Since its establishment in 2012, the American College of Surgeons (ACS) Advisory Council for Rural Surgery (ACRS) has sought to respond to the following question: How can the ACS make life better for rural surgeons and their patients? With respect to quality improvement, ACRS members have found that although many rural surgeons provide quality care, they often lack the means or platform to effectively work with their hospitals and communities to move from good to great quality care.
After years of study and effort, the ACS, under the direction of the ACRS, is developing a verification program to address the specific needs of surgery programs within rural hospitals. This program is in development and has recently begun pilot site visits to test the standards and verification process. Upon completion of the program pilot, the ACRS intends to offer the program to all interested rural hospitals. This article introduces readers to this program and describes how the initiative has the potential to improve care for rural surgical patients.
Resource issues in rural surgery
Rural hospitals are only as good as the resources they house. A rural surgeon is an important resource. Time is a valuable resource for rural surgeons. Hospital facilities, specifically a well-equipped emergency department (ED), radiology department, operating room (OR), and intensive care unit (ICU), are key resources. In addition to proper facilities, hospital personnel, specifically qualified surgeons, OR staff, nurses, and anesthesia staff, also are key resources. In other words, rural hospitals—like other health care centers—need to have the proper systems in place to ensure that they can provide the right care, in the right location, to the right patient.
The verification program is being designed to help rural hospitals and communities organize and maximize their resources and to develop and plan the use of future resources to build the best surgical programs possible.
Use of Red Book principles
The verification program being developed for rural hospitals uses the principles outlined in Optimal Resources for Surgical Quality and Safety, also known as the ACS Red Book.* The Red Book describes the common core standards that are applied across all ACS Quality Programs, including Trauma, Cancer, Bariatric, Children’s, and Geriatric Surgery. Each program addresses resources specific to an individual disease process or patient population, but the common goal across programs is to establish an infrastructure to, first, create a systematic way for hospitals to identify their own problems; second, develop internal resources to fix their problems; and third, anticipate or prevent future problems by creating vertical and horizontal channels for communication and education of hospital staff on lessons learned. Adherence to these core concepts allows hospitals to effectively create a culture of continuous quality improvement, safety, and high reliability. The Red Book outlines the infrastructure and mechanisms needed to establish surgical quality and safety across all surgical specialties, which includes everything from establishing a Surgical Quality Officer and measuring safety culture, to standardization across the five phases of care, case reviews, data, and quality improvement infrastructures. The Red Book articulates the need for surgeon leadership and engagement to improve care and highlights the value of surgeons as autonomous leaders of quality in the nation’s evolving health care system.
The principles outlined in the Red Book establish a framework for creating hospital standards that are verifiable and applicable to a hospital of any size. While a separate standards-based verification program is being developed on ACS Red Book principles for medium-large community and academic hospitals, the verification program being developed by the ACRS is specifically designed to assist rural hospitals ranging from 25-bed critical access hospitals (CAH) to 100-bed community hospitals and aims to address the unique needs of rural hospitals.
A different type of program
The rural surgery verification program will have a very different feel to it than some other hospital accreditation programs.
The rural surgery verification program will have a very different feel to it than some other hospital accreditation programs. This program is not being designed as a pass/fail program. Instead, it is intended to serve as a means of encouraging rural hospitals to continuously improve and hardwire the way they provide care to surgical patients. The program is being designed to evaluate where a given rural hospital currently is at in its quality journey and to provide meaningful and actionable feedback on what it needs to do next to improve. Obtaining verification through this program will be an achievable goal for most rural hospitals that can demonstrate an ongoing commitment to surgical quality and safety as outlined in the program standards. For example, this program will help a hospital to evaluate its method of credentialing and privileging surgical staff, and to determine if changes in these processes could lead to better patient care.
How the program will work
The program is being developed to set standards, verify each hospital against those standards, and provide recommendations for improvement as it relates to the hospital’s quality infrastructure across all surgical patients treated at a rural hospital. Each participating hospital and its surgeons will be asked to define its scope of practice; that is, the types of surgical patients and conditions that can safely receive care at the facility. Knowing the scope of practice will make it easier for the facility to determine the strengths and weaknesses of its infrastructure and to plan for use of its resources to improve care in the future.
For example, if a hospital and its surgeons intend to care for elderly surgical patients, this program will help the surgeons and hospital leadership to evaluate whether they are doing proper risk assessment and prehabilitation preoperatively, as well as evaluate whether their intensive care unit and postoperative floor has the necessary personnel and equipment to properly care for elderly surgical patients. For patients with surgical conditions that fall outside of their defined scope of practice, a rural hospital will need to develop written transfer agreements to larger hospitals.
We all know that certain standards need to be met to be able to provide high-quality care to surgical patients. This program will provide a list of standards and ask surgeons and hospitals to evaluate themselves on how well they are meeting these benchmarks. The program also will provide a plan and framework for surgeons and hospitals to continually improve on what they are doing to meet each of these important standards. Program standards will include:
- Institutional administrative commitment to the program
- Program scope and governance
- Facilities and equipment resources
- Personnel and services resources
- Patient care: Expectations and protocols
- Data surveillance and systems
- Quality improvement
Participating hospitals will be asked to complete a prereview questionnaire, which will be followed by an on-site review conducted by a peer reviewer and that includes interviews with various hospital leaders, surgeons, and multidisciplinary staff, as well as chart and documentation review. As mentioned previously, this is not a pass/fail program. Hospitals will receive feedback and recommendations from the site reviewers and the ACS regarding their strengths and weaknesses. By following the program standards and the site review recommendations, hospitals will gradually develop a culture dedicated to self-evaluation, proper use of resources, and continuous quality improvement. Similar to other ACS verification programs, it is anticipated that participating hospitals will be expected to host follow-up site visits on a regular basis to maintain verification and continue on their quality journey.
Rural surgeons and rural hospitals already are doing their best to provide quality care to their patients. This program will help hospitals make the best use of the surgeons, hospital personnel, and quality programs already in place. Through good organization and leadership, the work of these people and programs can be made more efficient and effective and can perpetuate a cycle of continuous quality improvement.
Rural surgeons and rural hospitals already are doing their best to provide quality care to their surgical patients. This program will help hospitals make the best use of the surgeons, hospital personnel, and quality programs already in place.
Participating hospitals will be asked to develop a Surgical Quality and Safety Committee, which will include representatives from all members of the hospital team that care for surgical patients—from the time of their first preoperative evaluation to the time of their discharge. Committee members will include surgeons; representatives from anesthesia; physicians who provide care to ICU patients; emergency medicine personnel; nurses in the preoperative, perioperative, and postoperative units; hospitalists; and hospital administrators.
With representatives from the full surgical team and hospital in place, the Surgical Quality and Safety Committee can address almost any aspect of surgical patient care, including case review, peer review, credentialing/privileging, data analysis to identify outliers, management of external collaborations in quality and safety, and establishment of quality and safety standards.
Benefits of participating in the program
Rural hospitals that participate in the program can expect to see the following benefits:
- Based on the hospital’s and surgeons’ defined scope of practice for surgical patients and conditions, it will be possible to create an accurate plan to define and establish the appropriate infrastructure.
- It will help unify the mission of the hospital board, hospital administration, surgeons, nursing staff, OR staff, and hospital staff in the care of surgical patients.
- It will be possible to develop transfer agreements to ensure patients who fall outside of the defined scope of practice will be sent to the hospitals that are appropriately resourced. Relationships with larger referral hospitals also will be strengthened.
- Objective data will be used to drive a cycle of continuous quality improvement.
- Recruitment and retention of surgeons will be enhanced.
- The program will create a unified team of players (surgeons, OR staff, postanesthesia care unit, anesthesia, ICU, postoperative nursing, radiology, laboratory, and so on) with the same goal—providing high-quality, excellent care to surgical patients.
- All aspects of surgical care are reviewed by a multidisciplinary team that comprises all the members necessary to effect change for better surgical patient care.
- Consistently high-quality care of surgical patients can lead to the improved financial viability of a rural hospital, especially if compensation eventually becomes tied to the delivery of value-based care.
- It will be clear to the local community that their hospital is committed to providing excellent surgical care to patients.
- High-quality care of the surgical patient becomes the top priority.
Status of the program
The first pilot site visit for this program was conducted in September 2019 at MidMichigan Medical Center-Alpena, a rural hospital in the northern portion of the lower peninsula of Michigan. For details on this visit, see the related article in this issue of the Bulletin. Upcoming pilot site visits are being planned at various rural community hospitals and CAHs across the country. Site reviewers are being recruited, and training for site reviewers will be developed.
After the pilot site visits and site reviewer training has been completed, the new program for verifying surgical quality in rural hospitals will formally launch. Any rural surgeons or hospital administrators interested in learning more about or participating in this program should contact Stephanie Mistretta, Project Manager, ACS Accreditation and Verification Program Development, at firstname.lastname@example.org or Amy Robinson-Gerace, Senior Manager, ACS Accreditation and Verification Program Development, at email@example.com.
*Hoyt DB, Ko CY, eds. Optimal Resources for Surgical Quality and Safety. Chicago, IL: American College of Surgeons; 2017.