Although the Institute of Medicine included equity as a domain of healthcare quality more than 20 years ago, progress toward ensuring equitable care in the US has been slow and uneven. At a Wednesday panel session, health equity experts discussed why and how equity can be integrated into surgical QI.
In discussing the ACS’ role in promoting equity in health, Bonnie Mason, MD, FAOOS, ACS Medical Director of Diversity, Equity, and Inclusion (DEI) made clear that it is in service the College’s broader mission.
“Our highest priority at the College is surgical excellence for our patients,” Dr. Mason said, “and when we talk about equity, it is necessary to achieve excellence.”
She noted that while the diversity in DEI tends to receive significant attention, the College aims to also foster the “inclusive excellence,” where “anybody who identifies from a diverse background in any number of areas is included in the work – rural hospitals and patients, those who have language needs, and beyond.”
To that end, the new ACS Equity in Quality Initiative will bring together the DEI office and Division of Research and Optimal Patient Care to create equity standards for ACS Quality Programs.
The ACS also should look to another framework for surgical quality improvement, according to panelist Ronald Wyatt, MD, MHA, chief science officer for the Society to Improve Diagnosis in Medicine – the Quintuple Aim, which builds on the well known Tiple Aim for improving the US health system by addition of addressing wellbeing as well as equity.
“You have to commit to crossing the Rubicon” of hesitation or inaction “to get to the Quintuple Aim,” Dr. Wyatt said. “We can’t pick and choose what aims are easiest – you need to commit to all of them.”
Dr. Wyatt framed his discussion through the lens of safety and equity, suggesting that there is no patient safety without equity; no patient equity without safety; and that equity cannot be assumed, it must be worked toward.
And healthcare equity is vital, as Black and brown patients suffer its lack most severely. Inequity is an unsafe condition that leads to adverse events, harm, and death, he said, but noted that surgeons “have the influence and capability to commit to abolishing inequity from healthcare.”
Returning on Wednesday for the panel session, Dr. Okanlami continued a discussion on the themes he explored in his Keynote Address to speak on the needs of the disabled community.
As a Black disabled individual, Dr. Okanlami said that he understood the difficulties of finding a sense of place or authority in a health system, even if you are familiar with it.
“When you come into a system that was not built with you in mind, when you come into a space that clearly makes you know that as a young disabled person of color, you are not what we see as a leader in this space, you feel as if you do not have the opportunity to speak up – that the system wasn’t made for you,” he said.
Dr. Okanlami explained that he saw the ableism affected disabled individuals in the healthcare workplace, but also within the lay disabled community in their lack of access to care - both in a medical context and in the community through physical activity. He drew on his passion for fitness to help create the Adaptive Sports and Fitness Program at the University of Michigan in Ann Arbor, which provides access to physical activities to disabled and non-disabled individuals alike.
Initiatives like these can “destigmatize disability by creating access,” he said, which can have a positive effect on attitudes that can influence healthcare quality.
While the focus for the Power of Quality campaign is on the future, at a Tuesday session ACS Executive Director and CEO Patricia L. Turner, MD, MBA, FACS looked to the College’s history to reiterate its commitment to quality.
“For 110 years, we have been improving quality, we have been focused on quality, and it continues to be the principle that undergirds everything we do—centered on the surgical patient and focused on enhancing their care,” Dr. Turner said. “Because of this legacy, we know what you need to be successful.”
Through the campaign, the ACS will partner with hospitals to promote the use of their already implemented ACS Quality Programs and bring others into the fold in a way that patients, press, payors, and policymakers can immediately understand.
“We are equipped to help you carry this message forward to all of your patients and all of your communities,” including through placement of the Surgical Quality Partner diamond, which is a visual representation of a hospital’s commitment to quality.
Building on Dr. Turner’s message, a follow-up session included Brian K. Edwards, MBA, ACS Chief of External Communications, speaking with Kirsten K. Edmiston, MD, MPH, FACS, vice president of surgical safety and operations at Inova Health System, about how the ACS can assist hospitals in amplifying the Power of Quality message.
Dr. Edmiston provided an overview of northern Virginia’s Inova Health System, the first to partner with the ACS in this new quality journey, and explained how its medical service lines and varying hospital sizes made it a good test case for the quality campaign, which is in part built on the foundation of the Quality Verification Program.
“There is nothing like the Quality Verification Program as an overarching construct to align everyone around quality improvement, which everyone agrees is very important,” Dr. Edmiston said.
Although surgery is increasingly diverse, there still exist barriers for entering the field—both physical and figurative—for individuals with disabilities. In his Keynote Address, Oluwaferanmi O. Okanlami, MD, MS, a physician and former orthopaedic surgery resident who is paralyzed from the chest down, discussed how accommodating disability is a necessary part of equity.
For Dr. Okanlami, the director of student accessibility and accommodation services at the University of Michigan in Ann Arbor and assistant professor of family medicine, physical medicine and rehabilitation, and urology at Michigan Medicine, his neck injury was a role reversal.
“Despite being a physician at this point and surgical resident who took care of people with disabilities… I hadn’t recognized how inaccessible our world and our healthcare system are for individuals with disabilities,” he said.
It was an affecting experience for Dr. Okanlami to be a patient because he became intimately aware that physicians often draw a line between themselves and patients when they or their colleagues could as easily be a patient in the future. That line can inadvertently mean that physicians limit a patient with disability’s access to the care they need because they may not understand their needs.
That lack of recognition of necessary accommodations can also become present when an individual with disabilities seeks a career in surgery.
Dr. Okanlami worked to show he could continue to operate by accessing tools such as a standing wheelchair to give him the positioning needed to perform surgery. While he was granted accommodations due to his past success, he said changing healthcare to make such accommodations equitable and accessible for trainees will take effort.
“It is culture change that we need to see that recognizes that a trainee with a disability should be seen as less than a trainee without,” he said. “Rather than limiting a candidate based on what you think they cannot do… you can build ramps to give an entire demographic of individuals who currently are not seen as competent or qualified to do this work the opportunity to revolutionize the field of surgery.”
“Quality is more critical than ever before." - Dr. Clifford Y. Ko
L’Etoile du Nord, French for “the star of north,” is Minnesota’s state motto and “emblematic of what you all do every single day as we try to achieve quality—we head toward that North Star,” said Clifford Y. Ko, MD, MS, MSHS, FACS, FASCRS, Director of the ACS Division of Research and Optimal Patient Care, in his introduction for the 2023 ACS Quality and Safety Conference.
Laying out the conference foci and themes, Dr. Ko said some attendees were there as representatives of the patient care space, others were that in the evaluation, registry, and data management space, and others put into practice the surgical quality and patient safety initiatives that will lead to improvement; some play a part in all three spaces.
“What we get to see at the College is the orchestra—all the pieces playing together,” Dr. Ko said. The Quality and Safety Conference provides an opportunity for various disciplines to share their initiatives, findings, and best practices, while coming together with the College to explore how the organization is providing more comprehensive resources that ever to improve patient care.
As examples, Dr. Ko discussed how the ACS’ Metabolic and Bariatric Surgery Quality Improvement Program, the Trauma Verification Program, and the National Accreditation Program for Breast Centers have each had a tangible impact on improving outcomes, decreasing complications, and more. And the ACS is expanding its reach to help ensure that all hospitals have the tools to improve their quality.
“Quality is more critical than ever before,” Dr. Ko said. “The ACS believes that quality improvement (QI) is such a high priority that we’re embarking on a new national QI effort—the Power of Quality campaign.” The campaign is aimed at elevating care for all patients undergoing surgery by raising awareness of quality paradigms and engaging hospitals, payers, and policymakers to advocate for initiatives that work.
“Ultimately, quality can only be achieved by working together,” he said.
The COVID-19 pandemic and other increasing stressors in healthcare have revealed the necessity of having true leaders in both surgery and surgical QI. But the concept of surgeon leadership is evolving, according to three leaders who spoke at a Monday afternoon panel session.
Despite their prima facie similarities, there are key differences between manager and leaders, according to Amalia Stefanou, MD, FACS, a colorectal surgeon at Moffitt Cancer Center in Tampa, FL, and Past-Chair of the ACS Young Fellows Association.
“Manager is a job title,” Dr. Stefanou said, one who focuses on structure, processes, eliminating risk, while “leaders focus on people—inspiring, motivating, and aligning members of the team to innovate and develop in service of a mission.”
There is overlap between a manager and leader, including a need to collaborate with their team members to see success, solicit and offer useful feedback, and to seek and recognize progress when possible and appropriate. But for most leaders, “management is just a first step toward leadership,” Dr. Stefanou said.
Regardless of titles, leaders in the surgical QI space should seek to be a “working foreman”—the expert “who really knows their stuff” when it comes to gathering and using data, according to Bruce L. Hall, MD, PhD, MBA, FACS, system chief medical officer for BJC Healthcare in St. Louis, MO, and Director of the ACS National Surgical Quality Improvement Program (NSQIP).
NSQIP and the other ACS databases and registries offer hospitals a plethora of information, and an important quality of a surgical QI leader is to be able to “understand how the data available to you matches your system’s mission and priorities,” Dr. Hall said. Make sure you understand what the information is telling you about the procedures, process, or service you are looking to improve, and use that information to help assuage fears or hesitation that your team might be feeling when it comes time to change your workflow.
Perhaps most importantly for surgeon and surgical QI leaders, all of whom will be well versed in the challenges facing their hospital or health system, is to act—to move beyond simply “admiring” a problem and instead work to resolve it, according to Patricia L. Turner, MD, MBA, FACS, ACS Executive Director & CEO.
“Action is key to leading,” Dr. Turner said, “and admiration is an impediment to action. We can admire a problem to death, but that alone won’t lead to addressing it.”
Effective surgical QI demands active leaders who can craft a strategy to reach a desired endpoint, inspire a team’s actions to change and transition, and “acknowledge that we need to define a problem before we can start creating solutions.”
Leaders who stay in the admiring stage too long will hinder any improvement, Dr. Turner said, outlining that time spent enumerating, contemplating, and talking about a problem, debating details, or deferring to committees can cost valuable time and motivation.
In the time not used to act on an issue, outside, non-expert groups—administrators or governments, for example—may take it upon themselves to act, which could lead to a less than optimal solutions in medicine. But the ACS is providing a strategy for executing QI through the Power of Quality campaign, which aims to work with surgeon, data registrants, and care teams to improve patient care and safety through ACS QI resources and institutional knowledge.