July 2, 2021
More than 700 surgeons and surgery residents registered for the first virtual American College of Surgeons (ACS) Leadership & Advocacy Summit, May 15–17.
The Leadership Summit took place from 10:00 am to 2:30 pm Saturday, May 15. Patricia L. Turner, MD, MBA, FACS, Director, ACS Division of Member Services, welcomed attendees to the conference, noting, “We have leaders of all stripes participating in this meeting, from both inside and outside of the ACS.” These leaders included ACS Regents, Officers, Governors, Chapter Officers, and Advisory Council members, she said.
“This really is an opportunity for leaders of all types to come together” to develop “concrete skills you can take home and use within your practice or in your institution immediately,” Dr. Turner added.
Clifford Y. Ko, MD, MS, MSHS, FACS, FASCRS, Director, ACS Division of Research and Optimal Patient Care, spoke on “getting to better” with respect to quality improvement (QI) and value-based care. “As surgeons, it is inherent in our work and in our thinking to be results based. Surgeons look at their outcomes and ultimately aim to have an impact for their patients,” Dr. Ko said.
He noted that when determining whether a QI program is leading to better patient care, surgeons should use data to measure the impact of the program and strategically prioritize the effort. Coming up with potential solutions to a problem can be challenging, but “failure is part of identifying solutions.” Leaders of QI programs should gather evidence, involve all stakeholders, be organized, plan ahead, and be resilient, Dr. Ko added.
“Plan the implementation ahead of time,” and have a framework for implementing the plan, which accounts for content, process, and context—the unique local factors that influence the success of the program, he said. Then, evaluate the effort. Conduct a needs assessment, and an impact evaluation, and evaluate the implementation process. “Learn from stakeholders,” Dr. Ko added. “Was care improved?”
Jeffrey D. Kurdish, PhD, associate dean, corporate relations and executive education, Villanova University, PA, spoke about the importance of teamwork in today’s health care environment. Teams allow leaders to cope with complexity, integrate knowledge and skills, enable flexibility, and foster motivation and engagement. “We’ve got to teach people how to work together,” he said.
“Success starts with identifying the attributes of ‘ideal team players,’” Dr. Kurdish said. “We want team members who have a passion for the mission of the team, who do more than is required.”
Team leaders should be humble—putting the team ahead of themselves. They also need to be emotionally intelligent, flexible, able to improvise, and have a positive attitude. Most importantly, “Leaders need to build trust,” Dr. Kurdish said. Emotional intelligence (EI) training and getting to know team members’ past experiences are helpful tools in building trust. When conflicts arise, “be tough on data, soft on people,” he said. Encourage them to focus on the facts and allow all points of view to be heard.
Several ACS chapter leaders reported on their successes, including Ranjan Sudan, MD, MBBS, FACS, President, ACS North Carolina Chapter, who reported on the chapter’s ability to fend off state legislation that would expand scope of practice for optometrists. He attributed such successes to the value that the chapter places on inclusion. Dr. Sudan noted that the board of the North Carolina Chapter is composed of representatives from all surgical specialties. “Each specialty representative brings issues pertinent to their group to the board’s attention,” he said.
Another example of the value that the chapter places on inclusion is reflected at its annual meeting, which not only includes participation from all surgical specialists in North Carolina but is held in conjunction with the South Carolina Chapter of the ACS. In addition, the North Carolina and South Carolina Bariatric Group runs its annual meeting during the chapters’ annual event. “Inclusivity permeates the annual meeting,” Dr. Sudan said.
Robert Maxwell, MD, FACS, President, Tennessee Chapter of the ACS, spoke on “the power of visionary and dedicated leadership” and outlined the chapter’s membership activities. Highlights from the last year include advocacy, a statewide trauma symposium run through the Tennessee Committee on Trauma (COT), formation of a new committee on racism, a paper competition on disparities in surgical care and training, a new on-demand library, and presentation of a 2020 virtual meeting, according to Dr. Maxwell.
The Tennessee Chapter’s advocacy program is particularly strong, housing a web browser for information on pending health care legislation. The chapter is a member organization of the Tennessee Medical Association’s Coalition for Collaborative Care, which gives strength to the state medical community’s voice. In addition, the chapter received a grant from the ACS, which it used to advocate for installation of STOP THE BLEED® kits in all Tennessee schools. Dr. Maxwell attributed some of these successes to Young Fellow and Resident involvement. In addition, the chapter hosts Virtual Fireside Chats on the importance of chapter success.
The ACS India Chapter has experienced particular challenges as the nation battles its second wave of coronavirus (COVID-19) cases, according to Professor Chintamani, MBBS, FACS, Chapter President. “Guidelines from the ACS have been very helpful” in terms of determining when to operate and how to care for COVID patients, he said.
Despite these tragic circumstances, the chapter was able to host successful annual meetings in 2020 and 2021. Like other chapter leaders, Professor Chitamani credited these successes to the chapter’s dedication to collaboration. Surgical societies from across Southeast Asia have contributed to these programs, he said.
The College’s “North Star” has remained the same for more than 100 years: “To serve all with skill and fidelity,” ACS Executive Director David B. Hoyt, MD, FACS, said. In today’s health care environment, a number of factors complicate accomplishing that goal, including insurance coverage, prior authorization requirements, affordability, and COVID-19.
Nonetheless, the ACS has never lost sight of the importance of focusing on quality, starting in 1917 with the introduction of the ACS Hospital Standardization Program, which ultimately evolved into what is now known as The Joint Commission. Throughout its history, “the College has led quality programs as much as anyone in medicine,” Dr. Hoyt said. Today, the ACS has 12 verification/accreditation programs, eight data registries, and three programs to support QI in place or in development. Approximately four years ago, the ACS released Optimal Resources for Surgical Quality and Safety (the Red Book) and, at press time, was poised to introduce a Quality Verification Program (QVP) to accredit hospitals and health systems that comply with the standards outlined in the Red Book.
“Has the pandemic created a crisis for hospitals to withdraw from ACS Quality Programs? The answer is ‘no,’” Dr. Hoyt said. Nonetheless, the College is considering bundling opportunities to receive verification or accreditation in one area of emphasis, such as trauma, cancer, or bariatrics, with the QVP to help limit the expense of undergoing multiple site visits. This initiative is tentatively known as Red Book-plus.
The ACS has partnered with the Harvard Business School (HBS) Institute for Strategy and Competitiveness, Cambridge, MA, to determine how QI efforts can contribute to solving the economic issues that affect health care delivery and create value-based health care (VBHC), Dr. Hoyt said. The current fee-for-service model is outmoded, unaffordable, and unsustainable, he noted. In response, the ACS and the HBS Institute have developed ACS THRIVE (Transforming Health care Resources to Increase Value and Efficiency).
Dr. Hoyt also provided an update on the College’s educational programs. He noted that Members of the ACS Academy of Master of Surgeon Educators™ appointed a Special Committee to Address Challenges and Opportunities Relating to Surgery Residency Training During the COVID-19 Pandemic, which has pursued significant opportunities that are important not only during the pandemic, but will result in transformational changes in surgical residency training afterward, he said. The Academy now has a new educational resources web page and a new listserv to enhance communication among the Academy Members.
Other educational resources that the College offers that have proven beneficial to surgeons during this time of change include the Surgical Education and Self-Assessment Program (SESAP®), now in its 17th edition, and the ACS Accredited Education Institutes, where trainees and practicing surgeons can learn through simulation, Dr. Hoyt noted.
In addition, in May the College hosted the successful ACS Summit on Surgical Training and is in the process of developing Optimal Resources for Surgery Residency Training (the Gold Book), Dr. Hoyt said. The Gold Book outlines the technical and nontechnical skills, knowledge, and competencies all surgeons should possess when they leave general surgery training and move on to the next stage of their careers.
Dr. Hoyt also described how the College is viewed as an advocacy organization in Washington, DC. “The College has a very, very good reputation” on Capitol Hill for serving as a trusted resource, he noted, adding that the ACS ranks third among all lobbying groups—not just health care associations—in terms of communication and collaboration in the halls of Congress.
To combat ongoing concerns about potentially deep cuts in Medicare physician payment, last year the College formed the Surgical Care Coalition in association with the DC-based Brunswick Group. The ACS and the other members of the Surgical Care Coalition are strategizing to tackle this threat to surgical patient care yet again in 2021 as the Centers for Medicare & Medicaid Services (CMS) begins drafting the proposed rule on the Medicare physician fee schedule (MPFS).
In the wake of the tragic death of George Floyd and other Black Americans last year, the ACS established a Task Force on Racial Issues, which has evolved into the Regents’ Committee on Anti-Racism and the ACS-START group for College staff, Dr. Hoyt said. At press time, the College was scheduled to host a Retreat on Anti-Racism June 23, he added.
Many surgeons and the members of their teams experienced moral injury during the COVID-19 pandemic, according to Mary Brandt, MD, FACS, professor of surgery, Tulane University School of Medicine, and pediatric surgeon, Children’s Hospital of New Orleans, LA, as they were forced to delay operative care for some patients and witnessed the devastating effects of the disease on others. “We have to be intentional about healing” the moral injuries these individuals experienced, Dr. Brandt said.
But first, surgeons need to understand what moral injury is and how it occurs, she said. “Moral differences are part of being human,” Dr. Brandt said. “We will not all have the same moral compass.”
“When there is stress because of our differences, moral differences become moral dissonance,” she said. “Dissonance becomes dilemma when we are required to choose and act against one moral good at the expense of another value we hold.”
Moral dilemmas become moral distress “when you are unable to do what you know is right, and that can lead to moral injury,” Dr. Brandt said. “Moral injury can accrue from accumulated distress in morally dissonant environments as much as from failure to act in accordance with one’s own moral codes,” she added.
Christopher J. Sonnenday, MD, MHS, FACS, director, transplant center, and executive vice-chair, department of surgery, Michigan Medicine, Ann Arbor, spoke on authentic leadership. “Leadership means you own the culture,” he said. “It provides you with the ability to shape the culture of the institutions and the teams you lead.”
Authentic leaders display passion, vulnerability, and courage, according to Dr. Sonnenday. They are transparent about what drives them as leaders. “Never assume that your passion is clear to everyone around you,” he said.
“The leader must become comfortable being vulnerable—sharing uncertainty, sharing failure, yielding power—and become comfortable reciprocating vulnerability among team members,” Dr. Sonnenday said.
Leaders exude moral courage, which creates psychological safety for the rest of the team, he added.
ACS Past-President Barbara L. Bass, MD, FACS, FRCS(Hon), FRCSEd(Hon), FRCSI(Hon), FCOSECSA(Hon), rounded out the Leadership Summit by offering what she described as a set of skills that surgeon-leaders need to possess. She said leaders willingly accept responsibility for others, communicate shared values and goals, motivate and inspire others to achieve shared goals, acknowledge and understand different perspectives, make difficult decisions to serve shared missions and principles, and recognize disruptive forces and mitigate them.
Leaders have integrity, a strong moral compass, and high emotional intelligence, Dr. Bass added. They acknowledge errors and take corrective action.
They are committed to people, their mission, and a cause. Furthermore, they are self-aware, acknowledging their impact, flaws, and errors, Dr. Bass said.
Physicians are “de facto team leaders.” Medical professionals are respected members of their community because of their years of education and training, she said. As a result, they are “accustomed to being in charge,” accepting responsibility and decisions.
Day-to-day leadership is dependent on individual actions, engagement, professionalism, and environment, Dr. Bass said. Exercising daily leadership requires professionalism and civility in the clinic and the operating room, as well as empathy, she added. The “captain of the ship” mentality no longer works in today’s environment, as it fails to recognize the contributions of other team members.
To be a leader today, surgeons should “understand your ‘why,’” she said. Remember, “leaders are chosen. Do good work.”
On May 16, Dr. Hoyt welcomed attendees to the Advocacy Summit, and Christian Shalgian, Director, ACS Division of Advocacy and Health Policy (DAHP), Washington, DC, provided an overview of what participants could expect during virtual Capitol Hill visits on Monday, May 17. The program featured several health care experts and congressional speakers, plus panel sessions focused on ACS health policy priorities such as health care reform, Medicare physician payment, and quality as a driver of VBHC.
Katie Keith, JD, MPH, part-time research faculty for Georgetown University’s Center on Health Insurance Reforms and principal, Keith Policy Solutions, LLC, Washington, DC, focused on the American Rescue Plan Act, which expanded access to care under the Affordable Care Act (ACA) during the COVID-19 pandemic and beyond. Under the legislation, “individuals with incomes of more than 400 percent of the federal poverty level (FPL) are eligible for premium tax credits,” Ms. Keith said. As a result, 3.7 million uninsured people became newly eligible for marketplace subsidies to offset the cost of health insurance premiums.
Next steps for health care reform include a White House proposal, the American Families Plan, she said. This proposal calls for making the ACA subsidies permanent for individuals with income greater than 400 percent of FPL and expanding Medicaid eligibility to individuals between 100 percent to 400 percent of the FPL. However, many barriers stand in the way of passage, Ms. Keith said, including budgetary constraints, the need for Democratic Caucus cohesion, and the looming 2022 midterm elections. Another hurdle is the question of “how to fill the Medicaid coverage gap,” she said. At present, 12 states have yet to expand Medicaid coverage under the ACA.
According to Sara Rosenbaum, JD, Harold and Jane Hirsh Professor of Health Law and Policy, School of Public Health and Health Services, and professor of law, George Washington University, Washington, DC, the 12 states that have not expanded Medicaid eligibility have resulted in more than 2 million of the nation’s poorest people lacking health insurance. “We’ve ironically built a safety net, but it’s not open to the very lowest-income Americans,” she said.
Nonetheless, the American Rescue Plan gives states a two-year “bump” to expand Medicaid, Ms. Rosenbaum said. The American Rescue Plan also provides coverage for treatment of COVID-19 patients, including “long-haul patients,” and provides 100 percent coverage for COVID vaccinations. Among other provisions, the American Rescue Plan provides enhanced postpartum coverage and pays for mobile substance abuse treatment and inpatient and outpatient mental health care.
Kansas is among the states that have not expanded Medicaid eligibility, according to James Hamilton, Jr., MD, FACS, assistant professor, bariatric surgery division, University of Kansas Medical Center, Kansas City. As a result, approximately 165,000 Kansans are uninsured. The Alliance for a Healthy Kansas, which Dr. Hamilton serves on, has sought to expand the state’s Medicaid program, known as KanCare, to the “large number of Kansans who earn too much for KanCare,” he said.
Rationales for KanCare expansion include better meeting the needs of patients with uncontrolled diabetes and addressing mental health and substance abuse concerns, he said. Dr. Hamilton further noted the economic benefits of Medicaid expansion. “Every state that expanded Medicaid has experienced a positive financial impact,” Dr. Hamilton said, noting that Montana, Louisiana, and Pennsylvania created new jobs after expanding their Medicaid programs. “Non-expansion is correlated with hospital closure,” whereas “expansion reduces hospital uncompensated care,” he added.
According to Dr. Hamilton, “63 percent of Kansans support KanCare expansion” even though it is “a very red state.”
Lee Fleischer, MD, Chief Medical Officer and Director, Center for Clinical Standards and Quality, Centers for Medicare & Medicaid Services (CMS), noted that the present payment and delivery model does not link quality outcomes to reimbursement; it is provider-centered and volume-driven, lacks coordination of care, and is unsustainable. The emerging VBHC system will be patient-centered, outcomes-driven, and emphasize coordinated care and sustainability. “The new payment system will include value-based purchasing, shared savings, episode-based payment, care management, and data transparency,” he said.
CMS has developed a Quality Action Plan to move toward digital measurement of outcomes and pricing, Dr. Fleischer said. He noted that the Biden Administration is focused on improving equity in care delivery. Surgeons and their institutions should ask, “How do you ensure all your patients are being treated equitably?” As a result, there is a movement toward bundled payments and population-based health, he said.
The agency is seeking to define what is high-value versus low-value health care and is developing Merit-based Incentive Payment System (MIPS) Value Pathways, which are intended to improve joint accountability, Dr. Fleischer added.
According to Francois de Brantes, MS, MBA, senior vice-president, Signify Health, “Nobody is really happy with the current system.” A key issue is the “inexorable increases in costs of care,” he said.
The new payment system will be tied more closely to episodes of care for both acute and elective care, changing the “unit of accountability,” and will look for “observed variation in episode costs,” Mr. de Brantes said.
“That’s what the private sector is looking for, and it’s the way to be successful in Medicare Advanced Alternative Payment Models,” he added.
The roles of compensation are to attract and retain talent, motivate people to work hard, and communicate priorities, said Susanna Gallani, PhD, assistant professor, business administration, HBS. Compensation systems run across a continuum at present, from fixed pay to volume-based payment. Under this system, surgeons are incentivized to increase volume to give them control over their earnings and remain financially viable. However, this model has made health care delivery transactional and has led to increased burnout, she said.
“Define value for your practice or institution,” Dr. Gallani said. She offered “a basket of motivators,” which she defined as STORM: Satisfaction/Success, Teamwork, Opportunities, Recognition, and Money.
The U.S. pays the highest amount of money in the world for health care, per capita, but routinely ranks at the bottom among all industrialized nations in terms of quality, according to Michelle Schreiber, MD, Director, Quality Measurement and Value-Based Incentives Group, and Deputy Director, Center for Clinical Standards and Quality, CMS. “You need to ask yourself, if you were a policymaker, what would you do?” Dr. Schreiber said.
“At CMS, we have several important levers for change,” Dr. Schreiber said, including physician and hospital payment incentives, penalties, and reforms; public reporting; conditions of participation; survey and certification; and QI programs. She noted that while many groups, agencies, and publications rank physicians and other providers in terms of quality, their measures and findings are not aligned.
Consequently, CMS has developed a Quality Measurement Action Plan, which Dr. Schreiber said is intended to “use meaningful measures to streamline and align quality measures.” More specifically, the action plan would leverage measures to drive improvement, enhance the efficiency of measures by transitioning to digital measures, focus on patient-directed quality measures and public transparency, promote equity, and more.
“What can you do to ensure high value?” she asked. Among other recommendations, Dr. Schreiber said physicians should view the patient and his or her goals of care as “the true north,” know their performance data, be lifelong learners, and get involved.
Mary Witowski, MD, MBA, fellow, HBS Institute for Strategy and Competitiveness, asked, “What is the definition of value?” She defined it as health outcomes that matter most to patients weighed against the costs of delivering those outcomes. Hence, the definition of value will vary from patient to patient because “patients needs are multidimensional.” She encouraged surgeons to move from the mindset of improving volume to adding value. She said surgeons can achieve this goal by accepting responsibility for the patient not only in the operating room and clinic, but throughout the care cycle.
“Quality is a program and not a measure,” said Jill Sage, MPH, Quality Affairs Manager, ACS DAHP. Quality verification involves looking not only at outcomes measures (such as readmissions, mortality, and complications), but also evaluating the structures and processes that contributed to those outcomes.
She echoed the sentiments that Dr. Schreiber and Dr. Witowski expressed with regard to the continuum of care, stating, “Quality as a program should link patient care across the facility and clinical services.” CMS could play a role in creating a value-based health care system by applying a payment framework to link incentives in support of quality as a program.
DAHP staff briefed attendees on the ACS’ legislative priorities in preparation for virtual Capitol Hill visits the following day. Those issues included looming Medicare physician payment cuts, prior authorization burden relief, mental health support for COVID-19 frontline physicians, surgical workforce shortages, funding for military-civilian partnerships, and firearm injury prevention.
Carrie Zlatos, Senior Congressional Lobbyist, ACS DAHP, noted that in 2020, the College-led Surgical Care Coalition successfully advocated for legislation that delayed implementation of provisions in the calendar year 2021 MPFS that would have reduced payment by up to 9 percent for some specialties. This year, CMS is expected to call for the cuts in 2022, so surgeons will again need to advocate for legislation to stop the payment reductions.
With respect to prior authorization, the College supports the Improving Seniors’ Timely Access to Care Act, H.R. 3107, which was introduced in the House of Representatives in May. This bill calls for the establishment of an electronic prior approval process and increased transparency, Ms. Zlatos said. The bill had previously been introduced in the Senate, and surgeons were asked to request reintroduction.
Capitol Hill visit participants also were asked to seek cosponsors for the Dr. Lorna Breen Health Care Provider Protection Act. This legislation is intended to respond to the depression and burnout many health care professionals have experienced during COVID-19 and its aftermath, Ms. Zlatos said.
Amelia Suermann, ACS Congressional Lobbyist, urged attendees to ask their senators to support the Ensuring Access to General Surgery Act, S. 1593, which would help maintain a strong surgical workforce. She also called upon surgeons to ask their legislators to support authorization of MISSION ZERO. This legislation, which was signed into law in 2019 as part of the Pandemic and All-Hazards Preparedness and Advancing Innovation Act (PAHPAI), promotes military-civilian partnerships. Full funding of the program is set at $11.5 million.
In addition, Ms. Suermann asked attendees to promote firearm injury prevention legislation that includes provisions that are related to the ACS Committee on Trauma’s 13 recommendations in the Firearm Strategy Team Workgroup report.
The program also incorporated comprehensive advocacy training in preparation for Hill visits. A record number of attendees, representing more than 43 states, participated in 289 meetings—31 of which involved meeting directly with the member of Congress.
Save the date for the next Leadership & Advocacy Summit, April 2–5, 2022.