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23 Principles ofPerioperative Safety andQuality ontheGlobal Stage
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The Role oftheAmerican College
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ofSurgeons inAdvancing Perioperative
24
Safety andEfficiency
JuliaR.Coleman andPatriciaL.Turner
Introduction
Since its creation in 1913, the American College of Surgeons (ACS) has been a
long-standing national leader in setting the standard of surgical practice and advocating for optimal patient care. With more than 82,000 members across 130 countries, the ACS has a global legacy of leadership with far-reaching effects on delivery
of patient care and advocacy for surgical quality.
The four key principles of ACS, proposed by the organization’s founders under
the leadership of Franklin Martin, MD, FACS, are to (1) set standards, (2) build an
appropriate infrastructure, (3) collect and analyze data, and (4) verify with outside
experiences [1]. In the spirit of these four principles, in 1913, the ACS implemented
professional and competency standards by establishing medical staff organizations
in hospitals, exclusively acknowledging licensed practitioners in good standing,
mandating regulations and policies regarding professional work, standardizing
medical records, and requiring access to diagnostic and therapeutic resources [2].
Since then, ACS’s mission and advocacy around perioperative safety and quality
have expanded in a new era of rising health care costs and use of quality measure
metrics (Fig.24.1).
The College’s commitment and leadership in this front have been in the form of
standardized national databases for research focused on quality and safety, consensus statements and regulatory measures from collaborative multidisciplinary committees, and formalized educational programming for residents.
J. R. Coleman
Department of Surgery, University of Colorado–Denver, Aurora, CO, USA
P. L. Turner (*)
American College of Surgeons, Chicago, IL, USA
e-mail: pturner@facs.org
© Springer Nature Switzerland AG 2024
J. J. Hoballah et al. (eds.), Principles of Perioperative Safety and Efciency,
https://doi.org/10.1007/978-3-031-41089-5_24
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Fig. 24.1 A depiction of the 100+ year history of quality and safety programs put forth by the
American College of Surgeons. Used with permission from the ACS
J. R. Coleman and P. L. Turner
Perioperative Safety Through Promotion ofEvidence-Based
Practice: American College ofSurgeons Databases
A core mission of the American College of Surgeons has been to collect, analyze,
and disseminate data on perioperative patient care and outcomes to inform evidencebased practice guidelines and standards of care. This has led to the development of
several quality improvement programs with nationwide databases, including the
American College of Surgeons National Surgical Quality Improvement Program
(ACS NSQIP); ACS NSQIP-Pediatrics, Trauma and Quality Improvement Program
(TQIP); National Trauma Data Bank (NTDB); and National Cancer Database. The
mission of promoting evidence-based practices has also spanned beyond the United
States, with several international collaborative databases. These databases have had
wide-ranging effects on various surgical specialties. Beyond promoting guidelines
and standards of care, several courses have been created, including the Advanced
Trauma Life Support (ATLS) course, which presents a concise approach to assessing and managing multiply injured patients.
ACS NSQIP, created by the Department of Veterans Affairs (VA) to compare
risk-adjusted survival outcomes to the private sector and continued through ACS, is
a national, validated, multispecialty outcome-reporting tool capable of assessing
risk-adjusted outcomes, validating interventions, identifying areas for improvement, and promoting best practices and resource allocation [3]. When initially created, data from ACS NSQIP informed evidence-based care practice changes at the
VA, which resulted in reduced morbidity and mortality rates at the VA by 43% and
47%, respectively, from 1991 to 2006 [3, 4]. With the motive to translate the ACS
NSQIP to the civilian and private sector, the ACS and Agency for Health Care
Research and Quality (AHRQ) awarded the Reporting System to Improve Patient
24 The Role of the American College of Surgeons in Advancing Perioperative Safety…
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399
Safety in Surgery grant to 14 private sector hospitals and four community hospitals
to examine risk-adjusted surgical outcomes. These data ultimately resulted in practice changes in reductions in postoperative morbidity, including surgical site infections and renal injury, leading to the ACS NSQIP becoming an open subscription
program. Since its initial development in 1994, ACS NSQIP has expanded to now
allow for predictive models for risk-adjusted 30-day morbidity and mortality in
eight difference surgical specialties (general surgery, vascular surgery, noncardiac
thoracic surgery, orthopedic surgery, urology, plastic surgery, otolaryngology, and
neurosurgery). The culmination of the decades of ACS NSQIP data and the College’s
long tradition of developing successful quality programs for improving surgical
care is The Optimal Resources for Surgical Quality and Safety manual (known as
“The Red Book”). The publication, consisting of information on case review and
peer review, credentialing and privileging, database and registries, and clinical practice guidelines, is the work of more than 100 contributing authors who are advocates
of the health care quality movement. The Red Book now serves as a trusted resource
for surgical leaders seeking to improve patient care in their institutions, departments, and practices.
One of the greatest impacts of ACS NSQIP has been identication of modiable
risk factors, leading to signicant progress in evidence-based practice changes
around perioperative safety in a population-, disease-, and phases of case-based
approach. This has spanned various postoperative safety and quality outcomes
around surgical site infections (SSIs) and sepsis [5–8] as well as urinary tract infections (UTIs) [6, 9, 10], venous thromboembolism [11], hospital length of stay [12–
16], readmissions [17, 18], reoperation rates [11, 19], and mortality [6, 19–23]. The
literature cited here is merely a small sample, with more than 2500 articles included
in PubMed from analyses of ACS NSQIP data, which highlights the true impact and
breadth of reach of ACS-driven education. The ACS NSQIP has become more
developed and sophisticated over the decades, allowing it to more accurately identify hospital rates of outcomes, such as surgical site infections, as compared to the
Centers for Disease Control and Prevention’s National Healthcare Safety Network
(NHSN) [24]. ACS NSQIP also led to the creation of a pediatric-based database,
leading to research surrounding similar perioperative outcomes among neonatal and
non-neonatal patients [25, 26]. This database includes nearly 100 hospitals and has
promoted heightened awareness and data analysis around resource utilization,
value-based metrics, and quality and safety measures [27], from evaluation of programs focused on reducing surgical site infection [28] to tools to predict perioperative morbidity risk factors [29, 30].
Adoption of ACS NSQIP into hospital performance standards and surgeon
benchmarks has ultimately resulted in decreased morbidity and mortality of
patients [31]. For example, Bliss etal. described adoption of surgical checklists for
73 surgeries and compared to 2079 historical control cases and 246 cases without
checklist use; patient cases in which surgical checklists were employed perioperatively had signicantly lower 30-day morbidity and safety-related events (in the
form of surgical site infections and readmissions) [32]. Often, changes in health
care delivery are prompted by the ACS NSQIP semiannual report. After having
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received the semiannual report with identication of their hospital as a high outlier
for postoperative Clostridium difcile infections (CDIs), Turner etal. described
employment of strategies to reduce CDIs in their hospital including antimicrobial
stewardship optimization of preoperative order sets, modication of terminal
cleaning practices, increased hand hygiene and personal protection equipment signage, improved antimicrobial stewardship, education through surgical grand
rounds, and routine data feedback via ACS NSQIP.After implementation of these
strategies, the observed rate of CDIs decreased signicantly from 1.27% to 0.91%
in 1 year alone [33]. In a similar success story of patient-centered, data-driven
change, John etal. described response to ACS NSQIP semiannual report of higher
SSI rates with audits of wound classication and SSIs, ultimately resulting in
improved assessment, standardization, and prompt diagnosis of wound classication [34]. These stories highlight the signicant translational impact of ACS
NSQIP data.
J. R. Coleman and P. L. Turner
Perioperative Safety Through Promotion ofCollaborative
Consensus Statement andNational Recommendations
The American College of Surgeons has a long-standing precedent of establishing
perioperative safety and quality improvement programs, beginning in 1917 with the
creation of what would become the Joint Commission, a system for surveying institutions to determine whether hospitals were complying with College standards of
care [1]. Programs focused on optimal patient care and perioperative safety comprise a myriad of collaborative efforts including, but not limited to, the Commission
on Cancer (CoC), the Committee on Trauma (COT), the American College of
Surgeons Oncology Group, the National Accreditation Program for Breast Centers
(NAPBC), the American College of Surgeons Program for the Accredited Education
Institutes, and the Metabolic and Bariatric Surgery Accreditation and Quality
Improvement Programs.
Developed in the same spirit of ACS NSQIP, the Safety Program for Improving
Surgical Care and Recovery (ISCR) was established in 2019, under the leadership
of the Agency for Healthcare Research and Quality, the American College of
Surgeons, and the Johns Hopkins Medicine Armstrong Institute for Patient Safety
and Quality [35]. This collaborative effort aims to disseminate best practices in
perioperative care to more than 750 hospitals across multiple procedures, from topics spanning postsurgical, specialty-specic pathways to perioperative safety outcome prophylaxis [35]. These best practices have been informed by decades of
research on core surgical components of perioperative safety and quality, including
patient education, bowel preparation, elimination of nasogastric tubes, minimization of surgical drains, early postoperative mobilization and feeding, conservative
uid management, prompt removal of urinary catheters, use of laxative and chewing
gum, surgical site infection reduction bundles, glucose management, and venous
thromboembolism [36–38]. These practice guidelines will ultimately allow for
future evidence-based best practices and benchmarking of institutions across the
nation and across surgical specialties.
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In addition to the interdisciplinary, collaborative efforts of ISCR, the ACS has
released several statements focused on perioperative safety to promote quality and
benchmarking in surgery. In 1996, the ACS Board of Regents released the “Statement
on Principles Underlying Perioperative Responsibility,” which outlined the core
responsibilities of the surgeon to ensure optimal patient care and perioperative
safety in the form of diagnosis conrmation, review of appropriate management
strategies, informed consent, proper preoperative preparation, safe operations, standardized postoperative care, and appropriate follow-up [39].
Beyond the expected conduct of the individual surgeon, the Board of Governors
Surgical Care Delivery Workgroup and the Board of Governors Committee on
Surgical Practice in Hospitals and Ambulatory Settings have issued several ofcial
statements on surgical patient safety focused on teamwork [40]. At the core of
these statements, the ACS encourages health care organizations and hospitals to
develop guidelines to ensure optimal perioperative safety. In 2018, the ACS issued
a revised “Statement on Patient Safety in the Operating Room: Team Care,” in
which a team approach to communication and conduct in the operating room is
encouraged [40]. In their “Statement on Surgical Patient Safety,” the ACS also
promotes adoption of a standardized curriculum developed by the Department of
Defense focused on leadership, situation monitoring, mutual support, and communication: the Team Strategies and Tools to Enhance Performance and Patient Safety
(TeamSTEPPS™) [41].
The focus on teamwork as an essential component of optimal perioperative and
operative care was inspired by the formation of the Committee on Perioperative Care
(CPC) in 2002 and the Council on Surgical and Perioperative Safety (CSPS) in 2004.
CPC, a result of integration of the Committee on Operating Room Environment
(CORE) and the Pre- and Post-Operative Care Committee (PPOC), works collaboratively with several organizations, including the American Society of Anesthesiologists
and the American Association of Surgical Physician Assistants, to serve as the primary
resource to the College on topics concerning perioperative care. Specically, the committee develops and presents information and recommendations related to education,
technology, standards of care, clinical and facilities management, and assessment of
outcomes [42]. Similarly, CSPS includes representatives from the ACS, the American
Society of Anesthesiologists (ASA), the Association of Registered Nurses (AORN),
the American Society of Nurse Anesthetists (ANA), the American Society of Physician
Assistants (AAPA), the American Society of Perianesthesia Nurses (ASPAN), and the
Association of Surgical Technologists (AST) [43]. With the goal of collaborating on
standards and guidelines for safe practice and patient safety, the CSPS has released
several statements including “Statement on Health Care Industry Representatives in
the Operating Room,” “Statement of Blunt Suture Needles,” and “Statement on the
Prevention of Retained Foreign Bodies After Surgery” to promote standardized practices around perioperative safety and quality. CPC and CSPS are only a couple of
exemplary demonstrations of ACS collaboratives, with other ACS partnering with the
American Association for the Surgery of Trauma, the American Society of Breast
Surgeons, the American Society of Transplant Surgeons, the Association of Women
Surgeons, the Association for Academic Surgery, the Association for Surgical
Education, and Eastern Association for the Surgery of Trauma, among others.
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These interdisciplinary, collaborative groups for adult care led to the development of the ACS Task Force for Children’s Surgical Care, a group composed of
leaders in pediatric perioperative medicine, in 2012 [44]. Under the direction of the
ACS and Children’s Hospital Association (CHD), this task force has established
benchmarks and recommendations around perioperative resource utilization and
access and quality improvement and safety, as well as created the Children’s Surgery
Verication and Quality Improvement Program (ACS CSG) in 2017. ACS CSG now
includes more than 125 pediatric surgical programs meeting specic requirements
for leadership and resource availability and continues to expand [44].
J. R. Coleman and P. L. Turner
Perioperative Safety Through Promotion ofResident Education
andCollaboration withACGME
While the American College of Surgeons has centralized its focus around patient
safety, it also recognizes that an integral component of this is through education of
future patient providers, surgical residents. In conjunction with the Accreditation
Council for Graduate Medical Education (ACGME), the ACS has led the movement
toward incorporation of perioperative safety into the curriculum of resident education. The ACGME and the American Board of Medical Specialties (ABMS) have
dened six core competencies for all residents, all of which are essential for patient
safety: (1) medical knowledge, (2) patient care, (3) interpersonal and communication
skills, (4) professionalism, (5) practice-based learning and improvement, and (6)
system-based practice [45]. Innovative curriculum design and promotion have been
led by the ACS around these core competences to promote patient safety. In 2005, the
ACS and Association for Surgical Education jointly co-sponsored a conference
focused on national educational efforts relating to patient safety in surgery [46]. This
conference led to a description of a comprehensive safety-centered curriculum
focused on institutional culture, clinical teaching and learning, team training, simulation exercises, transitions in care, and handling of adverse events and errors.
Aligned with the mission of educating residents about standards of surgical care
and implementation of quality-driven care, the ACS is part of a consortium led by
the American Board of Surgery entitled the Surgical Council on Resident Education
(SCORE). Formed in 2006, this nonprot consortium of leaders in the US surgical
education has a mission of improving the education of residents in general surgery
and related specialties through development of a national curriculum. The SCORE
portal, available to all residents across the country, delivers educational content
across the six clinical competencies mentioned above and spans across patient quality and safety.
ACS recognizes that a core component of resident professional development is
encouraging engagement in the College and nurturing leadership in the realm of
patient quality and safety. The Resident and Associate Society of the American
College of Surgeons (RAS-ACS) is an organization for surgical trainees and young
surgeons within ACS, which provides an avenue for participation in ACS affairs,
fosters development and use of leadership skills in organized surgery, and provides
24 The Role of the American College of Surgeons in Advancing Perioperative Safety…
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403
opportunities for opinions and concerns of young surgeons and trainees to be heard
by ACS leadership. RAS-ACS activities, from journal clubs and hangouts to ACS
Bulletin compositions and advocacy efforts, have focused on quality and safety,
instilling a deep sense of commitment and value for patient quality and safety in the
delivery of surgical care among resident trainees.
In addition to promoting education around perioperative safety in surgical resident curricula, the ACS has also been a leading voice in advocacy for resident
involvement in patient care. Research from the ACS NSQIP database on resident
involvement in patient care indicates longer operative times, but no difference in
perioperative safety outcomes and morbidity and mortality rates, debunking myths
and concerns about patient safety when residents are involved in patient care [47–
50]. For example, in an evaluation of all orchiectomies for testicular cancer in ACS
NSQIP from 2006 to 2013, resident involvement in patient care was associated with
longer operative time, but no difference in length of stay, complications, or mortality [49]. In a study of all thyroid surgeries in 2011 from ACS NSQIP, those with
resident involvement were associated with slightly longer operative time (119min
versus 102min, p<0.001), but unplanned reoperation rate was signicantly lower
in cases with residents, with no difference in overall postoperative complications
[47]. Similarly, in a study of all patients undergoing microsurgical procedures from
2005 to 2012in ACS NSQIP, resident involvement was not a signicant risk factor
for complications, ap failure, bleeding, and unexpected reoperation rates [51].
These studies highlight that resident involvement in patient care is not only safe, but
also benecial to patients. This emphasizes the importance of training residents
with patient-centered, safety-focused curricula.
Conclusion
The American College of Surgeons will continue to be a leader in advocating for
optimal patient care and focus on perioperative safety. This mission involves supporting ongoing database and risk calculator tools likes ACS NSQIP, fostering collaborative, multidisciplinary committees and task forces—in addition to timely and
evidence-based practice recommendations—and promoting resident training centered on perioperative safety and quality. The American College of Surgeons has a
history embedded in the mission of optimal patient care and will continue to lead
the future in patient care quality and safety through standards and performance
benchmarks, data-driven optimization in health care delivery, and excellence in
training.
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