August 3, 2023
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 welcome to the 2023 ACS Quality and Safety Conference.
More than 1,100 surgeons, nurses, registrars, surgical quality officers, and other members of the healthcare team attended the conference, which took place July 10–13 in Minneapolis, Minnesota. In addition to key general sessions, several of which will be summarized in this article, the conference featured dozens of breakout sessions, poster abstracts, the popular Quality Improvement (QI) Basics Preconference Workshops, and social events.
Laying out the conference foci and themes, Dr. Ko acknowledged that some attendees were there as representatives of the patient care space; others were in the evaluation, registry, and data management space; and others enact the surgical quality and patient safety initiatives that will lead to improvement. Some play a part in all three areas.
“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 learn how the organization is providing more comprehensive resources than ever to improve patient care.
As examples, Dr. Ko discussed how the ACS Metabolic and Bariatric Surgery Quality Improvement Program, Trauma Verification Program, and National Accreditation Program for Breast Centers have each had a tangible impact on improving outcomes and decreasing complications through useable data capture. 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 is such a high priority that we’re embarking on a new national QI effort—The Power of Quality campaign. Ultimately, quality can only be achieved by working together.”
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.
"Regardless of titles, leaders in the surgical QI space should seek to be 'working foremen'—the experts 'who really know their stuff' when it comes to gathering and using data."
Achieving effective surgical QI requires strong leadership, which the COVID-19 pandemic and other increasing stressors in healthcare have revealed in recent years. But the concept of surgeon leadership is evolving, according to three leaders who spoke in a panel discussion.
Despite their prima facie similarities, there are key differences between managers and leaders, according to Amalia Stefanou, MD, FACS, a colorectal surgeon at the Moffitt Cancer Center in Tampa, Florida.
Dr. Stefanou said that “manager” is a job title that focuses on structure, processes, and 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 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 “working foremen”—the experts “who really know 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, Missouri, and Director of the ACS National Surgical Quality Improvement Program® (NSQIP®).
NSQIP, as well as the other ACS databases and registries, offer hospitals a plethora of information, and an important characteristic of a surgical QI leader is to be able to “understand how the data available to you match your system’s mission and priorities,” Dr. Hall said. Make sure you understand what the information is telling you about the procedure, 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.
"Action is key to leading. And admiration is an impediment to action. We can admire a problem to death, but that alone won’t lead to addressing it.”
Perhaps most importantly for surgeon 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 requires active leaders who can craft a strategy to reach a desired endpoint, inspire a team’s actions to change and transition, and acknowledge that they need to define a problem before they can start creating solutions.
Leaders who stay in the admiring stage too long will hinder any improvement, Dr. Turner said, explaining that time spent enumerating, contemplating, and talking about a problem, debating details, or deferring to committees can cost valuable time and motivation.
“The ACS is here to support you,” Dr. Turner said. “We can help you move to the next level of quality, to move from good to great.”
While the focus for The Power of Quality campaign is on the future, Dr. Turner 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 work 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, payers, and policymakers immediately can understand.
The ACS is equipped to help you carry this message forward to all of your patients and all of your communities, she said, including through placement of the Surgical Quality Partner diamond, which is a visual representation of a hospital’s commitment to quality.
As part of the Power of Quality Campaign, participants of an ACS Quality Program are recognized as Surgical Quality Partners and will receive one complimentary Surgical Quality Partner plaque per hospital. Visit powerofquality.com to pre-order your plaque.
Building on Dr. Turner’s message, a follow-up session describing how the ACS can assist hospitals in amplifying The Power of Quality message, featured insights from Kirsten K. Edmiston, MD, MPH, FACS, vice-president of surgical safety and operations at Inova Health System in Falls Church, Virginia.
Dr. Edmiston provided an overview of northern Virginia’s Inova Health System, the first to partner with the ACS in this new quality journey. She explained how its medical service lines and varying hospital sizes made it a good test case for the quality campaign, which in part is 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 vital,” Dr. Edmiston said.
Although surgery is increasingly diverse, barriers still exist 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 easily be a patient in the future. That line inadvertently can mean that physicians limit a patient with disability’s access to the care because the physicians may not understand the patient’s needs.
That lack of recognition of necessary accommodations also can 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, he said changing healthcare to make such accommodations equitable and accessible for all individuals, especially trainees, will take effort.
“It is culture change that we need to see that recognizes that a trainee with a disability should not 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.”
Although the Institute of Medicine (now the National Academy of Medicine) included equity as a domain of healthcare quality more than 20 years ago, progress toward ensuring equitable care for all demographics in the US has been slow and uneven. Health equity experts discussed why and how equity can be integrated into surgical QI in a well-attended panel discussion.
In discussing the ACS’s role in promoting equity in health, Bonnie Simpson Mason, MD, FAAOS, ACS Medical Director of the ACS Office of Diversity, Equity, and Inclusion (DEI), made clear that it is in service of the College’s broader mission.
“Our highest priority at the College is surgical excellence for our patients,” Dr. Mason said, “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 also aims to foster “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 ACS Office of DEI and the 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 Triple Aim, helps improve the US health system by 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 is a goal that takes active participation.
Healthcare equity is vital, as Black and Brown patients suffer from these disparities most severely, he said, adding that inequity is an unsafe condition that leads to adverse events, harm, and death. He noted that surgeons “have the influence and capability to commit to abolishing inequity from healthcare.”
Returning for the panel session, Dr. Okanlami continued a discussion on the themes he explored in his keynote address. As a Black disabled individual, he 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 drew on his passion for fitness to help create the Adaptive Sports & Fitness program at the University of Michigan, which provides access to physical activities to disabled and nondisabled individuals alike.
Initiatives like these can “destigmatize disability by creating access,” he said, which can have a positive effect on attitudes that influence healthcare quality.
The 2024 Quality and Safety Conference will take place next July in Denver, Colorado.
Matthew Fox is the Digital Managing Editor in the ACS Division of Integrated Communications in Chicago, IL.