American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

Twelve Standards Create the Foundation for Surgical Quality

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Twelve salient elements of surgical quality have been adapted from the Red Book manual into standards that form the foundation of The ACS Quality Verification Program. These standards span all surgical specialties to provide a roadmap for hospitals to build a successful surgical quality program—by establishing, measuring, and continuously improving their hospital's infrastructure for surgical quality. Standards include detailed resources at both the hospital- and individual specialty-level to guide surgical departments broadly and dive deep into surgical quality in each specialty. Communication flow is an overarching theme, up and down from top-level administrators to front-line staff, as well as across specialties to minimize silos of quality. The ACS Quality Verification Program Standards include the following:

  1. Leadership Commitment and Engagement to Surgical Quality and Safety
    Hospital administrators demonstrate commitment through engaged leadership and financial resources to support surgical quality and ensure alignment with hospital strategic priorities.
  2. Surgical Quality Officer
    A designated, qualified surgeon leader(s) oversees and is accountable for quality across all surgery departments and divisions.
  3. Surgical Quality and Safety Committee
    A committee with representation from all surgical specialties and adjunctive disciplines serves as a forum for surgery-wide quality activities. This committee provides infrastructure that fosters communication across and up and down the institution.
  4. Safety Culture
    Establish a generative safety culture and practice of high-reliability principles that is core to the hospital's mission, embedded and identifiable throughout the institution. There is training and regular formal assessment of the hospital's safety culture at all levels of the institution— from frontline providers to hospital administration—and results drive tailored improvement initiatives and ongoing safety culture education.
  5. Data Collection and Surveillance
    Standardize processes and sufficient resources for collecting, analyzing, and reviewing clinically relevant data (risk-adjusted and benchmarked when available) to monitor and identify potential surgical quality and safety issues at the hospital and individual specialty level. Data are shared regularly with hospital leadership and frontline surgeons and staff.
  6. Continuous Quality Improvement Using Data
    Have dedicated and sufficient resources to support formal quality and process improvement on the basis of high-quality, reliable data at both the hospital and individual specialty level.
  7. Case Review
    Have a standardized, documented process for formal retrospective case review to monitor adverse events, assess compliance with protocols, and identify opportunities for improvement and standardization.
  8. Surgeon Review
    Have standardized processes to monitor and address quality and safety issues with individual surgeon practice through a formal peer review process.
  9. Surgical Credentialing and Privileging
    Have meaningful and thorough processes for credentialing and privileging that ensures all surgeons are qualified and able to provide safe and appropriate surgical care. Includes formal onboarding process with direct observation where appropriate and surgeon leadership involvement in development of specific privileging criteria for complex procedures.
  10. Standardized and Team Based Processes in the Five Phases of Care
    Have standardized processes across all surgical specialties and phases of care (I. Pre-operative, II. Immediate Pre-operative, III. Intra-operative, IV. Post-operative, V. Post-discharge). May include standardized preoperative evaluation and patient optimization procedures, enhanced recovery protocols, geriatric-specific protocols, intraoperative procedures such as timeouts and hand-offs, and discharge and post-discharge protocols to ensure safe pain and wound management, appropriate follow-up, and continuity of care is provided post-operatively.
  11. Disease-Based Management
    Have standardized, evidence-based, multi-disciplinary management of specific diseases. Often referred to as integrated practice units, these units may include multi-disciplinary care bundles for cancer care, joint replacement, colorectal surgery, bariatric surgery, inflammatory bowel disease, etc. Disease-based management programs may be locally developed or through participation in an external disease-specific program.
  12. Compliance with Hospital-Level Regulatory Performance Metrics
    Communicate regulatory performance metrics to front line surgeons and staff to drive awareness and quality improvement initiatives. Effort is made by leadership to balance prioritization of quality improvement based on regulatory metrics and other hospital-identified quality improvement initiatives to ensure both are resourced.