Development and Implementation of a Geriatric Surgery Verification Program Comprehensive Clinical Case Review Process

General Information

Institution Name: Kaiser Permanente

Author Name and Title: Cynthia Sinogui, DNP, MSN/Ed, RN, GERO-BC, ASC-BC, SCRN, CPHQ, Geriatric Surgery Verification Coordinator

Name of Case Study: Development and Implementation of a Geriatric Surgery Verification Program Comprehensive Clinical Case Review Process

Identification of Local Problem

At Kaiser Permanente Sacramento and South Sacramento Medical Centers, fewer than 1% of cases with American College of Surgeons (ACS)-defined complications were presented at Quarterly Geriatric Surgery Quality Committee (GSQC) meetings. Although one case per quarter was selected to meet the intent of Geriatric Surgery Verification (GSV) Standard 2.3, this random selection approach did not consistently represent site-specific or system-wide challenges, limiting the ability to surface meaningful trends or recurring issues within the geriatric surgical population.

Given ACS requirements for GSQC meeting agenda topics, combined with time constraints and a multidisciplinary audience—including Hospital Leadership, Program Champions, Department Representatives, and Frontline Providers—it was difficult to conduct comprehensive and meaningful case reviews within the allotted time. The lack of a structured, standardized process for identifying, reviewing, and prioritizing cases further contributed to variability in case selection and limited the depth of analysis.

As a result, the existing approach constrained the program’s ability to systematically review complications, identify patterns across cases, and translate findings into actionable quality and performance improvement initiatives. This gap reduced the overall effectiveness of GSQC meetings as a driver of data-informed decision-making and continuous improvement in geriatric surgical care.

Aim

To develop a streamlined systematic complications review process to:

• Increase the number of cases undergoing comprehensive quality review
• Enhance identification, analysis, and trending of program-specific and system-wide issues
• Establish a clear, efficient methodology for selecting a case for quarterly GSQC review                               

Provide data-driven, actionable recommendations to inform quality and performance improvement initiatives required in Standards 7.1 and 4.1

Context of the QI Activity

The ACS requires GSV programs to review ACS-defined complications during GSQC meetings in accordance with Standards 2.3 and 6.1. These complications include 30-day mortality, 30-day hospital readmissions, hospital length of stay greater than 14 days, ICU stays exceeding three days at ICU level of care, and post-operative delirium exacerbation. However, the GSV standards provide limited prescriptive guidance on how organizations should operationalize complication review, including how data should be analyzed and presented, and how cases should be selected for GSQC review. As a result, many organizations rely on selective or convenience-based case presentations, often incorporating random selection methods. This lack of a standardized methodology limits the ability to consistently review all relevant cases, reduces the identification of meaningful trends, and may result in case presentations that do not accurately reflect systemic issues or recurring opportunities for improvement within the geriatric surgical population.

Interventions

The core intervention was the development and use of a structured, interdisciplinary, and non-biased comprehensive chart review process focused on ACS-defined complications. This included the use of standardized data sources, such as automated data downloads from the electronic health record into an Excel spreadsheet, capturing patient identifiers, clinical details, surgical procedures, and outcomes, as well as a secondary, manually abstracted Excel database to support deeper analysis and trend identification. The intervention also incorporated routine, systematic review of missed episodes of care, along with the presentation of trended complication data to an interdisciplinary Complications Review Committee. Through this process, the team evaluates outcomes, identifies gaps in adherence to ACS GSV standards, and makes recommendations for clinical process changes, quality improvement initiatives, and performance improvement projects. Additionally, it included the development of a defined pathway to prioritize and escalate high-impact cases for presentation at Quarterly Geriatric Surgery Quality Committee (GSQC) meetings, with cases selected based on factors such as severity, recurrence, preventability, and alignment with known system gaps.

Implementation Strategy

To support adoption and consistent execution of this intervention, several implementation strategies were employed. The GSV Program Coordinator initiated the effort by conducting a brief, targeted literature review to inform best practices and guide the design of the review process (1-4). She then established and convened a multidisciplinary committee, including clinical, quality, and leadership stakeholders, to ensure diverse perspectives and promote shared ownership, with flexible attendance to maintain engagement. Standardized workflows were created, starting with a monthly preliminary, systematic review of charts that included all identified ACS-defined complications, followed by the compilation of trended analyses for presentation at monthly Complications Review meetings. These trends were reviewed by the multidisciplinary team, and additional individual deep-dive chart reviews were conducted to determine system-wide issues, identify missed care opportunities, and inform quality and performance improvement project recommendations. Additionally, cases were identified and recommended for GSQC presentation. An individual provider feedback process was created, and data dissemination strategies were also implemented, including distributing analyses to program champions and leadership teams, and posting results on the hospital intranet to increase transparency, as well as frontline awareness and engagement. The coordinator’s role in conducting preliminary reviews and preparing analyses further supports consistency and efficiency, while ongoing feedback loops and committee discussions reinforce accountability and continuous improvement across participating stakeholders.

Costs and Funding Sources

No additional costs or external funding were required.

Overall Results and Analysis

Between April 2023–March 2025, 1,683 cases were included in the GSV Program for Kaiser Permanente Sacramento and South Sacramento Medical Centers. Local program inclusion criteria were broadened from the standard ACS GSV program criteria to include patients who stayed one or more midnights in the core service lines identified for each medical center. Additional patients enrolled in the program who did not meet local program criteria were excluded from the dataset. Patients who underwent multiple surgeries during the same hospital encounter were counted only once for each ACS-defined complication. Geriatric surgical case complications also included cases with identified Total Harm complications, including hospital-acquired pneumonia, central line-associated bloodstream infections, Clostridium difficile, catheter-associated urinary tract infections, and inpatient falls.

Stratified data for Kaiser Permanente Sacramento included 926 total cases during this timeframe from General Surgery, Neurosurgery, Orthopedic Surgery, Spine, Vascular Surgery, and Urology. Of these, 28% (256/926) were identified as having at least one ACS-defined and/or Total Harm complication. The GSV Program Coordinator conducted the preliminary monthly analysis and presented trended outcomes to the Complications Review Committee. Of these, 95% (244/256) cases were brought forward to the monthly Complications Review Committee. The committee reviewed these cases, identified areas of opportunity for individual provider follow-up and local department follow-up, and selected nine cases for quarterly GSQC review during that timeframe, representing 3.7% of cases presented at the meeting.

Stratified data for Kaiser Permanente South Sacramento included 757 total cases during this timeframe from General Surgery, Orthopedic Surgery, Thoracic Surgery, Vascular Surgery, and Urology. Of these, 26% (200/757) were identified as having at least one ACS-defined and/or Total Harm complication. The GSV Program Coordinator performed the preliminary monthly analysis and presented trended outcomes to the Complications Review Committee. Of these, 94% (188/200) cases were brought forward to the monthly Complications Review Committee. The committee reviewed these cases, identified areas of opportunity for individual provider follow-up and local department follow-up, and selected nine cases for quarterly GSQC review during that timeframe, representing 4.7% of cases presented at the meeting.

This process met all intended aims, including shifting the program from random case review (<1%) to a structured, comprehensive review process (at least 90% of complication cases), enabling identification of both site-specific and system-wide trends within 12 months. This directly addressed the initial limitation of non-representative case selection and improved the ability to identify meaningful trends. Furthermore, the process enabled Kaiser Permanente Sacramento and South Sacramento GSV programs to proactively identify program-specific and system-wide issues and make data-informed recommendations for quality and performance improvement projects to enhance both the program and geriatric surgical care.

After incorporating this process into practice, we were able to identify and implement several quality and performance improvement initiatives. These included projects focused on intraoperative code status discussions and timely attending provider notification of positive Confusion Assessment Method (CAM) screenings. Additionally, we enhanced our approach to implementing evidence-based GSV standards in clinical practice by shifting from a primarily process-focused measurement approach to one that evaluates the quality of documentation. This ensures that the care provided is accurately captured and aligned with the intent of the ACS GSV standards.

Limitations

This study is limited by its individual-site, descriptive design, which restricts generalizability and does not allow for causal conclusions about the impact of the intervention. The results primarily focus on process measures. Additionally, there is potential for selection and reviewer bias in how cases were identified, flagged, and reviewed, and the lack of standardized criteria and detailed methodology may limit reproducibility. Finally, the relatively small sample size and limited study timeframe constrain the ability to evaluate long-term trends or sustained effects of the review process. Future analyses will evaluate the impact on geriatric surgical patient outcomes such as LOS, readmissions, and complication rates.

Lessons Learned

Developing an interdisciplinary Complications Review Committee—comprising GSV Medical Directors and Coordinators, Surgeons, Geriatricians, Palliative Care providers, Quality Nurse Consultants, and other ad hoc members—proved essential in bringing diverse clinical and operational perspectives to the review process. This multidisciplinary approach enabled more comprehensive evaluation of cases and fostered a deeper understanding of the relationship between missed episodes of care, variation in practice, and resulting patient outcomes. It also strengthened collaboration across departments and promoted shared accountability for improvement efforts.

Establishing a comprehensive and efficient review process significantly increased the volume and consistency of complications reviewed across both programs. This structured approach allowed for more reliable identification of both local program-specific issues and broader system-wide trends, which may have otherwise been missed with less standardized methods. The ability to consistently capture, review, and analyze complication data created a more proactive and data-driven infrastructure to support ongoing quality and performance improvement work.

The biggest barrier encountered was the consistent availability of members of the interdisciplinary review team. While attendance has generally been limited, the sessions that do occur are thorough and meaningful. Reviews are conducted with strong engagement from those present, resulting in well-developed recommendations that are shared broadly to enhance overall program performance. Continued meeting time adjustments are in progress to identify a more consistent schedule that accommodates a majority of interdisciplinary team members and supports more robust and representative participation.

Conducting a preliminary review of all cases with ACS-defined complications was critical in determining which cases would be the most meaningful and impactful to present at Quarterly GSQC meetings. This approach ensured that case selection was intentional and aligned with identified trends, areas of risk, and opportunities for improvement, rather than relying on random or convenience-based selection. As a result, GSQC discussions became more focused, relevant, and actionable, supporting more effective engagement of leadership and frontline teams in driving targeted improvements in geriatric surgical care.

References

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