Looking forward – June 2021

David B. Hoyt, MD, FACSThe American College of Surgeons (ACS) has been conducting pilot site visits for the last 18 months at hospitals interested in helping us to advance the ACS Quality Verification Program (ACS QVP) and is on the cusp of launching the program nationwide. More recently, we conducted a site visit to see how hospital systems—conglomerations of several hospitals that are affiliated with a single administrative entity—can receive ACS verification and work more closely together to ensure all their patient populations can have access to quality, safe, and highly reliable care.

What is the ACS QVP?

The ACS QVP is based on Optimal Resources for Surgical Quality and Safety, also known as the Red Book—the surgical quality how-to manual gleaned from the knowledge of hundreds of surgeon content experts and the ACS’ experience working with the 3,000 hospitals that participate in ACS Quality Programs, including the ACS National Surgical Quality Improvement Program (ACS NSQIP®), as well as programs in trauma, bariatric and metabolic, geriatric, and pediatric surgery, and cancer. The manual establishes an overarching framework to ensure quality resources and infrastructure to improve care for all surgical patients.

The ACS QVP takes core elements of the Red Book to establish standards and a process for verification that aims to create a surgical quality program that improves efficiency, care, and value for all surgical patients across all divisions of surgery within the hospital.

Twelve salient elements of surgical quality have been adapted from the Red Book into standards that form the foundation of the ACS QVP. These standards span all surgical specialties to provide a blueprint for hospitals and hospital systems to build a successful surgical quality program by establishing, measuring, and continuously improving their hospital’s infrastructure. The ACS QVP standards are as follows:

  • Leadership commitment and engagement to ensure surgical quality and safety
  • A designated Surgical Quality Officer who is accountable for quality across all surgery departments and divisions
  • A Surgical Quality and Safety Committee with representation from all surgical specialties and adjunctive disciplines, which serves as a forum for surgery-wide quality activities and provides an infrastructure that fosters communication throughout the institution
  • A safety culture and practice of high-reliability principles that is at the core of the hospital’s mission, embedded and identifiable throughout the institution
  • Standardized processes and sufficient resources for collecting, analyzing, and reviewing clinically relevant data (risk-adjusted and benchmarked when possible) to monitor and identify potential surgical quality and safety issues at the hospital and individual specialty level
  • Continuous quality improvement using data
  • A standardized, documented process for formal retrospective case review to monitor adverse events, assess compliance with protocols, and identify opportunities for improvement and standardization
  • Standardized processes to monitor and address quality and safety issues with individual surgeon practice through a formal peer review process
  • Meaningful and thorough processes for credentialing and privileging that ensure all surgeons are qualified and able to provide safe and appropriate surgical care
  • Standardized and team-based processes in the five phases of care (preoperative evaluation, immediate preoperative, intraoperative, postoperative, postdischarge)
  • Standardized, evidence-based, multidisciplinary management of specific diseases
  • Compliance with hospital-level regulatory performance metrics

The ACS QVP is designed to establish a comprehensive surgical quality program at both the hospital level and across hospital systems and networks. Participating hospitals have found this verification process to be invaluable in establishing and improving their organizational infrastructure for surgical quality.

What a site visit entails

Our goal with the ACS QVP site visits is to partner with hospitals and health care systems to help ensure they have the resources necessary to succeed on their quality improvement journey. Then the participants can use the information garnered from the experience to work with the C-suite to attain the equipment and personnel needed to meet the ACS’ standards.

The ACS QVP offers four options for individual hospitals and hospital systems to participate in quality improvement. They are as follows:

  • ACS QVP Focused Verification: These site visits are approximately five hours long and are intended for small to midsize hospitals that do not serve as tertiary or quaternary referral centers and encompass a limited number of surgical specialties in addition to general surgery. Also eligible for this level of verification are midsize to large tertiary or quaternary care referral hospitals that are highly matrixed with several surgery departments or specialty divisions that are in the early stages of developing an overarching surgical quality infrastructure. For institutions of this size and complexity, these visits are intended to serve as a precursor to an ACS QVP Comprehensive site visit. Hospitals that participate in other ACS accreditation or verification programs may request that the visit be conducted in tandem with another ACS verification site visit, such as those for Cancer, Bariatrics, or Trauma, or as standalone visit.
  • ACS QVP Focused Verification for ACS NSQIP Hospitals: These site visits are similar to the ACS QVP Focused Verification visits described previously; however, areas of focus will be driven by the hospital’s ACS NSQIP data, and there will be specific discussion and emphasis on how the use of ACS NSQIP data can be used to drive improvement.
  • ACS QVP Comprehensive Verification: These site visits are approximately 10 hours long and include individual meetings with each surgical specialty chief and are intended for midsize to large tertiary or quaternary referral hospitals that are highly matrixed with several departments or specialty divisions that have already begun development of an overarching surgical quality infrastructure. During these visits, reviewers do a deep-dive assessment into each of the surgical specialties to evaluate for both vertical and horizontal integration of the model for surgical quality.
  • ACS QVP System Verification: In addition to each hospital being assessed for either ACS QVP Verification or Comprehensive Verification, we have a four-hour discussion and feedback session with system-level leadership. This level of verification is intended for hospital systems that have begun or intend to organize and align elements of the surgical quality infrastructure across affiliates. Each participating hospital receives an individualized report in addition to a system-level report detailing strengths and opportunities for future development of surgical quality infrastructure across the system.

In February, we piloted the System Verification site visits at a suburban hospital system composed of five hospitals. The largest hospital was evaluated for Comprehensive Verification, and the other four were evaluated for Focused Verification. We then met with the health care system’s leadership.

More specifically, we reviewed the system, hospital, and specialty prereview questionnaires (PRQs) submitted before the virtual site visit; requested documentation submitted with the PRQs; and reviewed patient charts submitted in advance of the visit. Over the course of four consecutive days, we interviewed approximately 50 leaders from across the entire hospital system.

Our goal with the ACS QVP site visits is to partner with hospitals and health care systems to help ensure they have the resources necessary to succeed on their quality improvement journey.

Forging ahead

The goal of the ACS QVP Verification process is to help hospitals and hospital systems find their own problems, fix their own problems, and prevent problems from reoccurring. The reports generated through the site visits, which for the past year have been taking place virtually because of the coronavirus 2019 pandemic, are designed to provide meaningful feedback using the 12 ACS QVP standards. Hospitals, health systems, and individual surgical specialty leaders can use the reports to identify strengths and opportunities for improvement. The reports, in short, can provide a road map for future development and alignment of the surgical quality and safety infrastructure. We recommend broad distribution of the findings to all relevant stakeholders at all levels of the institution to guide discussion and strategic planning as it relates to building out a surgical quality infrastructure.

The ACS presents these reports to support continuous quality improvement for hospitals at all phases of their surgical quality improvement journey, based on our belief in the value of ongoing pursuit and assessment by an external peer group to achieve the highest quality and safety for surgical patients. The ACS QVP is designed to be continuous, with follow-up site visits and evaluation approximately every three years.

Our target date for formally launching the ACS QVP is this summer. All hospitals are encouraged to participate in the ACS QVP to ensure they are delivering optimal care that meets the highest standards to their patients. For hospitals participating in ACS NSQIP, a special opportunity will be announced at the 2021 ACS Quality and Safety Conference VIRTUAL, July 12–16. Stay tuned for more details.





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