The 2020 American College of Surgeons Quality and Safety Conference VIRTUAL took place August 21−24. All sessions are still available for viewing to all registrants through the end of October.
As has been the case for the live conference, this conference revolved around the College’s Quality Programs, which emphasize optimal patient care in bariatric and metabolic, pediatric, trauma, cancer, and geriatric surgery. Although each area was covered in the course of the conference, the overarching theme was that quality improvement requires a systems-based approach that requires all contributors to patient care—from surgeons to nursing staff, from pharmacy to the C-suite, from patients and their at-home caregivers to occupational and physical therapists—to develop and execute a treatment plan that is cost-effective and adds to quality of life. This theme was echoed in 62 Panel Sessions and 29 Fireside Chats. One particularly well-received Fireside Chat involved Selwyn Vickers, MD, FACS, Birmingham, AL, and incoming ACS President J. Wayne Meredith, MD, FACS, and focused on racial inequities in the U.S. health care system.
This article highlights several Panel Sessions on hot topics this year.
The delivery of equitable care is paramount in any discussion of health care quality and safety. Lesly Ann Dossett, MD, MPH, Ann Arbor, MI, pointed to several studies that demonstrate that disparities affect preoperative care. Daniel I. Chu, MD, FACS, FASCRS, Birmingham, AL, noted, “Eliminating disparities is an achievable, necessary, and just goal” for [surgeons] and has found that “standardizing care is one way to do it.” Rachel E. Patzer, PhD, MPH, Atlanta, GA, offered a systematic approach to addressing disparities by building an electronic hospitalization risk dashboard. Zara Cooper, MD, MSc, FACS, Boston, MA, moderated the panel discussion.
As the U.S. population ages, older adults are anticipated to have growing surgical needs. The Geriatric Surgery Verification (GSV) Program aims to address this health care challenge by equipping hospitals with 30 essential standards for providing optimal geriatric surgical care. Marcia McGory Russell, MD, FACS, Los Angeles, CA, gave an overview of how the GSV Program has evolved. Ronnie Rosenthal, MD, MS, FACS, explained that the GSV Program is “important now more than ever” because it is increasingly necessary for health care providers to “provide a safe environment, understand the individual’s unique health care goals, identify an individual’s unique vulnerabilities, and make plans that address those vulnerabilities.”
The U.S. health care system was suffering from maldistribution of medical and surgical supplies before the COVID-19 crisis raised awareness about the health care system’s lack of ability to leverage personal protective equipment (PPE), according to Patrick A. Kenney, MD, Yale University, New Haven, CT. He and Kimberly Amrami, MD, Mayo Clinic, Rochester, MN, urged health care providers and suppliers to collaborate to eliminate maldistribution of supplies to improve value. “Physician engagement in supply chain is important,” Stacy Alan Brethauer, MD, FACS, The Ohio State University, Columbus, said. “It de-escalates surgeon frustration, builds consensus, controls variation, and drives value.” Bruce L. Hall, MD, PhD, MBA, FACS, Washington University, Saint Louis, MO, moderated the live chat session.
Bundled payments have been touted as an effective means of ensuring patients receive value-based care. Bundled payment encourages market-based incentives for the provision of more coordinated, team-based approaches that lead to better outcomes, which are the driving force for this model, according to Mary Witkowski, MD, MBA, Harvard School of Business. Mark Reardon, MD, MBA, Johns Hopkins, Baltimore, MD, and Elizabeth Wick, MD, FACS, University of California San Francisco, described their experience with applying this approach to value-based outcomes. Dr. Wick said, “I have to admit, at first I was skeptical of this model,” but after seeing its affect on patient outcomes, she now endorses it.
Process-based steps are essential for implementing quality improvement (QI) projects. “Along the way, be sure to share not only the process but also the progress of the project with stakeholders to maintain engagement. And make it personal—at the end of the day, quality and safety will not only improve the lives of our patients, but also those of our providers,” said Rachel R. Kelz, MD, MSCE, MBA, FACS, Philadelphia, PA. Obtaining data from multiple sources—including the ACS National Surgical Quality Improvement Program (NSQIP®) and Hospital Consumer Assessment of Healthcare Providers and Systems surveys—are critical for identifying process-based steps for QI initiatives. Claire Larson Isbell, MD, FACS, Temple, TX, described the differences between brainstorming and planning sessions, both of which play an essential role in QI strategies with lasting results. Colonel Peter Learn, MD, USAF, Bethesda, MD, noted that the same principles for becoming a successful surgeon apply to QI, especially mentorship and training; Lillian S. Kao, MD, FACS, Houston, TX, moderated the session’s Q&A, in which panelists discussed overcoming barriers to implementing successful QI initiatives.
Hospitals have implemented significant modifications to meet the needs of the older adult surgical patient during the COVID-19 pandemic, including enhanced communication strategies. “Patients who would normally lip-read have had that ability taken away [due to face masks]. It’s made cognitive evaluations more difficult because of patients’ inability to understand longer sentences. The inability to hear and see the provider’s face has created a natural barrier to the development of that provider-patient relationship that we all know is important,” said Matthew Schiralli, MD, FACS, Unity Center, NY. Other barriers to care, according to Dianne Bettick, MSN, RN, Baltimore, MD, include minimal discharge teaching to caregivers due to the no-visitor policies and an increase in patient and family resistance to postoperative placement. Subhendra Banerjee, MD, FACS, Fresno, CA, described the design and buildout phase of its Senior Surgical Care Program/GSV program that launched in the fall of 2019. Ronnie A. Rosenthal, MD, MS, FACS, West Haven, CT, moderated the session’s Q&A, in which panelists discussed why optimal surgical care for older adults is essential during the pandemic.
PS27. Introducing ACS Quality Verification: How Principles of the Red Book Create a National Model for Quality and Safety Across the House of Surgery
In this session, quality improvement leaders identified tools for assessing and enhancing quality care across surgical specialties. “Every hospital every day has variability, and our goal in quality is to reduce unnecessary variability…every outcome has multiple causes and effects. Getting a handle on these is key to this endeavor of trying to move toward quality across the House of Surgery,” Dr. Meredith said. Developing a framework for quality improvement begins with a four-pillar model, including standards, infrastructure, data, and verification, noted Chelsea P. Fischer, MD, Chicago, IL. These QI principles are a key component of the Optimal Resources for Surgical Quality and Safety manual (the Red Book), which is the foundation of the ACS Quality Verification Program. James W. Fleshman, Jr., MD, FACS, FASCRS, Dallas, TX, described lessons learned from an ACS Quality Verification Program pilot site visit at Baylor University Medical Center in October 2019, including the development of QI groups with five phases of care and scheduled biweekly morbidity and mortality conferences with data reporting. Michael C. Chang, MD, FACS, Winston-Salem, NC, moderated the session’s Q&A, in which panelists discussed how the principles in the Red Book have created a national model for quality and safety.
Patient-reported outcomes (PROs), which represent patient perceptions, are important measures to enhance patient-centered care. “Patients don’t have surgery with the goal of avoiding a complication,” said Andrea L. Pusic, MD, MHS, FACS, FRCSC, Boston, MA. “Patients come to surgery to improve their quality of life, and they hope to avoid a complication in the process. I think what is exciting is how the ACS is incorporating PRO measurement into NSQIP.” Brian C. Brajcich, MD, MS, Chicago, IL, described several guiding principles for incorporating PROs into ACS NSQIP, including sourcing psychometrically sound data, developing patient-friendly reporting tools, and promoting only those PROs that enable actionable improvement. Larissa K.F. Temple, MD, FACS, Rochester, NY, noted several imminent changes to PROs, which she expects will unspool within the next several years in the areas of technology, measurement science, performance measurement, and value. Frank G. Opelka, MD, FACS, Washington, DC, moderated the session’s Q&A, in which panelists discussed strategies for implementing PROs into surgeons’ everyday workflow, and the ability of PROs to accurately measure some patients’ unrealistic expectations.
Surgical QI efforts are complex initiatives that require dedicated teamwork from the involved parties. As surgeons and QI team members well know, comprehensive data collection is vital in service of the “what (are we trying to accomplish) informed by why,” “when,” “who,” and especially the “how (will the effort be accomplished),” according to Angela Ingraham, MD, MS, Madison, WI. Carrie Yvonne Peterson, MD, MS, FACS, FASCRS, Milwaukee, WI, explained that because QI is so time- and resource-intensive, it is vital to get buy-in from colleagues, team members, and leadership by overcoming resistance to taking on a project. Perhaps the most critical component of successful QI is fostering a culture receptive to improving quality, as Timothy Jackson, BSc, MD, MPH, FACS, FRCSC, Toronto, ON, explains: “All hospitals will have a certain structure, policies and protocols, work processes, technology, and so on, but it’s important to remember that all of these things are dependent upon human behavior that will be informed and influenced by the culture of an organization.” Dr. Jackson also moderated the panel discussion.
The use of video in surgical education and training has demonstrated an impact of individual and systemwide QI efforts, according to Oliver A. Varban, MD, FACS, Ann Arbor, MI, who introduced this session. One of video’s primary strengths is allowing reviewers to closely monitor surgical trainees—Scott R. Steele, MD, MBA, FACS, Cleveland, OH, noted that “Video can help you look at the nuance of a procedure. If you give me unedited video, I can follow all of the different aspects of the procedure to be able to compare you not only to the standard, but to your peers.” Jonah Stulberg, MD, PhD, FACS, Chicago, IL, explained that monitoring a surgeon’s technical skill through video can be critical to improving patient outcomes, as superior technical skill is correlated with lower complication rates and unplanned reoperation rates. The positive results of video also are apparent for practicing surgeons, as John C. Byrn, MD, FACS, Ann Arbor, explained that a tailored, video-based coaching experiment led to improved results. Dr. Stulberg also moderated the panel discussion.
PS46. Strategies Related to Surgical HR Deployment/Preparedness and Logistics/Procedures Related to Resuscitation
COVID-19 presented immense challenges to trauma surgeons and systems. John P. Hunt, MD, MPH, New Orleans, LA, discussed how his trauma center managed their literal human resources to meet the COVID-19 surge while maintaining trauma services, which required careful management and deployment of employees. Intensive care units (ICUs) have been critically important in treating severely ill COVID patients, and Robert J. Winchell, MD, FACS, New York, NY, described the decisions that hospitals needed to make: “Perhaps the biggest decisions you will face [in preparing to create ICU capacity for COVID-19 patients] is that of hospital mission. Are you a system resource, or will you be able to offload patients to a bigger facility? Will you be able to maintain any other critical mission, such as trauma, burn, STEMI, or stroke in the face of the COVID pandemic?” The pandemic also presented challenges in trauma/critical care resuscitation, surgery, and procedures at Harborview Medical Center, Seattle, WA, according to Bryce Robert Holvey Robinson, MD, FACS, who explained the process his hospital developed to manage, triage, test, and treat trauma patients with uncertain COVID status. Dr. Hunt also moderated the panel discussion.
Telemedicine has become a critically important communication and medical technology due to the COVID-19 pandemic, as it guarantees a measure of safety for both patients and practitioners and was especially useful early in the pandemic’s course. “Telehealth allowed us to protect some of our providers and our patients from the transmission back and forth as we were catching up on PPE and figuring out what we needed to do to keep safe from a PPE standpoint,” said Heather Yeo, MD, MHS, MBA, MS, FACS, FACRS, New York, NY. The practical benefits of telehealth have abounded for a community-based bariatric program during the pandemic, according to Ioannis Raftopoulos, MD, FACS, West Hartford, CT, who describes greatly reduced office time, increased patient access to care, patients who were “lost” to follow-up returning for treatment, and more. Andrew R. Watson, MLitt, MD, FACS, Pittsburgh, PA, discussed how increased utilization of telehealth appointments and services also led to a reimagining and relaxation of the some of the stringent regulations that payors such as the Centers for Medicare & Medicaid Services had enacted for the technology, allowing physicians to be fairly compensated for their virtual work. Heather Leigh Evans, MD, MS, FACS, moderated the panel discussion.
Although surgery is a uniquely challenging career, there are parallels and lessons to be learned about the practice from potentially unexpected sources, such as a boat trip to circumnavigate Lake Michigan. Shanu N. Kothari, MD, FACS, FASMBS, Greenville, SC, described his nautical journey, taken during a sabbatical with his family in the summer of 2011, where he discussed topics including the surgical parallels between boating and life as a surgeon, with topics including the use of surgical checklists, teamwork and communication, leadership, and surgical mentorship. The task of piloting a boat holds several similarities to leading a surgical team, Dr. Kothari said, relating a story of when his family was traveling through a powerful storm: “When my daughter came to me in that harrowing situation and said, ‘Daddy, are you scared?’ I had to maintain a sense of leadership and calmness. That’s what prompted her to say, ‘If daddy isn’t scared, why should I be?’ If we show evidence that we’re losing it in the operating room, you can’t imagine what is happening to our team members during those difficult times.” Teresa R. Fraker, MS, RN, moderated the panel discussion.
PS57. Introducing the ACS Quality Verification for Rural Hospitals: Moving from Concept to Construct When It Comes to Improving Surgical Care in Rural Communities
Rural surgeons face unique challenges, which are in part defined by the barriers to measuring and improving quality in a rural setting, according to Michael D. Sarap, MD, FACS, Cambridge, OH. Although the timeliness, efficiency, and patient-centeredness of rural care are advantageous, surgeons are limited in resources and time for QI efforts, and systems lack institutional and technological support for QI. The QI struggles of rural surgeons has been aided by the backing of the ACS, though, says Julie A. Conyers, MD, MBA, FACS, Ketachikan, AK, who discusses how ACS NSQIP and the College’s QI principles have helped to guide quality efforts at PeaceHealth Ketchikan Medical Center in rural Alaska—and the ACS is further standardizing care in the unique circumstances faced by rural surgeons through a new rural surgery verification program. “[In rural settings,] you can’t have every resource in your hospital, and you can’t take care of every patient’s problem; and, for these reasons, patient transfers are more common. Because of these differences, we feel we need a separate verification program with some standards that support this,” said Mark W. Puls, MD, FACS, Alpena, MI. Tyler G. Hughes, MD, FACS, Salina, KS, moderated the panel discussion.
The COVID-19 pandemic necessitated changes not just in surgery and hospital operations, but also in how hospitals would gain or maintain their accreditation/verification in ACS Quality Programs. In introducing this session, Clifford Y. Ko, MD, MS, MSHS, FACS, FASCRS, Director, ACS Division of Research and Optimal Patient Care, explained that all in-person site visits for Quality Programs were changed to virtual visits and invited speakers to discuss how virtual visits will look for different programs. Broadly speaking, “Virtual site visits can be less restrictive, refocused, and more illustrative, all while maintaining the essential quality verification process that the ACS is known for,” said Genevieve Ranieri, MSN, RN-BC, Chicago, who discussed how the virtual visits allow hospitals to demonstrate GSV standards in action. Other speakers echoed this sentiment through describing their respective programs.
Virtual site visits for the Children’s Surgery Verification program both required and encouraged flexibility, according to Mary E. Fallat, MD, FACS, Louisville, KY. Discussing the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) experience, Teresa L. LaMasters, MD, FACS, FASMBS, DABOM, Des Moines, IA, suggested that although virtual site visits lose some of the spontaneity of in-person conversation, the virtual visits allows more time for informative conversation between the site surveyor and the program representatives. William H. Marx, DO, FACS, Syracuse, NY, spoke on the development of a virtual site visit plan for trauma verification, which involved creation of a detailed agenda, ensuring reviewer access to the hospital’s electronic medical record, assigning a site visit coordinator to address any issues, and more. The ACS Cancer Programs enrolled 10 hospitals in pilot virtual site visits, performed in July and August, which served as starting points to determine what worked and what needed to change for the initiation of formal site visits to start in Fall 2020, according to Connie Bura, Chicago.
The shift to virtual visits affected programs in development as well, said Amy Robinson-Gerace, Chicago, who described the principles of ACS Quality Verification Program, which are based on Optimal Resources for Surgical Quality and Safety. Ms. Robinson-Gerace spoke on the ongoing pilot testing for the program and explained that verification is being offered virtually, aligning with the ACS’ other Quality Programs. She explained that although the format might be new, the underlying requirements for success are the same—familiarize yourself with the Red Book, assemble your leaders and get buy-in, and then contact the ACS to start your new quality journey.
To access this content through the end of October, visit the ACS Quality and Safety Conference VIRTUAL web page.