Improving Quality and Safety for Surgical Patients

The American College of Surgeons Quality Verification Program (ACS QVP), launched in July at the 2021 ACS Quality and Safety Conference VIRTUAL, will provide a proven, standardized method for establishing, measuring, and improving a hospital’s quality infrastructure across all surgical departments.

ACS QVP is based on 12 program standards, adapted from core elements of the Optimal Resources for Surgical Quality and Safety, or “Red Book.” The program builds on the College’s longstanding commitment to surgical quality by using principles gleaned from experience working with the roughly 3,000 hospitals that participate in ACS Quality Programs. The key principles of ACS QVP are driven by data surveillance and standardized processes and systems to identify problems and improve the quality and safety of surgical patient care.

“The aim of the Red Book is to lay out how to operationally achieve surgical quality and safety for any hospital. ACS QVP serves to help hospitals verify that standards laid out in the Red Book are optimally in place, which is important for hospitals on the surgical quality journey,” said Clifford Y. Ko, MD, MS, MSHS, FACS, FASCRS, Director, ACS Division of Research and Optimal Patient Care.

Many programs effectively capture important data about various aspects of surgical care, but until now, there hasn’t been one that uses evidence-based standards to find, fix, and prevent problems for all surgical patients. ACS QVP has been developed in such a way that hospitals can identify problems with reliable, clinically relevant benchmarked data. Hospitals will have appropriate mechanisms in place to solve their problems along with the underlying infrastructure to communicate findings and prevent future problems. ACS QVP provides the tools for hospitals to develop a standardized approach to surgical care to help reduce complications, minimize waste, and increase the value of surgical care for their patients.

As a roadmap for surgical quality that spans all surgical specialties in a hospital, ACS QVP standards provide a framework for surgery departments to quickly and effectively implement changes, such as the COVID-19 response protocols. Caroline Reinke, MD, FACS, assistant professor of surgery at Atrium Health, Charlotte, N.C., said participation as an ACS QVP pilot site in August 2019 helped her hospital be better prepared for the COVID-19 pandemic due to cross-specialty collaboration and the existence of a surgical quality officer (one of ACS QVP’s 12 program standards).

“We had the opportunity to identify a quality leader within each surgical specialty. When COVID came, we had a defined person to reach out to. They had already been connected to the new surgical quality officer and had an enhanced collaboration from participating in the ACS QVP site visit,” Dr. Reinke said. “We really saw participation in ACS QVP as an opportunity to understand what our current structure was and then we could learn and grow.”

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Verification site visits for ACS QVP-participating hospitals will occur approximately every three years and be conducted by an external peer review team. These site visits help hospitals provide a customized, detailed report that helps hospitals promote their strengths and address areas that need further development.

Baylor University Medical Center, Dallas, Texas, was another ACS QVP pilot site. James Fleshman, Jr., MD, FACS, FASCRS, Sparkman Endowed Professor and Chair in the department of surgery at Baylor, said QVP brought people from across the hospital together around surgical quality.

“The QVP program is unique in that it expects a hospital, including the leadership, culture, and infrastructure, to support quality and safety to cover all surgical services,” Dr. Fleshman said. “I’m very proud of Baylor for stepping up. Having this quality improvement process has changed the way we do business and the way we treat patients, and the ones who benefit are the patients.”

Hospitals participating in ACS QVP benefit from a cost-effective, low-burden method to ensure quality and safety for all surgery patients. Each facility receives a customized report with actionable recommendations for building and improving a surgical quality infrastructure. Recognition as an ACS QVP-participating hospital means patients can be confident that a hospital is committed to high-quality care and a core infrastructure exists that underpins quality across all departments and divisions of surgery.

“The ACS QVP is an opportunity for those who are really trying to provide the best surgical care for patients to take a deep, long, and honest look at themselves with the intent of identifying things that they can work on and improve,” said ACS Executive Director David B. Hoyt, MD, FACS. “None of us have reached the ideal state. We’re all working toward that; in fact, that’s the motivation behind all ACS quality efforts. We think everyone who participates in ACS QVP will benefit from the program.”