June 7, 2023
Resources for implementing QI projects vary by local setting but fundamentally include leadership, personnel, time, skills and expertise, access to evidence, and organizational capacity to make improvements.‡
To support this QI work, the College released the ACS Quality Framework and Toolkit, which was developed by surgeon and staff representatives from seven ACS accreditation/verification programs—trauma, cancer, breast disease, rectal cancer, children’s surgery, bariatric surgery, and geriatric surgery.
These resources provide an organized approach to guide surgeons and quality teams in planning, conducting, evaluating, and reporting of improvement projects.
The Quality Framework consists of eight components with associated criteria organized around the three phases of a QI initiative—planning, conducting, and reflecting.
An effective improvement plan begins with assessing the current situation to determine the project focus and implementation process, and then developing strategies to put the plan in place. The three components in the Planning Phase are:
Developing a plan of action to successfully implement the project and evaluate results at regular intervals is key to a successful project. There are three components in the Conducting Phase:
Sharing the results and lessons learned from the project contributes to a culture of QI. The two components of the Reflecting Phase are:
The accompanying Toolkit includes a range of optional resources to support QI efforts, including a project charter, communication plan, data plan, and planning worksheet. A User Guide was developed to help QI teams plan and execute QI projects.
The ACS would like to ensure that the initial version of the Quality Framework is improving and evolving to meet the needs of surgeons and clinical teams. The College welcomes your feedback, which is critical to future versions of this tool: surveymonkey.com/r/ VR86P7P.
An informational webinar will be held on Wednesday, June 14, at 12:00 pm CT. Register at attendee.gotowebinar.com/register/8918888011345909343?source=CPN
In addition, the ACS has developed a range of resources to help build skills and knowledge and support your team’s quality improvement work. The ACS Quality Improvement Course: The Basics is a self-paced, online course on the basic principles of surgical quality and safety. The course—intended for anyone working in a healthcare setting who is learning the foundations of QI—can help QI teams learn the necessary concepts, processes, and tools needed to meet the criteria of the Quality Framework. Visit facs.org/quality-programs/quality-improvement-education for all available resources.
Learn more about the Quality Framework and other resources at the Quality and Safety Conference, July 10-13, in Minneapolis, Minnesota, at facs.org/qsc2023. Three sessions will be dedicated to understanding and implementing the Quality Framework.
For more information about the Quality Framework and Toolkit, contact ACSQualityFramework@facs.org.
The ACS is launching a case study repository later this summer to share how participating hospitals use programmatic data to improve their performance and outcomes. This collection of QI initiatives will allow the ACS to share lessons learned and educate surgical teams on small-scale quality initiatives that have been deployed in hospitals around the country to improve patient outcomes.
Karen Pollitt is the Senior Manager of the Quality Resource Team in the ACS Division of Research and Optimal Patient Care in Chicago, IL.
*Harvey G, Wensing M. Methods for evaluation of small scale quality improvement projects. Qual Saf Health Care. 2003;12(3):210-214.
†Ko CY, Tejen S, Nelson H, Nathens A. Developing the American College of Surgeons Quality Improvement Framework to Evaluate Local Surgical Improvement Efforts. JAMA Surg. 2022;157(8);737-739.
‡Ko CY, Shah T, Nathens A, Grant C, et al. How well is surgical improvement being conducted? Evaluation of 50 local surgery-related improvement efforts. J Am Coll Surg. 2022;235(4):573-580.