More than 5,000 health care professionals and other individuals with an interest in surgical quality and safety participated in the 2021 American College of Surgeons (ACS) Quality and Safety Conference VIRTUAL, July 12–16. This event featured live (later available as recordings) and on-demand content for more than 90 sessions presented by more than 300 quality and safety experts. The conference also featured more than 400 abstract posters and updates to ACS Quality Programs, including the official launch of the ACS Quality Verification Program, future directions for ACS Quality Programs, and more.
“Anyone who works to improve surgical quality and safety is the audience for the Quality and Safety Conference,” said Clifford Y. Ko, MD, MS, MSHS, FACS, FASCRS, Director, ACS Division of Research and Optimal Patient Care, in the conference’s opening session. Dr. Ko noted that the virtual format broadened the scope of attendees to include more domestic and international physicians, nurses, hospital leaders, trainees, and medical students.
This article summarizes some of the notable topics and live sessions presented at the 2021 ACS Quality and Safety Conference VIRTUAL.
Although data-driven progress in outcomes and safety represents the core of surgical quality improvement (QI), it is important to remember that, for patients, the focus is not always on the clinical side. In his keynote address, chef Eduardo Garcia recounted his recovery from a life-altering incident in which he received a 2,400-volt electric shock.
An avid outdoorsman, Mr. Garcia explained how in 2011 he took a solo hunting trip to the Montana woods, near where he grew up and his family resided, walking three miles into an isolated area. While there, he unknowingly plunged a knife into a live electrical current. He was knocked unconscious, and when he awoke, he started to walk back to his car and took stock of his body. His left hand was curled into a tight claw grip with deeply blackened fingers, and he had an electrical blowout wound in his thigh and elbows.
He passed a Samaritan who helped him get medical transport, eventually arriving via Medjet at the burn trauma intensive care unit (ICU) at University of Utah, Salt Lake City. When he arrived and expressed concern about how he would get home that night, Mr. Garcia said a health care worker told him he would be there for more than just one day, “I’ll never forget that moment—he was so kind, so caring, so critically focused on saving my life, but at the same time, brought humanity to the moment of meeting me where I’m at,” Mr. Garcia said.
Although data-driven progress in outcomes and safety represents the core of surgical quality improvement (QI), it is important to remember that, for patients, the focus is not always on the clinical side.
It was the humanity that shone through each of the members of Mr. Garcia’s care team in his 50-day stay and in the following period, in which he would undergo 22 operations, including amputation of his left hand. “There was nothing clinical about it from my point of view. For my surgeons, for the nurses, there was a lot that needed to happen, but what I remember was that right off the bat, I was greeted with these smiles every day,” Mr. Garcia said. “The amount of humanity that the team had below the masks, below the visors, the gloves, the gowns—that was what stuck with me in my ICU stay,” he added, noting that he built a bond with his health care team.
And the ICU staff made Mr. Garcia feel like he was part of the team. “After the first surgery [to repair electrical blowout wounds on both elbows], I wasn’t bound, so I moved my arms afterward and broke the stitches, and wasted that operation,” he recounted. “So, I said, ‘I need you to splint my arms up for however long it’s going to take to heal.’ I remember that moment because I remember thinking, ‘Oh, I’m on a team here.’ It seemed like I was just a patient, without any agency,” but that moment told him he did have a role.
As a patient requiring frequent care, clinical details of the day were ever-present, Mr. Garcia noted. But the humanity his team showed in speaking with him, sharing details of their lives as rock climbers, parents, and children, was the crux of his recovery. “They would bring their character, their actual heartbeats, into the room. It elevated me out of the woe and sorrow of the situation.”
Mr. Garcia said that now, nearly 10 years after the incident and initial treatment, he always remembers the “unsung heroes” of the medical community and his personal caregivers. “They came together to say, ‘You may walk out of the woods solo, but to get back on your feet, we do this together. We do this as a community.’”
Mr. Garcia’s full address is available online at bit.ly/3z2CaIp.
Quality Improvement Basics
Although the ACS houses several resources to help hospitals learn about and implement quality improvement (QI) projects, the complexity of the process called for a more focused didactic experience, according to Lillian S. Kao, MD, MS, FACS, McGovern Medical School, University of Texas Health, Houston. She worked with the ACS to develop the Quality Improvement Course and discussed the accompanying QI Basics session series offered at the Quality and Safety Conference.
Dr. Kao outlined the importance of QI as it related to four concepts. Primarily, it improves patient outcomes by increasing consistency and reducing error. “Although we may debate how many deaths may be attributable to medical errors per year, we can all agree one preventable death is too many,” Dr. Kao said. She then discussed how QI can reduce the gaps in care that can lead to significant patient harm and missed opportunities; how QI can provide a significant return on investment through reduced use of resources, length of stay, and complications, noting that “small per-patient savings can lead to significant savings overall for the hospital;” and how QI helps to satisfy groups that hold external accountability, including governmental health care oversight agencies, and over hospitals by setting standards, providing accreditation, and so on.
With that in mind, “The purpose of the course is to provide a quality improvement education course for practitioners performing or overseeing quality improvement efforts, including surgeons, trainees, residency program directors, and anyone involved in the process,” Dr. Kao said. The course comprises six core modules, including the following:
- Introduction to QI, which covers the rationale for investing in quality of care and fundamental concepts
- The QI process, which covers how QI happens, a generic QI framework, and starting a project
- Data measurement and analysis, which covers the role of different data, common data sources, and tools for display and analysis
- Change management, which covers strategies and challenges for implementing change
- Patient safety, which covers defining patient safety and how to measure it, high-reliability organizations, and safety culture
- The QI team, which covers the importance of teamwork, traits and behaviors of teams, and the role of leadership
Quality Databases in Low- and Middle-Income Countries: Challenges and Opportunities
Building a quality, usable surgery QI database takes considerable effort, even in the best-equipped, well-funded health system, and the difficulty heightens when the setting is in low- and middle-income countries (LMICs). Syed Nabeel Zafar, MD, MPH, University of Wisconsin, Madison, said that the infrastructure for registries is limited in these countries; however, “There is proof that surgical outcome data collection is possible, and there is proof that continuous, systematic data collection for QI is feasible and beneficial to LMICs.” Extant periodic surgical outcome studies and focused QI studies from several LMICs provide a starting point. Maternal mortality is of particular concern in LMICs, according to Bethany Hedt-Gauthier, PhD, Harvard Medical School, Boston, MA, who advised that developing national surgical, obstetric, and anesthesia plans should measure across all quality domains, ensuring data are useful and integrating data generation into existing systems.
David C. Chang, PhD, MPH, MBA, Harvard Medical School, discussed how LMICs can do “less with more” by reducing the costly burden of generating surgery QI data through reducing sampling, variables, and granularity and making sure to rely on more accurate machine-collected variables. To provide a perspective from the front lines in an LMIC, Lillian Mwape, CNO, National Heart Hospital, Zambia, explained how data collection remains a challenge in the COSECSA (College of Surgeons of East, Central and Southern Africa) region, but opportunities exist to grow surgical databases through the use of national investment plans, including data capture as part of health care training programs and implementation of pilot projects to examine the impact of surgical services.
“Whether it’s the vast responsibility of the rural surgeon to care for members of his or her community, to surgical specialists in an academic medical center, to our military physicians deployed, to our surgeons in the lab advancing surgical science, all of us differentiate, but our ‘surgical DNA’ is 95 percent the same,” said L. Scott Levin, MD, FACS, Chair, ACS Board of Regents, in introducing a panel of specialists who shared items of interest from their respective specialties, with the intent of potentially applying lessons learned to other specialties.
In orthopaedic surgery, Philip Wolinsky, MD, FACS, University of California Davis Medical Center, discussed how administrative burden is leading to moral injury and burnout, the effect of quality-of-care metrics from multiple sources that make it challenging to get appropriate data, and the need for mental health resources for patients. Linda R. Duska, MD, MPH, FACS, University of Virginia HealthSystem, Charlottesville, spoke from the perspective of obstetrics and gynecology on how minimally invasive surgery has improved the care of conditions while being a potential step back for others, recent advances in postpartum hemorrhage interventions, and the need to induce intentional culture change to reduce gender discrimination, even with more women surgeons in the workforce.
In thoracic surgery, Mark R. Moon, MD, Washington University School of Medicine, St. Louis, MO, discussed the culture change necessary to improve diversity, equity, and inclusion in the specialty, noting that diversity helps enhance patient outcomes as the result of improved mortality, with gender and racially concordant surgeons leading to improved feelings of trust between patient and surgeon, among other directives such as training to decrease implicit bias and hiring diverse leaders.
Finally, Christopher Saigal, MD, MPH, University of California Los Angeles, spoke from the urologist’s perspective about technical advances, such as use of small access tracts to treat large kidney stones, changes in policy that affect allocation of renal transplant organs to reduce disparities, and application of registry data to improve care at the population level through actionable data specifically meaningful to urologists.
Implementing the Geriatric Surgery Verification Program
As the average age of the U.S. population rises, it is becoming increasingly important that geriatric surgery is performed in a safe, high-quality manner. Dianne Bettick, RN, National Surgical Quality Improvement Program clinical coordinator, Johns Hopkins Bayview Medical Center, Baltimore, MD, outlined the steps to implement the Geriatric Surgery Verification (GSV) standards, which started with the “brass tacks” questions: What is required to meet this standard? Where will the standard be met (preoperative stage, intraoperative, or postoperative)? and the other key “who, when, and how” questions.
As the average age of the U.S. population increases, it is becoming increasingly important that geriatric surgery is performed in a safe, high-quality manner.
Thomas Robinson, MD, MS, FACS, Rocky Mountain Veterans Affairs Medical Center, Aurora, CO, acknowledged that meeting the entire GSV slate of standards is daunting. “Implementing all 33 GSV standards at one time represents an enormous task,” Dr. Robinson said, suggesting that a program focus on one of two strategies: “Either limit the number of specialties or specialists you are aiming to improve, or start with implementation of the specific standards that will mean the most for your hospital.” Either strategy requires an enthusiastic champion—not necessarily a surgeon—to lead implementation, choose a process of high clinical relevance, and select processes that already are partially implemented to build on existing efforts.
Implementing transformative standards can be difficult, according to Matthew P. Schiralli, MD, FACS, Rochester Regional Health, NY, who practices at Unity Hospital—the first Level 1-verified GSV hospital—but it is possible, and important, to transform challenges into successful standard implementation. Dr. Schiralli discussed turning potential sticking points—such as the screening process to meeting GSV standards taking too long on the provider end—into solutions, including simplifying the questions being asked and relying on nurses and other team members to fill in critical patient information.
Quality Improvement Projects on Steroids: Elevating the Bar on QI Projects
What does a high-quality, effective QI project look like from the perspective of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP)? Matthew Brengman, MD, MSHA, FACS, HCA Virginia Health System, Richmond, suggested that teams focus on the beginning and work on choosing a meaningful topic and defining effective project parameters. He said projects should be patient-focused, target a specific clinical outcome based on MBSAQIP data and identify a specific intervention, produce a measurable result, and use the PDSA (plan-do-study-act) methodology to enact the study and find a meaningful result. At project’s end, it is critical to review the success of the intervention and decide how to proceed. “Every time we decide to do something in our program, it’s more work for many people, so you need to pull back on things if they aren’t helpful,” Dr. Brengman said. “Making that thoughtful determination is really important so you’re saving the good stuff and dropping the things that aren’t useful.”
Betsy Felde, RDN, LDN, Northwestern Medicine Huntley Hospital, IL, discussed an enhanced recovery after surgery (ERAS) QI project that was undertaken at her institution to reduce length of stay and reduce postoperative patient returns to the ambulatory surgery clinic for rehydration after weight loss surgery. After meeting with key stakeholders in the metabolic and bariatric surgery (MBS) team, Ms. Felde and team introduced a revised nutrition drink before surgery, patient education protocols on hydration, and postoperative checkup phone calls; afterward, average length of stay dropped by approximately half a day and patients needing to return for hydration dropped from more than 8 percent to approximately 5.5 percent.
In discussing a different MBS project from Banner University Medical Center, Phoenix, AZ, Melissa M. David, DNP, ANP-BC, CNS, FAANP, emphasized the importance of the MBSAQIP Semiannual Report in helping hospitals to review key data and identify areas of need. Using the MBSAQIP standards as a guide, Ms. David and her team at Banner identified needs for various projects and interventions, ranging from implementing a respiratory protocol to eliminate postoperative respiratory arrests to gaining accreditation to perform MBS surgery on children, in addition to adolescents and adults.
Measuring and Reducing Disparities in Cancer Care
Enormous gaps in health care exist for racial minorities in the U.S. compared with their white counterparts, according to Samuel Cykert, MD, professor of medicine, University of North Carolina School of Medicine-Chapel Hill, and are particularly stark in cancer care. Dr. Cykert spoke specifically on the disparities in access to care and mortality for lung cancer for white patients versus Black patients. Dr. Cykert and his colleagues performed a study involving system-level interventions to address gaps in early lung cancer treatment and included implementing a warning system that alerted medical teams when patients missed appointments and feedback from clinical teams regarding completion of cancer treatment according to race, among others. In the intervention group, completion of care dramatically improved for Black patients, as did health outcomes. “We have to remedy a systematic, institutional-level bias, and to do that, we need to work with communities to help understand a solution, because they can tell you [the gaps] they have experienced,” Dr. Cykert said.
Lauren M. Willcox, MD, M. Eng, Emory University Hospital, Atlanta, GA, discussed a project that examined whether Medicaid expansion equalized gaps in post-mastectomy reconstruction, a procedure that has proven to improve quality of life for patients with breast cancer. However, minority women must overcome more barriers to get surgery, including a more common lack of health insurance. Specifically looking at Black women, Dr. Willcox’s research showed that Medicaid expansion reduced but did not erase the gap with white women, which suggests that these disparities are a more complex societal problem.
The coronavirus 2019 (COVID-19) pandemic exacerbated existing disparities in the health care system, according to Shruti Zaveri, MD, MPH, Mount Sinai Hospital, New York, NY, who noted that minority patients felt the effects of these disparities during the pandemic, as there was less opportunity for surgical cancer patients to receive care after New York State lockdowns began and resources were devoted to COVID-19. Dr. Zaveri specifically examined opportunities for surgical oncology patients to transfer to treatment centers outside the virus’s original epicenter, but because of financial, transportation, language, and cultural barriers, only 1 percent were able to successfully move their care.
Though COVID-19 infections and treatment have stressed the U.S. health system in many ways, some of its serious consequences include preventing the public from engaging in common preventive health measures, such as cancer screening.
Best Practices in Improving Surgical Oncology
Six speakers discussed the QI measures or studies their institutions have developed to improve cancer care, as follows:
Maribeth Anderson, MS, University of Maryland, Baltimore, and Washington, DC, Medical Center, spoke on the role of robotic surgery for rectal cancer in a community cancer center.
Combining laparoscopic and robotic surgery into a single “minimally invasive” category, Ms. Anderson and her team’s study found that minimally invasive surgery provides a lower-cost treatment that also improves mortality and reduces postoperative length of stay.
- Katherine Kopkash, MD, FACS, Northshore University HealthSystem, University of Chicago Pritzker School of Medicine, IL, described a study on breast cancer re-excision rates and associated factors. Re-excision is a known risk for breast-conserving cancer surgery, but Dr. Kopkash and colleagues found that there was variability in re-excision rates at her institution on both a per-surgeon and a per-methodology basis; that is, the manner in which re-excision rates are calculated. More standardized decision-making could reduce over re-excision rates, she noted.
- Joseph J. Weber, MD, FACS, Aurora Medical Center Grafton, WI, spoke on his experience establishing and directing a patient-centric, multidisciplinary, high-risk breast cancer prevention and management program. Dr. Weber and his team brought together physicians, imaging specialists, geneticists, dietitians, and other specialists to create a foundation for individualized treatment and patient communication, which since 2019 has helped to identify and direct multiple patients at high risk for developing breast cancer.
- Jodi Selzer, DNP, White Plains Hospital, NY, spoke on the value of prehabilitation for surgical breast cancer patients, specifically focusing on reducing incidence of postoperative upper extremity range of motion (ROM) complications. Ms. Selzer and her team initiated a home-based, seven-exercise regimen in preparing patients to undergo breast cancer surgery. Although the difference was small, this study showed that prehabilitation improved ROM in terms of shoulder flexion, extension, and abduction after surgery.
- Xynyi “Cathy” Luo, MD, Ocshner Health and Tulane School of Medicine, New Orleans, LA, also discussed prehabilitation, but with a focus on patients undergoing Whipple surgery, which often results in slow patient return to baseline functionality, in part because of a risk of complications. After using the ACS NSQIP Surgical Risk Calculator to find an expected risk rate, Dr. Luo and her team initiated a four-week exercise prehabilitation program in a group of 19 patients, the findings of which suggested that prehabilitation moderately lowers risk of serious complications, readmissions, and surgical site infections.
- Garren M.I. Low, MD, MS, University of Texas Health Sciences Center at Houston, spoke on the potential impact of early postoperative mobilization and its effect on head and neck cancer patients. Noting that the literature largely supports mobilization as early as possible after surgery (in line with ERAS protocols), Dr. Low and colleagues performed a retrospective study on three years of data at their hospital, 2017−2020, and found that patients who mobilized earlier than four days after surgery had reduced length of stay and greater likelihood of being discharged to home, compared with patients who mobilized after four days.
Re-Engagement in Cancer Screening in the Era of COVID-19
Though COVID-19 infections and treatment have stressed the U.S. health care system in many ways, some of its serious consequences include preventing the public from engaging in common preventive health measures, such as cancer screening. According to session moderator Elizabeth R. Berger, MD, MS, Yale University School of Medicine, New Haven, CT, common cancer screenings decreased by up to 90 percent as a result of COVID-19 lockdowns, shelter-in-place orders, and patient hesitancy to go to a health care facility.
Kathie-Ann Joseph, MD, MPH, New York University Langone Health, NY, spoke on how her hospital emphasized the importance and supported the work of lay patient navigators, who are suited to establishing a trusting, open relationship with women in the community. Once screening services reopened in 2020, navigators contacted patients on their “gap lists,” engaged patients in conversation about COVID-19 safety measures, and provided appointment scheduling services. These efforts led to a more than 30 percent increase in women screened in 2021. To help provide a baseline understanding of how to measure data in return to screening initiatives or other quality projects, Christina A. Manami, MD, MS, Brigham and Women’s Hospital/Dana Farber Cancer Institute, Boston, MA, described the key elements of the “measure” and “analyze” steps in the DMAIC (define, measure, analyze, improve, control) process for QI.
Heidi Nelson, MD, FACS, Medical Director, ACS Cancer Programs, explained how the ACS and the Commission on Cancer (CoC) launched a national effort to return the nation’s patients to screening in spring 2021. “[The ACS] was ready to take on this project through infrastructural and cultural readiness,” Dr. Nelson said, noting that the College’s Cancer Programs have broad reach through internal programs, such as the CoC and the National Accreditation Program for Breast Centers (NAPBC), as well as partnerships with other organizations. This reach provided a foundation to get the public back to screening. Using a PDSA design paradigm, ACS Cancer Programs and partners developed a series of interventions that cancer centers could choose from to encourage screening, from social media posts and press releases to individual patient outreach. Preliminary data suggest that involved centers could see significant monthly increases in breast cancer, colorectal cancer, lung cancer, and cervical cancer screenings compared with 2020. And the benefits of the project may extend beyond only a return to screening: “Not only are we hoping this [project] will help us close the screening gap, but it may help us identify what interventions are most effective in improving screening rates overall” after the pandemic, Dr. Nelson said.
Incorporating the Patient Journey into Quality Standards
The cancer patient’s journey “is a very intense, emotional experience, from the time of diagnosis all the way through survivorship,” said session moderator and presenter Jill Dietz, MD, MHCM, FACS, Allegheny Health Network Cancer Institute, Pittsburgh, PA, and Chair, NAPBC Standards and Accreditation Committee. Dr. Dietz noted upcoming revisions to NAPBC standards focus on the patient journey, including recommendations that care teams make suggestions on exercise regimens, emphasize shared decision-making, and more.
With patient-centeredness at the heart of the program, formalizing the patient journey into its standards is a natural fit, Dr. Scott Dietz said.
Randy Stevens, MD, White Plains Hospital for Cancer Care, NY, and NAPBC Lead Site Reviewer, further detailed the new NAPBC standards and site review protocols. Most breast centers that seek NAPBC accreditation do so to improve patient care and to standardize care, Dr. Stevens said. Focusing standards to ease the patient into the complicated journey ahead can help centers improve communication, care, and outcomes.
Scott Kurtzman, MD, FACS, University of Connecticut Health Center, Farmington, and NAPBC Chair, described how the new focus on the patient journey in NAPBC standards is a paradigm shift. The program’s early standards were focused on forming a structure of treatment that could reach across all certified centers. However, NAPBC leadership came to realize that the center of the program’s “universe” had become the program itself—not the breast centers and patients that the NAPBC should be serving, according to Dr. Kurtzman. He noted that although this patient focus is a new program goal, the NAPBC still will be aligning with ACS guidance on synoptic reporting, operative standards, and standard structure.
Dr. Jill Dietz spoke with Michelle Bean, PhD, Christus St. Vincent Regional Medical Center, Santa Fe, NM, on Dr. Bean’s experience as a breast cancer patient. Dr. Bean noted that her initial breast cancer diagnosis was only revealed when she examined her own medical chart—a significant failure of communication that started her journey from a subpar position. Dr. Bean explained that patients need strong support, not just from family and friends, but providers as well. “As a patient, when we’re going to each appointment, we’re holding on to every word for that glimpse of hope from our physicians,” she said.
The benefits of incorporating the patient journey in cancer care may reach beyond breast cancer, according to David W. Dietz, MD, University Hospitals Cleveland Medical Center, OH, and member of the National Accreditation Program for Rectal Cancer (NAPRC) Executive Committee. The NAPRC already emphasizes multidisciplinary patient care with the goal of making an individualized care plan for patients. With patient-centeredness at the heart of the program, formalizing the patient journey into its standards is a natural fit, Dr. Scott Dietz said. Shared decision-making can lead to high-value care that benefits all stakeholders, from patients to hospital executives.
The next conference
The 2022 ACS Quality and Safety Conference is scheduled for next July in Chicago.