American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

ACS Quality Verification Program

Verifying Quality Across the House of Surgery

The ACS Quality Verification Program is based on the Optimal Resources for Surgical Quality and Safety or “Red Book,” the surgical quality how-to manual gleaned from the knowledge of hundreds of surgeon content experts and the ACS’ experience working with the 3,000 hospitals that currently participate in ACS Quality Programs. The Red Book manual establishes an overarching framework to ensure quality resources and infrastructure improve care for all surgical patients at your institution. The ACS Quality Verification Program takes core elements of the Red Book to establish standards and a process for verification that aims to establish a surgical quality program that improves efficiency, care, and value for all surgical patients across all divisions of surgery within the hospital. It is designed to establish a comprehensive surgical quality program at both the hospital level and also across hospital systems and networks. Participating hospitals have found this verification process to be essential to establishing and improving their hospitals’ organizational infrastructure for surgical quality.

Optimal Resources for Surgical Quality and Safety -> ACS Quality Verification

Twelve Standards Create the Foundation for Surgical Quality

Twelve salient elements of surgical quality have been adapted from the Red Book manual into standards that form the foundation of The ACS Quality Verification Program.  These standards span all surgical specialties to provide a roadmap for hospitals to build a successful surgical quality program—by establishing, measuring, and continuously improving their hospital’s infrastructure for surgical quality.  Standards include detailed resources at both the hospital- and individual specialty-level to guide surgical departments broadly and dive deep into surgical quality in each specialty. Communication flow is an overarching theme, up and down from top-level administrators to front-line staff, as well as across specialties to minimize silos of quality. The ACS Quality Verification Program Standards include the following:

  1. Leadership Commitment and Engagement to Surgical Quality and Safety
    Hospital administrators demonstrate commitment through engaged leadership and financial resources to support surgical quality and ensure alignment with hospital strategic priorities.
  2. Surgical Quality Officer
    A designated, qualified surgeon leader(s) oversees and is accountable for quality across all surgery departments and divisions.
  3. Surgical Quality and Safety Committee
    A committee with representation from all surgical specialties and adjunctive disciplines serves as a forum for surgery-wide quality activities.  This committee provides infrastructure that fosters communication across and up and down the institution.
  4. Safety Culture
    Establish a generative safety culture and practice of high-reliability principles that is core to the hospital’s mission, embedded and identifiable throughout the institution. There is training and regular formal assessment of the hospital’s safety culture at all levels of the institution— from frontline providers to hospital administration—and results drive tailored improvement initiatives and ongoing safety culture education.
  5. Data Collection and Surveillance
    Standardize processes and sufficient resources for collecting, analyzing, and reviewing clinically relevant data (risk-adjusted and benchmarked when available) to monitor and identify potential surgical quality and safety issues at the hospital and individual specialty level. Data are shared regularly with hospital leadership and frontline surgeons and staff.
  6. Continuous Quality Improvement Using Data
    Have dedicated and sufficient resources to support formal quality and process improvement on the basis of high-quality, reliable data at both the hospital and individual specialty level.
  7. Case Review
    Have a standardized, documented process for formal retrospective case review to monitor adverse events, assess compliance with protocols, and identify opportunities for improvement and standardization.
  8. Surgeon Review
    Have standardized processes to monitor and address quality and safety issues with individual surgeon practice through a formal peer review process.
  9. Surgical Credentialing and Privileging
    Have meaningful and thorough processes for credentialing and privileging that ensures all surgeons are qualified and able to provide safe and appropriate surgical care.  Includes formal onboarding process with direct observation where appropriate and surgeon leadership involvement in development of specific privileging criteria for complex procedures.
  10. Standardized and Team Based Processes in the Five Phases of Care
    Have standardized processes across all surgical specialties and phases of care (I. Pre-operative, II. Immediate Pre-operative, III. Intra-operative, IV. Post-operative, V. Post-discharge). May  include standardized preoperative evaluation and patient optimization procedures, enhanced recovery protocols, geriatric-specific protocols, intraoperative procedures such as timeouts and hand-offs, and discharge and post-discharge protocols to ensure safe pain and wound management, appropriate follow-up, and continuity of care is provided post-operatively.
  11. Disease-Based Management
    Have standardized, evidence-based, multi-disciplinary management of specific diseases. Often referred to as integrated practice units, these units may include multi-disciplinary care bundles for cancer care, joint replacement, colorectal surgery, bariatric surgery, inflammatory bowel disease, etc.  Disease-based management programs may be locally developed or through participation in an external disease-specific program.
  12. Compliance with Hospital-Level Regulatory Performance Metrics
    Communicate regulatory performance metrics to front line surgeons and staff to drive awareness and quality improvement initiatives.  Effort is made by leadership to balance prioritization of quality improvement based on regulatory metrics and other hospital-identified quality improvement initiatives to ensure both are resourced.

Ensure your surgery program is able to…

…. FIND your problems with reliable, clinically relevant, benchmarked DATA

… have appropriate mechanisms to SOLVE your problems

… and have the underlying organizational infrastructure to COMMUNICATE findings and PREVENT future problems.

The ACS Quality Verification Program standards and ongoing participation as an ACS Quality Hospital provides tools to develop…

STANDARDIZATION and a SYSTEM APPROACH to care

  • reduce complications
  • minimize waste
  • and increase value for patients

Not sure where to begin?

Many hospitals and individual surgeons are committed to improving quality for surgical patients, but disjointed communication across departments and variability of dedicated resources and infrastructure often hamper meaningful progress.

Are you confident that…

  • Your Quality Officer is aware of all surgical complications through a robust surveillance process?
  • Complications are evaluated consistently and resolved appropriately across departments of surgery?
  • You can identify and distinguish between system problems and poor performance by providers?
  • You have a process and sufficient resources for achieving quality improvement?
  • You have the appropriate tools to increase the value of the care you offer?

Using the framework established in The ACS Quality Verification Program, you can instill confidence in your hospital leadership, surgeons, clinical staff, and patients that there is a core infrastructure that underpins quality across all departments and divisions of surgery.

The ACS Quality Verification Program Will Help You Improve Quality

The ACS Quality Verification Program partners with you to help you establish the resources and team you need to build a robust quality infrastructure. 

  • The Red Book serves as a “how-to manual” to articulate a comprehensive framework and serve as guide to surgical quality.
  • The ACS Quality Verification Programs serves as a template for creating a surgical quality program at your hospital or across a hospital system or network.
  • The ACS Quality Verification Program Standards help you make the case to hospital administration to obtain the resources you need.
  • Participation in The ACS Quality Verification Program helps you break through the noise to focus attention on surgical quality and helps you engage leaders and frontline surgeons and staff to build a coalition for quality.
  • Verification site visits approximately every three years conducted by an external peer review team help you hold up the mirror to your institution and provide a customized, detailed report that serves as a roadmap to help you promote your  strengths and address areas that need further development.
  • Recognition as an ACS Quality Hospital helps you demonstrate to patients and your community that your hospital is committed to high quality care and to providing value to patients.

The Continuous Quality Journey

Regardless of the maturity of your surgical quality processes, The ACS Quality Verification Program is designed to help you celebrate and promote your surgery program’s strengths as well as identify opportunities for improvement and ensure you are on the right path to improving surgical quality and subsequently value for all patients.

To find out more about how your institution can participate, contact ACSQuality@facs.org.