COMMENTARY

Achieving High-quality Surgical Care Observations From the American College of Surgeons Quality of Care Programs Clifford Y. Ko, MD, MS, MSHS, Jennifer L. Paruch, MD, and David B. Hoyt, MD

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t is in the best interest for everyone if we can identify ways to improve the quality of care we deliver. Although this issue has been in the spotlight since the 2000 Institute of Medicine report, “To Err Is Human,”1 it has been an issue for far longer. The thoughts of Drs Mehrotra and Dimick are interesting and topical in the current environment. We would like to add to their thoughts, largely based on the 100-year history of the American College of Surgeons (ACS), which has focused on quality of care for the surgical patient, in addition to surgical education, training, and policy. The following are some thoughts on the issue of achieving surgical quality improvement. First, although the authors suggest using outcome measures as a driver for quality in favor of structural or process measures, we believe that no single construct (including outcomes) will likely be sufficient to evaluate and achieve improvement in quality of care. We instead suggest the advantages of incorporating a combination of constructs. More specifically, incorporating meaningful structural, process, and outcome measures would be preferable and, in fact, many (including Dr Dimick’s work with the Leapfrog Group2 ) have supported this idea of “composite” measures being advantageous. Second, in our experience at the ACS, we have found that a good way to operationalize and scale the implementation of composite measures is actually through a well-developed, well-executed accreditation program. In most instances, successful accreditation programs use an array of measures (ie, program standards) that are the evidence-based or thought leader–developed standards (or both) that support the delivery and achievement of better quality of care. One of the longest running ACS programs that has well illustrated this notion is the Committee on Trauma Verification Program. This program is releasing its eighth iteration of Trauma Center Standards, and after hundreds of site visits to verify these standards, the program has demonstrably shown improved commitment and performance at individual centers and proven better outcomes across the population.3 Of course, it is important to recognize that not all accreditation (or Center of Excellence) programs are the same. Certainly, the specific clinical topic areas will lead to variability in the ability of individual accreditation programs to develop meaningful standards. Given the experience, iterative improvements, and lessons learned from the decades of ACS quality programs, we have identified 4 principles that we believe are important for evaluating care and achieving higher surgical quality. In addition, these principles support and align with meaningful accreditation. These 4 principles are (1) setting standards, (2) building the right infrastructure, (3) using data, and (4) verification of these elements. Finally, in our journey toward achieving better care, in 2015, the ACS will release a Surgical Quality Manual that will describe how surgical leaders have attained high-quality surgical care and outcomes. The manual is authored by more than 100 leaders and provides several decades worth of experience, insight, and pearls—and not, coincidentally, supports the use and application of the 4 principles.

REFERENCES 1. Kohn LT, Corrigan JM, Donaldson MS. Institute of Medicine (US) Committee on Quality of Health Care in America. To Err Is Human: Building a Safer Health System. Washington, DC: National Academies Press; 2000. 2. Leapfrog Group. Fact Sheet: Survival Predictor (Surgical Mortality). Available at: http://www.leapfroggroup.org/media/file/FactSheet SurvivalPredictor.pdf. Published March 21, 2011. Accessed October 2, 2014. 3. MacKenzie EJ, Rivara FP, Jurkovich GJ, et al. A national evaluation of the effect of trauma-center care on mortality. N Engl J Med. 2006;354:366–378.

From the American College of Surgeons, Chicago, IL. Disclosure: The authors declare no conflicts of interest. Reprints: Clifford Y. Ko, MD, MS, MSHS, Department of Surgery, American College of Surgeons, 633 N. St. Clair St, Chicago, IL 60611. E-mail: [email protected] C 2014 Wolters Kluwer Health, Inc. All rights reserved. Copyright  ISSN: 0003-4932/14/26102-0240 DOI: 10.1097/SLA.0000000000001070

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Annals of Surgery r Volume 261, Number 2, February 2015

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Achieving high-quality surgical care: observations from the American College of Surgeons Quality of Care Programs.

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