The ACS Rural Hospital Surgical Verification and Quality Improvement Program

In order to help hospitals in rural America to provide high quality care to surgical patients, the American College of Surgeons is developing the ACS Rural Hospital Surgical Verification and Quality Improvement Program. This program is designed for rural hospitals ranging in size between 25 bed Critical Access Hospitals to 100 bed hospitals. Based on the principles outlined in the ACS book Optimal Resources for Surgical Quality and Safety, otherwise known as The Red Book, this program will serve two functions, first as a Surgical Verification Program, meaning that if a rural hospital meets the standards outlined in the program it will be verified by the ACS, and secondly as a Quality Improvement Program by using data to drive continuous quality improvement and create a culture of patient safety and high reliability.

This program is a verification program, not an accreditation program. This is not a “Pass/Fail”, program, instead it is a program that provides a framework for a rural hospital to continuously improve the way they care for surgical patients. Not all rural hospitals are expected to already meet all of the program standards at the time of their site visit. For standards that are met, the hospital will document how they meet the standard. For standards that aren’t met, the hospital will be expected to submit a plan for how they intend to meet the standard in the future.

Participating rural hospitals will be asked to show how they meet, or how they will work to meet, the following standards:

• Institutional Administrative commitment to the program

• Program scope – This program will oversee all surgical procedures done at a rural hospital. The rural hospital will be required to clearly define the types of surgical patients and conditions that can be safely cared for at their facility. For patients with surgical conditions that fall outside of their defined scope of practice, written transfer agreements to larger hospitals will be developed.

• Facilities and equipment resources – Hospitals will be required to show that they have the proper infrastructure in their ER, OR, PACU, inpatient treatment areas, Laboratory, Blood Bank, Pharmacy, and Radiology Department to care for surgical patients within their defined scope of practice.

• Personnel and services resources – Hospitals will be required to demonstrate that they have qualified surgeons, Nursing services, surgical OR team, On-call coverage, Anesthesia services, and medical specialty services to care for surgical patients within their defined scope of practice

• Patient care – Hospitals will need to have standardized and team-based processes to ensure surgical quality, safety, and reliability in the five phases of surgical care (preoperative, immediate preoperative, intra-operative, postoperative, and post-discharge). Hospitals also need to have programs in place to assure patient education, informed consent, risk assessment and pre-habilitation, infection prevention, rapid response and rescue protocols, enhanced recovery and rehabilitation, discharge planning and social services, and the ability to readmit 24/7.

• Data collection and data surveillance – Hospitals need to have established processes for collecting and using objective clinical data to surveil for and identify potential surgical quality and safety issues.

• Quality Improvement – Hospitals will need to demonstrate that their Case Review, Peer Review, and Surgical Credentialing and Privileging Programs work together to develop a hospital-wide culture of patient safety and high reliability. Proper data collection and analysis will be used to drive continuous quality improvement efforts.

In order for this program to function, good leadership will be essential. A rural hospital will need to appoint people to the following leadership positions: Surgical Quality Officer, Surgery Program Manager, Quality Improvement Practitioner, and Clinical Data Abstractor. A hospital will also need to develop a Surgical Quality and Safety Committee, which will be comprised of the individuals filling the positions mentioned above, along with all surgeons from the hospital, and representatives from Anesthesia, Physicians caring for ICU patients, Emergency Medicine, Nursing (pre-op, OR, PACU, ICU, and post-op units), Hospitalists, and Hospital Administration. This committee includes all members of the hospital team that cares for the surgical patient from the time of their first evaluation to the time of their discharge. With all of the team members and decision-makers in place on the committee, the Surgical Quality and Safety Committee can address almost any issue regarding the surgical patient, such as:

• Case Review

• Peer Review

• Credentialing and Privileging

• Planning, implementing, and executing Performance Improvement Activities and Patient Safety Activities

• Developing, aligning, and implementing Corrective Action Plans

• Monitoring primary data as well as data reports to identify consistent surgical issues

• Coordinating and managing external collaborations in quality and safety

• Establishing quality and safety standards, guidelines, and surgery-related policies

• Fostering, leading, and implementing culture improvement activities in the context of achieving better surgical care and outcomes

Rural hospitals that participate in the ACS Rural Hospital Surgical Verification and Quality Improvement Program can expect to see the following benefits:

• All aspects of surgical care are reviewed by a multidisciplinary team that contains all the members necessary to effect change for the better of the surgical patient

• Based on the hospital’s defined scope of practice for surgical patients and conditions, an accurate plan for current and future hospital infrastructure needs will be clear

• Through transfer agreements, patient transfers will be accomplished more easily, and relationships with larger referral hospitals will be strengthened

• Objective data is used to drive a cycle of continuous quality improvement

• It will help in the recruitment and retention of surgeons

• High quality care of the surgical patient becomes the top priority

• It will help to unify the mission of the hospital board, hospital administration, surgeons, nursing staff, OR staff, and hospital staff in the care of surgical patients

• Care of surgical patients will improve as a result of this program creating a unified team of players (surgeons, OR staff, PACU, anesthesia, ICU, post-op nursing, radiology, laboratory, etc.) with the same goal - providing excellent care to surgical patients

• It will be clear to your community that their hospital is very committed to providing excellent surgical care to patients