Journal of Pediatric Surgery 49 (2014) 25–28

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Journal of Pediatric Surgery

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Journal of Pediatric Surgery Lecture

100 Years of inspiring quality at the ACS: How did we get here?

David B. Hoyt a,⁎, Diane S. Schneidman b

a American College of Surgeons, 633 North Saint Clair Street, Chicago, IL 60640, United Statesb Division of Integrated Communications, American College of Surgeons

a b s t r a c ta r t i c l e i n f o

⁎ Corresponding author. Tel.: +1 312 202 5305.E-mail address: dhoyt@facs.org (D.B. Hoyt).

0022-3468/$ – see front matter © 2014 Published by Ehttp://dx.doi.org/10.1016/j.jpedsurg.2013.09.026

Article history:Received 10 September 2013Accepted 30 September 2013

Key words:QualitySurgical standardsRegistriesVerification

Throughout its 100-year history of working to ensure that surgical patients receive safe, high-quality, cost-effectivecare, the American College of Surgeons has adhered to four key principles: (1) Set the standards to identify and setthe highest clinical standards based on the collection of outcomes data and other scientific evidence that can becustomized to each patient's condition so that surgeons can offer the right care, at the right time, in the right setting.(2) Build the right infrastructure to provide the highest quality care with surgical facilities having in placeappropriate and adequate staffing levels, a reasonable mix of specialists, and the right equipment. Checklists andhealth information technology, such as the electronic health record, are components of this infrastructure. (3)Collect robust data so that surgical decisions are based on clinical data drawn frommedical charts that track patientsafter discharge from thehospital. Data should be risk-adjusted and collected in nationally benchmarked registries toallow institutions to compare their care with other providers. (4) Verify processes and infrastructure by having anexternal authority periodically affirm that the right systemsare inplace at health care institutions, that outcomes arebeing measured and benchmarked, and that hospitals and providers are proactively responding to these findings.

lsevier Inc.

© 2014 Published by Elsevier Inc.

For 100 years, the American College of Surgeons (ACS) – theworld's largest professional organization representing surgeons of allspecialties – has sought to raise the standards of surgical practice andthereby improve the care of surgical patient. The College's commit-ment to quality patient care is reflected in the many programs andactivities that the organization has developed and implemented in thelast century.

These efforts are deeply rooted in four key principles proposedby the College's founders under the leadership of Franklin H. Martin,MD, FACS—set standards, build an appropriate infrastructure, collectand analyze data, and verify with outside experts. With these

concepts serving as guideposts, ACS programs have improvedquality in trauma and cancer care, bariatric surgery, and surgicalcare as a whole.

These principles and programs are particularly relevant acentury later as the nation attempts to create a value-based healthcare system that will address two key challenges: improvinghealth care quality and reducing spending. To raise awarenessabout the College's quality improvement programs, the ACSlaunched the Inspiring Quality initiative in 2011. This ongoingprogram centers on the presentation of ACS Surgical Health CareQuality Forums across the country. Our goal is to encourage anational conversation during which the College would educatepolicymakers, legislators, and other stakeholders about what theorganization has learned about successful quality improvement. Atthe same time, we anticipated learning from them about the rolethat the ACS and surgeons can and must play as the nation movesforward with health care reform.

1. Our guiding principles

Throughout its 100-year history of working to ensure that surgicalpatients receive safe, high-quality, cost-effective care, the College hasadhered to four key principles:

1. Set the standards: Identify and set the highest clinicalstandards based on the collection of outcomes data and otherscientific evidence that can be customized to each patient'scondition so that surgeons and other health care providers canoffer the right care, at the right time, in the right setting.

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2. Build the right infrastructure: To provide the highest qualitycare, surgical facilities must have in place appropriate andadequate staffing levels, a reasonable mix of specialists, and theright equipment. Recently, checklists and health informationtechnology, such as the electronic health record, have becomeintegral components of this infrastructure as well.

3. Collect robust data: As Ernest A. Codman, MD, FACS,controversially proposed during the College's infancy, medicaland surgical decisions should be based on clinical data drawnfrommedical charts that track patients after discharge from thehospital. These outcomes data should be risk-adjusted andcollected in nationally benchmarked registries to allow in-stitutions to compare their care with that provided at otherhealth care facilities.

4. Enlist a third party to verify processes and infrastructure:Allow an external authority to periodically affirm that the rightsystems are in place at health care institutions, that outcomesare being measured and benchmarked, and that hospitals andproviders are proactively responding to these findings.

The College has found that when these four guiding principles areimplemented, a continuous loop of quality improvement develops forphysicians and hospitals, which leads to provision of better care andlower costs.

2. Quality improvement programs: A lasting legacy

The College's first initiative developed with these values in mindcentered on the establishment of minimum standards for hospitals in1917 and a system for surveying institutions to determine whetherthey were complying with these guidelines (a program that evolvedinto what is now known as The Joint Commission). Another earlyeffort in this arena was the creation of a bone sarcoma registry that Dr.Codman created in the 1920s.

Since then, the ACS has implemented increasingly sophisticatedcontinuous quality improvement (CQI) programs that have beenproven to be effective in delivering optimal, cost-effective care to thesurgical patient. Examples, in chronological order, are as follows:

• The Commission on Cancer (CoC) was founded in 1922 incollaboration with the American Cancer Society and otherprofessional organizations to improve survival and quality oflife for cancer patients through standard-setting, prevention,research, education, and monitoring of comprehensive treat-ment strategies. CoC-accredited institutions report their out-comes to the National Cancer Data Base, the largest clinicalregistry in the world.

• The Committee on Trauma (COT) established in 1950 toimprove all phases of care for injured patient. It evolved fromthe Committee on Treatment of Fractures, established in 1922.The COT issues guidelines for the prevention of traumaticinjuries, sets protocols for the provision of safe and effectivetrauma care, and establishes standards for trauma centerverification. In addition, the COT manages the National TraumaData Bank (NTDB®) – the largest aggregation of U.S. traumaregistry data – which issues annual adult and pediatric reports.The COT's recently established Trauma Quality ImprovementProgram (TQIP®) provides risk-adjusted benchmarking to tracktrauma patient outcomes.

• The American College of Surgeons Oncology Group launchedin 1998 to conduct clinical trials in cancer care. This group is nowpart of Alliance for Clinical Trials in Oncology and is known as theACS Clinical Research Program.

• The ACS took responsibility for bringing the Department ofVeterans' Affairs National Surgical Quality Improvement Pro-gram into the private sector in 2004 as ACS NSQIP®. Thisprogram is the first CQI initiative to use nationally validated,

risk-adjusted outcomes to measure and enhance the quality ofsurgical care. More recently, the ACS collaborated with theAmerican Pediatric Surgical Association to develop ACS NSQIPPediatric, which enables approximately 50 participating chil-dren's hospitals to collect highly reliable clinical data points andcompare their surgical outcomes with those of other participat-ing institutions.

• The National Accreditation Program for Breast Centers(NAPBC®) launched in 2005 and is an ACS-administeredconsortium of national professional organizations dedicated toimproving the care of patients with breast disease throughongoing evaluation every three years.

• The American College of Surgeons Program for the AccreditedEducation Institutes was initiated in 2008 to develop a globalnetwork of regional education institutes to improve surgicalquality through innovative education and training and thedevelopment of standards and metrics.

• The ACS administers the Metabolic and Bariatric SurgeryAccreditation and Quality Improvement Program (MBSAQIP).This initiative is the product of 2012 agreement to combine ACSBariatric Surgery Center Network Accreditation Program (estab-lished in 2005) verification activities with those of the AmericanSociety of Metabolic and Bariatric Surgery. To be accredited,bariatric surgery centers must maintain certain physical andhuman resources, report their patient outcomes to the ACSBariatric Surgery Database, and undergo peer evaluation.

We have considerable evidence that these programs are effectiveand enable the College to carry out its mission of providing surgeonswith the tools, measures, and standards of care needed to deliveroptimal care to their patients. Perhaps most significantly, a 2009study in Annals of Surgery concluded that ACS NSQIP-participatinghospitals have successfully used the program to prevent 250–500complications and save 13–26 lives at each institution. At an averagecost of $11,000 per complication, this program, if implemented inevery hospital throughout the nation, would save the U.S. $13 to $26billion annually with total estimated savings over a decadeapproaching $260 billion [1]. Another study indicated that patientswho receive care at the more than 300 COT-approved trauma centershave mortality rates that are 25% lower than those treated atundesignated hospitals [2].

Quality is measurable, and data analysis reveals scientifically validprotocols for improving care. When health care professionals andinstitutions follow and maintain these standards, patient careimproves and costs go down. It's that simple.

3. Inspiring quality tour

In 2011, the College leadership determined the time was ripe toshare this message with all stakeholders and embarked on a nationalInspiring Quality tour inMay 2011. Our first stopwasWashington, DC,where ACS leaders met with legislators and regulators to inform themof how the College's quality improvement programs may be used inthe development of a value-based health care delivery system.Participants, with their titles at the time, are listed in Table 1.

It was a time of change in Washington, as policymakers weregrappling with the implementation of the Affordable Care Act, whichwas enacted in 2010 with the objectives of improving quality,constraining spending, and expanding access to care. We believe themembers of Congress and senior congressional advisors with whomwe met grasped how the College's quality improvement programscould be used to help foster a safer, more effective health caresystem. They made clear to us that our message is resonating inWashington, DC.

From June 2011 to January 2013, 95 surgeons and other health careleaders had spoken at the forums to a combined audience of more

Table 1ACS leaders who traveled to Washington, DC.

Dr. Britt, ACS PresidentDr. Pellegrini, Chair, ACS Board of RegentsDon E. Detmer, Medical Director, Division of Advocacy and Health Policy (DAHP)Dr. Ko, Director of ACS NSQIP and the Division of Research and Optimal Patient CareFrank G. Opelka, MD, FACS, Associate Medical Director of the DAHPACS advocacy staff, including Dr. Hoyt, ACS Executive Director, and ChristianShalgian, Director of the DAHP

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than 1300 people (including those who participated via live stream orconference call). Each of these ACS Surgical Health Care QualityForums had a unique theme and focus. These meetings can besummarized as follows:

• July 18, 2011: L.D. Britt, MD, MPH, FACS, FCCM, FRCS(Eng)(Hon),FRCS(Ed)(Hon), FWACS(Hon), the immediate Past President ofthe ACS, and I hosted a session at the College's headquarters inChicago, IL. U.S. Sen. Mark Kirk (R-IL) provided the keynoteaddress, and a panel of surgeons from local medical centersdiscussed how the information gleaned from ACS qualityprograms can used to create the culture changes necessary toachieve sustained performance improvement. An estimated 500Americans viewed the event information and live stream on theACS website.

• August 30, 2011: The College presented a forum at JohnsHopkins University School of Medicine in Baltimore, MD, withU.S. Sen. Ben Cardin (D-MD) providing the keynote address.Current ACS Board of Regents Chair Julie A. Freischlag, MD, FACS,hosted, and health care leaders from throughout Marylanddescribed how ACS tools play an important role in thedevelopment of innovative quality programs.

• March 2, 2012: At Scripps Memorial Hospital in La Jolla, CA, apanel of experts representing San Diego area institutions led adiscussion titled Inspiring Quality in Surgical Health Care —

Quality Improvement Programs that Improve Outcomes andReduce Costs. A. Brent Eastman, MD, FACS, the College'sPresident, moderated the program, which focused on the criticalelements of successful quality programs.

• April 11, 2012: The ACS hosted aviation industry leaders inSeattle, WA. This event focused on how the aviation industry hasused checklists, standardization, culture shifts, and transparencyto improve flight safety and how those processes may be used insurgery to improve patient safety and reduce unnecessary costs.Carlos A. Pellegrini, the current ACS President, hosted the event,and U.S. Rep. JimMcDermott (D-WA) provided opening remarks.

• June 4, 2012: A panel of experts gathered in Boston, MA, todiscuss the College's proposition that quality surgical care notonly yields better patient outcomes, but also better financialoutcomes. This forum featured keynote speaker Stuart Altman,PhD, economist and health policy expert and The Sol C. ChaikinProfessor of National Health Policy at The Heller School for SocialPolicy and Management at Brandeis University, Waltham, MA.Andrew L. Warshaw, MD, FACS, Chair of the ACS Health Policyand Advocacy Group, and ACS Regent Michael J. Zinner, MD,FACS, hosted.

• August 3, 2012: We traveled to Chattanooga, TN, for the 2012Tennessee ACS Annual Chapter Meeting. This session highlightedthe Tennessee Surgical Quality Collaborative — the first ACSNSQIP collaborative to form a three-way quality improvementrelationship between hospitals, payors, and surgeons. The forumfeatured keynote speaker State Sen. Bo Watson (R), and washosted by Joseph B. Cofer, MD, FACS, professor and residencyprogram director, department of surgery, University of Tennes-see College of Medicine-Chattanooga.

• September 10, 2012: During a forum in Houston, TX, keynotespeaker U.S. Rep. Sheila Jackson Lee commended the ACS forproactively working to improve health care quality and urgedsurgeons and physicians to be involved in health care policydiscussionsmoving forward. ACS Regent H. Randolph Bailey, MD,FACS, cohosted the program with Barbara Lee Bass, MD, FACS, aformer ACS Regent.

• October 12, 2012: At a forum in Philadelphia, PA, keynotespeaker U.S. Rep. Jim Gerlach (R) encouraged surgeons to addtheir knowledge to the health care policy process and ensure theright programs are implemented or sustained to most effectivelyimprove care and reduce costs. Cohosting the event wereMarshall Z. Schwartz, MD, FACS, and Howard M. Snyder III,MD, FACS, both ACS Regents.

• November 16, 2012: Multiple stakeholders examined thechallenges and benefits of implementing data-driven healthcare initiatives at a program presented in New York, NY. FabrizioMichelassi, MD, FACS, Lewis Atterbury Stimson Professor andchairman, department of surgery, and surgeon-in-chief, NewYork-Presbyterian/Weill Cornell Medical Center, hosted.

• December 12, 2012: Held at the American Cancer Societyheadquarters in Atlanta, GA, this forum highlighted preventionand partnerships as key components of transforming the healthcare system. LaMar S. McGinnis, Jr., MD, FACS, ACS Past-President,and John Sweeny, MD, FACS, W. Dean Warren DistinguishedProfessor of Surgery at Emory University in Atlanta cohosted.

• January 23, 2013: Held at Rollins College in Winter Park, FL, thisforum featured a variety of health care perspectives and focusedon achieving higher quality health care through a systemsapproach. John P. Rioux, MD, FACS, an ACS Governor, and JosephJ. Tepas III, MD, FACS, FAAP, professor of surgery and pediatrics,University of Florida College of Medicine-Jacksonville, hosted.

Through these programs, the College was able to inform policy-makers and the public of the College's enduring commitment to data-driven quality improvement, with ACS Fellows sharing researchfindings and case studies illustrating the correlation between betterquality and lower costs. However, the forums also provided theCollege's leadership with opportunities to hear from surgeons andstakeholders about what quality means to them and how the ACScan assist them in their efforts to deliver high-quality care.Through this process we learned six key lessons (Table 2), whichare described below.

4. Six key lessons

1. The future of medicine is dependent on quality: The policy-makers, regulators, payers, and hospital administrators thatparticipated in these forums clearly are seeking means ofreducing health care spending and variations in care. The ACSregistries and databases described previously have proven to beeffective instruments for achieving these goals. As SenatorCardin, who participated in our Baltimore program said of ACSNSQIP, “The $250 billion dollars in cost savings caught myattention—that and lives saved. That's a lot of money. That couldgo a longway in dealing with costs in health care, and that's justsurgery.” So, surgeons and our efforts to develop and applyscientifically reliable clinical data can play an important role inimproving the nation's health care system.

2. Quality is measurable: A number of representatives fromsurgical institutions participating in the Quality Forumsindicated that they are effectively using ACS NSQIP and otherquality improvement programs to arrive at best practices. Theyfurther indicated that implementation of high-reliability sys-tems of care enabled them to reduce significantly the rate ofcomplications in their hospitals significantly.

Table 2Lessons learned.

Quality improvement is the future of medicineQuality is measurableHigh-quality data are essential for quality improvementQuality thrives in a supportive cultureCollaboration spurs innovation and higher qualitySurgeons must lead on quality: in the OR, On Capitol Hill, and in the classroom

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For example, at the New York forum, Alfons Pomp, MD, FACS,FRCSC, chief of laparoscopic and bariatric surgery at New York-Presbyterian/Weill Cornell Medical Center, described his hos-pital's use of an in-house data collection system and ACS NSQIPto track complications and interventions. They found thatalthough their mortality rate was relatively low, their morbidityrate was rather high due to surgical site infection (SSI),particularly among colorectal patients. The hospital formed acommittee that developed protocols for skin prep, administra-tion of prophylactic antibiotics, and documentation of dosinginformation. As a result, the medical center has cut SSI forcolorectal procedures by more than 50%.

3. High-quality data are essential: Hospitals are increasinglyusing ACS NSQIP and other ACS quality improvement programsto set quality targets, measure performance, and uncover areasof concern. Speakers repeatedly emphasized the importance ofproviding surgeons and surgical teams with risk-adjusted,verified, clinical data for tracking the results of qualityinitiatives and benchmarking against a national standard.They noted that surgeons and other members of the operatingroom teams at their institutions have been willing to changehow theyworkwhen they are presentedwith performance datathat they trust.At the New York forum, Clifford Y. Ko, MD, MS, MSHS, FACS,Director of ACS NSQIP and the ACS Division of Research andOptimal Patient Care, pointed to a study that the Collegeconducted with the Centers for Medicare & Medicaid Services,comparing ACS NSQIP data with claims data. The study showedthat claims data yielded a high percentage of false positives forcomplications. Similarly, correlation when ranking hospitalsbased on clinical versus claims data was poor, underscoring theimportance of knowing the source of the data when makingclinical decisions [3].

4. Supportive culture needed: Studies have consistently shownthat evidence-based care delivered by high-performance teamsresults in better patient outcomes. Hospitals and surgeonsshared their experiences with instilling teamwork, fostering aquality-centered mindset, and creating culture change.During the Chicago Quality Forum, Nathaniel Soper, MD, FACS,surgeon-in-chief at NorthwesternMemorial Hospital noted thathis institution was “an early adopter of ACS NSQIP, and weknew that to improve outcomes, a culture change wasnecessary.” He went on to say that by developing a quality-driven culture, Northwestern Memorial saw an 80% reductionin adverse events and a 30% decline in liability claims.

5. Power of collaboration: National and state-level collaborativeefforts have enabled insurers, health care professionals, medicalinstitutions, and government agencies to share data and work

together to improve quality of care. Speakers at our WashingtonState forum discussed the Surgical Care Outcomes AssessmentProgram (SCOAP)—a voluntary, clinician-led, collaborative thatincludes insurers, policymakers, professional organizations,physicians, nurses, hospitals, and the ACS Washington StateChapter. In addition, David R. Flum, MD, MPH, FACS, associatechair for research and surgery and professor of surgery, healthsciences, and pharmacy at the University of Washington, Seattle,described the state's Comparative Effectiveness Research Trans-lation Network (CERTAIN). This network creates a “learninghealth care system,” Dr. Flum said, by linking data from medicalrecords, insurance claims, patient surveys, and so on, to helpSCOAP hospitals assess the long-term effects of care complica-tions in patients and the health care system.The positive effect of other state-level collaborative qualityimprovementprograms, including theTennessee Surgical QualityCollaborative and the Florida Surgical Care Initiative, also wasdiscussed during tour stops in Chattanooga and Winter Park,respectively.

6. Surgeons must lead: Continuous surgical quality improvementrequires surgeon leadership not only within our institutions,but within our halls of government as well. Federal agencieswant feedback on how regulation affects medical and surgicalpractice. Members of Congress want to hear from surgeonsregarding how legislation affects patient care. Policymakers areinterested in learning how quality improvement initiativesreduce spending and in exploring opportunities for collabora-tion. And, as we look toward the future of surgery, surgeonsneed to instill a quality focus in their medical students andtrainees.During the Boston program, Dr. Altman reinforced the need forsurgeon involvement in the formulation of health systemreform. He noted, “In the past, we didn't include physiciansand surgeons in discussion on how to fix the American healthcare system because we thought they were part of the problem—a big mistake. We need them as part of the solution becausethey are American health care.”

5. Moving forward

As the American College of Surgeons enters its second century, welook forward to learning more about what programs and activities wecan offer to further inspiring all stakeholders to improve quality andreduce costs so that all Americans receive optimal care. As always, welook forward to collaborating with other professional organizations,members of Congress, policymakers, insurers, and, of course, patientsto bring about meaningful change. Together, we can set the standards,build the infrastructure, collect the data, and carry out theaccreditation procedures needed to take patient care to the next level.

References

[1] Hall BL, Hamilton BH, Richards K, et al. Does surgical quality improve in theAmerican College of Surgeons National Surgical Quality Improvement Program? Anevaluation of all participating hospitals. Ann Surg 2009 Sep;250(3):363–76.

[2] MacKenzie EJ, Rivara FP, Jurkovich GJ, et al. A national evaluation of the effect oftrauma-center care on mortality. N Engl J Med 2006;354(4):366–78.

[3] Lawson EH, et al. A comparison of clinical registry versus administrative claims datafor reporting of 30-day surgical complications. Ann Surg 2012;256(6):973–81.