certify patient education programs, resources, and
materials; optimize resources through collaboration
and sharing; train patient educators in interdisciplinary and interprofessional teams to deliver the
best surgical care; credential and certify patient
educators; and increase awareness of the positive
impact of patient education on patient care outcomes and safety.
The ACS Committee to Enhance Peak Performance
in Surgery through Recognition and Mitigation
of the Impact of Fatigue has been engaged in the
development of an online curriculum. A manuscript based on the activities of the committee is
Continuous quality improvement (CQI)
The 10th annual ACS National Surgical Quality
Improvement Program (ACS NSQIP®) National Conference took place in July in Chicago with more than
1,500 attendees from 676 medical institutions and
15 countries. Some of the nation’s top researchers,
clinicians, and surgeons led lectures, panel discussions, and workshops on a range of topics aimed at
reducing surgical complications, applying quality
improvement techniques to surgical problems, and
maximizing efficiency and resource utilization.
The Joint Commission and the National Quality
Forum presented ACS NSQIP with the 2014 John M.
Eisenberg Patient Safety and Quality Award for Innovation in Patient Safety and Quality at the National
Level. The Eisenberg Awards recognize individuals
and organizations who have significantly contributed to improving patient safety and health care
The Coalition for Quality in Geriatric Surgery Project launched July 1 with funding from the John
A. Hartford Foundation. The project has seven
objectives: set standards, engage key stakeholders,
develop meaningful measures, establish a verification program, educate providers and patients,
pilot the program, and launch the Geriatric Surgery
The Children’s Surgery Verification Program continues to develop. The ACS Task Force for Children’s
Surgery developed the first draft of the Pre-Review
Questionnaire and Optimal Resource Standards from
2012 through 2014 with support from the Society of
Pediatric Anesthesia and the American Pediatric
Surgical Association. The pilot phase launched this
spring and was completed within one month. The
program is set to launch next spring.
More than 800 facilities participate in the
Metabolic and Bariatric Surgery Accreditation and Quality
Improvement Program (MBSAQIP). Over the course
of a year, with 75 trained surgeon surveyors to support the verification effort, more than 325 site visits
The MBSAQIP’s Decreasing Readmissions
through Opportunities Provided (DROP) project
launched in March with more than 120 centers
participating in this effort to decrease 30-day postoperative readmissions.
Review and revision of the second version of the
MBSAQIP standards is under way, with an anticipated release in early 2016, and the MBSAQIP was
again selected as a QCDR for PQRS in 2015.
The number of surgeons participating in the
SSR continues to rise. Surgeons use the registry
to fulfill PQRS and Maintenance of Certification.
Furthermore, on June 15, a measures group was
submitted to CMS for consideration during the
open call for measures PQRS 2017 reporting period.
If approved for PQRS 2017, this measures group,
developed in alignment with the College’s quality
manual, currently in development, includes eight
newly developed, clinically relevant surgical measures, in addition to two applicable PQRS-approved
The ACS, in conjunction with the Northwestern
Patient Safety Education Program (PSEP) and the
Armstrong Institute for Patient Safety and Quality,
piloted a successful one-day “Surgeons Leading Quality”
course October 4. The course featured national leaders in quality improvement who have assisted with
other College courses and QI programs.
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DEC 2015 BULLETIN American College of Surgeons
EXECUTIVE DIRECTOR’S ANNUAL REPORT