these proceedings.

Even when treatment and rehabilitation are successful, the road to recovery can be difficult. Recovering substance abusers often face discrimination, but they should be given the opportunity to prove themselves through careful monitoring. Most state regulatory agencies will restore a license with conditions outlined in a public document, which may be used as guidelines for the local credentialing body. For those health care professionals with substance abuse problems, either alcohol- or drug-related, the typical period of observation is five years without recidivism.

This journey can be long and arduous, but with determination, discipline, and self-awareness, complete rehabilitation is achievable. In some instances, the road to full rehabilitation may be particularly challenging, and the individual may have to establish a new, modified professional routine. The Federation of State Physician Health Programs and the American Society of Addiction Medicine are both excellent resources for accomplishing that goal.

*American Medical Association. Model medical staff code of conduct. 2013 revision. Accessed August 26, 2014.

Federation of State Medical Boards of the United States, Inc. Policy on physician impairment. April 2011. Accessed August 18, 2014.

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The Patient-Centered Outcomes Research Institute Wed, 01 Oct 2014 05:29:42 +0000

The Patient-Centered Outcomes Research Institute (PCORI) is a not-for-profit organization established in the Affordable Care Act (ACA). It was created to help patients, clinicians, purchasers, and policymakers make more informed health care decisions “by advancing the quality and relevance of evidence” on how to prevent, diagnose, treat, monitor, and manage diseases, disorders, and other conditions.1 PCORI’s objective is to better ensure that patients, health care professionals, and other stakeholders have the evidence they need to make informed decisions when comparing treatment options through research guided by patients, caregivers, and the broader health care community.2

This column discusses PCORI’s focus on patient-centered care, comparative effectiveness research (CER), research funding, and innovative projects. It also provides information on how surgeons can get involved.

How will PCORI meet the ACA mandate?

To meet the ACA mandate of enhancing the quality and relevance of patient-centered outcomes research, PCORI has adopted the following strategic goals:

  • Increase the quality, quantity, and timeliness of usable, trustworthy information to support health care decisions
  • Advance the implementation and use of research evidence
  • Influence research funded by others so it is more patient-centered3

To meet these goals, PCORI specifically focuses on clinical comparative research to investigate which currently available health care products and treatments work best for a given patient, caregiver, or other stakeholder. To achieve this aim, PCORI works from the premise that research might be enhanced if investigators routinely interact with patients to develop research questions. PCORI-funded research must demonstrate that it answers questions and addresses gaps identified by stakeholders to determine the solutions that work best for them. To gain the information needed to address a broad range of health care decisions, PCORI funds research based on five stakeholder-identified national priorities (see table).3,4

PCORI funds research related to five national priorities

National priorities Examples of funded projects
Assessment of Prevention, Diagnosis, and Treatment Options Improving Patient Decisions about Bariatric Surgery
Patient-Centered, Risk-Stratified Surveillance after Curative Resection of Colorectal Cancer
Improving Healthcare Systems A Comparative Effectiveness Trial of Optimal Patient-Centered Care for U.S. Trauma Care Systems
Building a Multidisciplinary Bridge Across the Quality Chasm in Thoracic Oncology
Communication and Dissemination Research Improving Communication in the Pediatric Intensive Care Unit for Patients with Life-Changing Decisions
[University of California-San Francisco Computed Tomography] Radiation Dose Registry to Ensure a Patient-Centered Approach for Imaging
Addressing Disparities Eliminating Patient-Identified Socio-legal Barriers to Cancer Care
Impact of Patient Navigators on Health Education and Quality of Life in Formerly Incarcerated Patients
Accelerating Patient-Centered Outcomes Research and Methodological Research Understanding Treatment Effect Estimates When Treatment Effects Are Heterogenous for More Than One Outcome
Improving the Use of Patient Registries for Comparative Effectiveness
Access all upcoming and previous funding opportunities.

In what innovative ways is PCORI advancing national research on PCOR?

In March, PCORI launched the National Patient-Centered Clinical Research Network (PCORnet), a national, interoperable multicenter research network specifically designed to support observational and randomized PCOR studies.5 PCORnet is a health data initiative which will work to conduct clinical research within patient communities and health care systems across a wide geographic area.

PCORI has awarded more than $93 million to 11 Clinical Data Research Networks (CDRNs) and 18 Patient-Powered Research Networks (PPRNs), which fall under the PCORnet umbrella. The purpose of CDRNs and PPRNs is to stimulate patient-driven research. The figure illustrates how many sites affiliated with one or more of PCORnet’s 29 partner networks are expected to be established in each state.6 CDRNs are health system-based clinical data networks covering large populations that collect information in electronic health records (EHRs) in the course of routine patient care. The CDRNs are charged with building a large nationwide patient cohort with longitudinal electronic clinical data, developing policy for the standardization of data, and focusing on data security to improve patients’ ability to participate in multi-network, randomized clinical trials and observational studies.7

Expected State Sites for PCORnet’s Partner Networks

Expected State Sites for PCORnet’s Partner Networks

Reproduced with permission.

PPRNs are operated and governed by groups of patients, caregivers, or families connected by a shared health condition and who are interested in participating in CER. PPRNs are required to collect data on 80 percent of the population they represent.7 Half of existing PPRNs represent patients with rare diseases and are therefore critical for advancing research on these conditions. PPRNs organized around a specific disease will represent a group of motivated individuals ready to participate indefinitely in studies related to that disease. Typically, research grants have supported collaboration across a consortium of academic medical centers to study a rare disease, but the researchers and study group have often dispersed when the specific project is completed. PPRNs will not disperse, and the PPRN rare disease cohort will remain available to participate in future studies.

The initial phase of development for the CDRNs and PPRNs is 18 months, after which it is anticipated that PCORnet will have available information on several million diverse patients. This will greatly increase the statistical power of patient-centered CER due to larger samples. PCORnet works to advance the speed and efficiency of research by building a health care community that will produce meaningful information for end users. PCORnet has the potential to seamlessly include health research as a part of routine patient visits without interrupting care, thereby creating a national resource for health research.

How does PCORI research involve patients and other stakeholders in the application and review process?

The specific focus on providing useful and practical comparative data for patients and caregivers is what distinguishes PCOR. PCORI’s funding criteria specifically address patient-centeredness, engagement, and likelihood of changing practice.3 To receive funding, applicants must involve patients in clinical research design and decision-making processes to ensure that research questions are relevant to patients and other stakeholders.4

Examples of questions that PCOR might address include:

  • “Given my personal characteristics, conditions, and preferences, what should I expect will happen to me?”
  • “What are my options, and what are the potential benefits and harms of those options?”
  • “What can I do to improve the outcomes that are most important to me?”
  • “How can clinicians and the care delivery systems they work in help me make the best decisions about my health and health care?”2

Another way that PCORI engages patients and stakeholders is through the research application and review process. PCORI is the first large funding agency in the U.S. to require non-scientist reviewers to be involved in the review of all applications for its funding.8 The purpose of their involvement is to improve the relevance of PCORI-funded research for the stakeholders who take action based on the findings.Each funding application submitted to PCORI funding is reviewed by four merit reviewers—two clinical scientists, one patient or patient advocate, and one health care stakeholder, such as a clinician, purchaser, or representative from the health care industry. Through this process, end users have the ability to provide input on which research proposals PCORI should fund.

PCORI has developed resources to help stakeholders communicate and work with patients, because those researchers seeking funding for PCOR have identified patient engagement as one of their biggest challenges. View a webinar that provides examples of meaningful engagement.9

How can surgeons get involved in PCORI?

Surgeons can get involved in PCORI in several ways. PCORI has approved $549 million to more than 300 research projects and initiatives since 2012, and as much as $1.5 billion will be committed to research projects in the upcoming three years—most of which will focus on targeted funding announcements and large pragmatic studies.3 A few engagement opportunities include:

  • Eugene Washington PCORI Engagement Awards: These awards provide funding for smaller projects to develop knowledge concerning how consumers of health care information view and use PCOR, to build capacity for community engagement in PCOR, and to support channels for the dissemination and implementation of PCOR. Applications for funding are reviewed on an ongoing basis. For more information, visit the Eugene Washington PCORI Engagement Awards.
  • Large pragmatic studies: In 2014, PCORI launched a new initiative to fund large pragmatic clinical trials, large simple trials, or large-scale observational studies. This initiative provides an opportunity for clinicians to partner with diverse stakeholders, including patients, purchasers and/or payors, and professional organizations. These studies will involve broadly represented patient populations to ensure a large enough sample to evaluate differences in treatment effectiveness in patient subgroups. The studies aim to address prevention, diagnosis, treatment, or management of a disease and/or symptom improvement in health care system performance, and elimination of disparities in health care, and must be conducted in a typical clinical care and community setting.10
  • Other PCORI funding opportunities: PCORI also issues regular funding announcements under its five broad national priorities for research and occasional calls for proposals on specific, high-impact topics. All funding opportunities are listed in PCORI’s funding center.
  • PCORI funding reviews: PCORI seeks guidance from clinicians and other stakeholders on the evaluation of proposals for its funding and to formulate research questions. Clinicians are critical stakeholders in the PCORI merit review process. Learn about the experience of past reviewers.
  • PCORnet: Once PCORnet is operational in late 2015, surgeons involved in research may be able to link external data to PCORnet to supplement their current study population. Linking clinical data registries to PCORnet may be especially effective in creating a large, diverse study cohort. Surgeons may also have the opportunity to help leverage EHRs to help recruit eligible patients, monitor patient safety and study conduct, and collect clinical outcomes.

Other areas of engagement include opportunities to provide input on study design for integration with physician clinic or office operations, disseminate study findings, or contribute to the evaluation of PCORI-funded projects.11

For additional questions and concerns regarding PCORI, contact the American College of Surgeons Division of Advocacy and Health Policy at or 202-337-2701.


  1. Patient-Centered Outcomes Research Institute. Patient Protection and Affordable Care Act. 42 U.S.C. § 1320e. 2010. Accessed September 16, 2014.
  2. Patient-Centered Outcomes Research Institute. Accessed July 16, 2014.
  3. Selby J, Lipstein S. PCORI at 3 years—progress, lessons, and plans. N Engl J Med. 370(7):592-595. Accessed June 18, 2014.
  4. Patient-Centered Outcomes Research Institute. PCORI funding awards: Cycle III and inaugural improving methods for conducting PCOR. September 10, 2013. Accessed September 16, 2014.
  5. Daugherty S, Wahba S, Fleurence R, PCORnet. PPRN Consortium. Patient-powered research networks: Building capacity for conducting patient-centered clinical outcomes research. J Am Med Inform Assoc. 2014;21(4):583-586. Accessed June 16, 2014.
  6. Patient-Centered Outcomes Research Institute. PCORnet coverage map. Accessed June 16, 2014.
  7. Fleurence R, Curtis L, Califf R, Platt R, Selby J, Brown J. Launching PCORnet, a national patient-centered clinical research network. J Am Med Inform Assoc. 2014;21(4):578-582. Accessed June 11, 2014.
  8. Fleurence RL, Forsythe LP, Lauer M, et al. Engaging patients and stakeholders in research proposal review: The Patient-Centered Outcomes Research Institute. Ann Intern Med. 2014;161(2):122-130. Accessed August 13, 2014.
  9. Patient-Centered Outcomes Research Institute. Promising practices of meaningful engagement in the conduct of research. September 19, 2013. Accessed September 16, 2014.
  10. Patient-Centered Outcomes Research Institute. Pre-announcement: Pragmatic clinical studies and large simple trials to evaluate patient-centered outcomes. Accessed June 16, 2014.
  11. Patient-Centered Outcomes Research Institute. Recent PCORI research initiatives: Highlighting opportunities for clinicians. Accessed June 16, 2014.
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ACS intervenes to resolve questions about the 96-hour rule Wed, 01 Oct 2014 05:28:31 +0000

In the fall of 2013, the American College of Surgeons (ACS) listserv for rural surgery began receiving inquiries from surgeons at critical access hospitals (CAHs), who were getting requests from their administrators to sign certification that inpatients would reasonably be discharged within four days. Thus was the introduction of most rural surgeons, and the physicians and staff in the ACS Division of Advocacy and Health Policy (DAHP), to a minor clause in a long-standing federal law known as the 96-hour rule.


The federal government created the CAH system as part of the Balanced Budget Act (BBA) of 1997 to ensure the financial viability of hospitals in remote rural areas, and thereby improve access to care for patients in these areas of the nation. In contrast to other hospitals, which are paid a set fee for patient hospital admissions under a diagnosis-related group (DRG) schedule, Medicare pays CAHs 101 percent of the actual hospital costs of caring for these patients. However, CAHs must comply with specific rules to participate in the program.

In the 1997 BBA, Congress defined both conditions of participation and conditions of payment for CAHs, requiring them to “provide acute inpatient beds… for a period not to exceed 96 hours.” In the 1999 Balanced Budget Refinement Act (BBRA), Congress changed the conditions of participation to a period that does not exceed, as determined on an annual average basis, 96 hours per patient.* This language change allowed surgeons in CAHs to care for patients who might require inpatient care exceeding 96 hours, as long as the average care for patients treated at these institutions on an annual basis remained at 96 hours or less. However, the conditions of payment were never updated to reflect the new language. The discrepancy was not noted in Washington, DC, until 2013, when new mandates regarding the two-midnight rule for inpatient admission were to take effect.

Administrators at the Centers for Medicare & Medicaid Services (CMS) began to notify rural CAHs that, in addition to the requirements for the two-midnight rule for hospital admissions, the conditions of payment in the BBA of 1997 would apply, which meant that CMS would not pay CAHs for inpatient stays exceeding 96 hours. According to posts on the rural surgery listserv, administrators at a handful of small hospitals began confronting surgeons about their compliance with the new requirements and asked the surgeons to sign attestations stating that their patients would be reasonably discharged within 96 hours. This new regulation would of course greatly restrict the patients who could receive health care services at a CAH.

From confusion, clarity

Members of the ACS Advisory Council for Rural Surgery (ACRS) responded to the listserv traffic and contacted the DAHP in Washington, DC. Vinita Ollapally, JD, ACS Regulatory Affairs Manager, investigated the 96-hour rule and learned that the only real option for overturning the 96-hour rule was legislative; Congress would have to pass a new law. Ms. Ollapally briefed the ACS leadership, including the ACS Health Policy Advisory Group (HPAG), individuals involved in the ACS grassroots advocacy program (ACS-SurgeonsVoice), and the ACRS on her findings.

Meanwhile, the American Hospital Association (AHA), the National Rural Healthcare Association (NRHA), and other professional societies were discovering the same information and rushing to develop a strategy to change the rule. ACS advocacy staff contacted these organizations and began to work on a plan.

A plan emerges

In early discussions, ACRS members and the DAHP staff, agreed that a multifaceted approach involving ACS-SurgeonsVoice was needed to mitigate the damage caused by the 96-hour rule, as even the best-laid plans in Washington often fall victim to politics, inaction, or unforeseeable events. The proposal presented at the December 2013 ACS Health Policy and Advocacy Group meeting featured a three-pronged strategy:

  • Work with CMS to explore administrative options to offer relief from the rule
  • Develop a legislative solution to repeal the 96-hour rule
  • Inform surgeons and prepare them for the impact of the rule

ACS DAHP staff, along with their counterparts at the American Medical Association, AHA, and NRHA, began discussions with CMS staff to attempt to find solutions to the conflicting rules. In these discussions, CMS staff explained that they had limited ability to act, and due to the fact that the 96-hour rule was established under a federal law, only Congress could correct the unintended consequences of this legislation.

Nonetheless, the ACS DAHP staff realized that there were some means of mitigation. Because CMS had previously overlooked the mandate, prior violations would not be pursued. CMS also revealed that enforcement would be through audits of claims paid and Recovery Audit Contractor (RAC) recovery. Although CMS did not have the authority to simply “ignore” the rule, they did have some leeway in their approach to enforcement. DAHP’s involvement probably played a role in ensuring that no hospitals would be forced to repay CMS for these patients over the first six months of the 96-hour rules issued in 2013.

The College also prepared two educational documents: a PowerPoint presentation titled Critical Access Hospital 96-Hour Rule, and Advice For the Rural Surgeon Regarding the 96-Hour Rule. Both have been posted to the ACS rural listserv and uploaded to the rural community website ( for reference.

The third part of the strategy to resolve questions related to the 96-hour rule was legislative in nature, and led by members of DAHP, specifically John Hedstrom, JD, Deputy Director, and Matt Coffron, Government Affairs Associate. Once again engaging in collaborative efforts with other stakeholder organizations, the ACS began lobbying lawmakers for relief. Much of the early advocacy effort occurred at the grassroots level, with individual rural surgeons contacting members of Congress with whom they already had established relationships. The result of this effort was the quick (by Washington standards) introduction of S.B. 2037 and H.B. 3991, the Critical Access Hospital Relief Act. The bills were introduced in both houses in March by Sens. Pat Roberts (R-KS) and Jon Tester (D-MT) and Rep. Adrian Smith (R-NE). This legislation would change the wording of the conditions of payment to match that of the conditions of participation, allowing surgeons and CAHs to treat patients as they had been all along.

Gathering support

The College used several tools to successfully gather support for the bill. First, rural surgeons were mobilized on the listserv to contact their representatives and senators. A second wave of advocacy was initiated via the ACS-SurgeonsVoice action alerts, recruiting more surgeons to contact their legislators. At the ACS Leadership & Advocacy Summit in April, the 96-hour rule was designated an item for discussion for surgeons who were participating in Capitol Hill visits.

Around the time that surgeons were mobilizing to overturn the 96-hour rule, the ACS was involved in a larger attempt to repeal the sustainable growth rate (SGR) formula used to calculate Medicare physician payments. The political and economic climate of 2014 brought the medical community closer than ever to fully repealing the SGR, with bills making it through committees in both the House and Senate. Unfortunately, just before the Leadership & Advocacy Summit, Congress scratched the permanent SGR fix and rapidly adopted another temporary patch. This legislation contained some important provisions, however. One suspended implementation of the two-midnight rule—the regulation that brought the 96-hour rule to light. By suspending this provision, Congress essentially halted further administrative pursuit of the 96-hour rule, leaving CMS in limbo but taking the pressure off the CAHs.

These legislative efforts, especially grassroots lobbying by individuals, effectively generated support for the Critical Access Hospital Relief Act. At the end of July, the bill had 81 cosponsors in the House and 29 in the Senate. At press time, however, the legislation seemed to be languishing. Perhaps with the temporary patch for the SGR, attention is elsewhere, or, perhaps, the impending mid-term elections are preventing movement on some pieces of legislation. For whatever reason, H.R. 3991/S.B. 2037 had not been scored by the Congressional Budget Office, a necessary step for the passage of any bill.


To ensure that Congress returns attention to the legislation, DAHP Medical Director of Advocacy, Patrick V. Bailey, MD, FACS, has brought up the legislation in meetings with the Congressional Medical Caucus (a group of legislators with medical backgrounds) and other congressional leaders. Dr. Bailey predicts that for the bill to succeed, it will need to be attached to a larger piece of legislation, such as an appropriations bill. However, he doesn’t foresee Congress acting on this issue until later this fall.

So, at press time, the 96-hour rule remained dormant, but still hung over the heads of surgeons in rural practices who use CAHs. The best source of relief will almost certainly emanate from new legislation. Knowing how important this issue is to rural surgeons and CAHs, the ACS DAHP, ACRS, and College leadership will continue their efforts to achieve passage of this legislation.

ACS-SurgeonsVoice plays critical role

by Tyler G. Hughes, MD, FACS

Editor’s note: The following is an invited commentary from Tyler G. Hughes, MD, FACS, ACS Governor and Chair of the Advisory Council for Rural Surgery.

Dr. Savarise’s column clearly shows the value of the American College of Surgeons grassroots advocacy program (ACS-SurgeonsVoice), and emphasizes how hard the members of the ACS DAHP and HPAG are willing to work on an issue that is of critical importance to rural surgeons and CAHs.

Everywhere I go, I hear questions regarding the effectiveness of the College. There’s no question that we often fight uphill battles on Capitol Hill. The people who lobby against us are well-funded and are motivated by forces far different from those of the average surgeon. The 96-hour rule is a great example of the ACS leadership listening to a problem, understanding its significance, allocating resources to the issue, and quickly springing into action to get a bill introduced. The value of individual surgeons contacting their members of Congress, the effect of the SurgeonsVoice action alerts, and the effect of multiple surgeons discussing this issue with their members of Congress at the ACS Leadership & Advocacy Summit in April also cannot be underestimated. The results on this issue, as outlined in Dr. Savarise’s article, clearly show that the College’s advocacy efforts can be very effective.

The 96-hour rule may seem like a small matter, but it is not in principle or effect. If surgeons can get a win on this issue, it’s one more stone in building a foundation for a better system for patients with surgeons’ input. Be politically active in whatever way you can, and meet with your members of Congress when they are home in the coming months.

*American Hospital Association. Critical care access hospitals. CAH legislative history. Accessed August 26, 2014.

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