Surgical quality and safety rely on institutional leadership, resources, and culture

September 28, 2020

CHICAGO: Hospital resources and infrastructure dedicated to improving quality and safety are essential for achieving safe and high-quality surgical outcomes. A comprehensive review of four key principles of the American College of Surgeons (ACS) Quality Verification Program demonstrates the importance of an overall hospital culture of quality and safety, including top- and mid-level, quality-focused leadership and a committee dedicated to quality improvement. Results of the review are published as an "article in press" on the Journal of the American College of Surgeons website in advance of print.

"This peer-reviewed article highlights how important it is for hospitals to have infrastructure and resources for building a surgical quality improvement program. Leadership, in the corporate suite, mid-level leadership involved in improving quality, committees focused on surgical quality and safety, and an overall culture of safety and high-reliability help assure the delivery of high-quality care to patients," said Chelsea Fischer, MD, MS, ACS Clinical Scholar in Residence and co-first-author of the literature review.

The ACS Quality Verification Program helps surgeons and hospitals identify the resources needed for robust surgical quality improvement. The program is based on a set of principles or standards at the foundation of surgical quality. These principles were gleaned from the knowledge and experience of surgical experts as well as the ACS' experience with 3,000 hospitals that participate in the ACS Quality Program. The principles were published in the Optimal Resources for Surgical Quality and Safety, also known as the ACS Red Book.

"By using the ACS Red Book framework, the ACS Quality Verification Program provides a structured mechanism by which hospitals can focus on their surgical quality efforts in a standardized manner. The program has been developed to assure hospital leadership, surgeons, clinical staff, and patients that there's a core infrastructure in place underpinning quality across all departments and divisions of surgery," said David B. Hoyt, MD, FACS, article coauthor and ACS Executive Director.

The basis of the Quality Verification Program rests on 12 standards: leadership commitment and engagement, surgical quality officer, surgical quality and safety committee, safety culture, data collection and surveillance, continuous quality improvement using data, case review, surgeon review, surgical credentialing and privileging, standardized and team-based processes of care, disease-based management, and compliance with regulatory performance metrics.

The literature review in JACS is the first of three investigations to examine the evidence that supports these standards. The study gathered and analyzed evidence associated with the first four principles that address institutional and administrative factors necessary for high quality surgical care: a top-down commitment to quality, mid-level leadership, and committee structure, including the scope and governance of a quality program and infrastructure.

"This article provides a robust body of evidence for the foundation of the ACS Quality Verification Program. The program is based on standardization and a system approach to surgical care. This program has been developed to reduce patient complications, minimize waste for surgical care teams, and increase the value of surgery for our patients," explained article coauthor, Clifford Y. Ko, MD, MSHS, FACS,

FASCRS, Director of the ACS Division of Research and Optimal Patient Care.

The U.S. National Library of Medicine's Medline database was searched for articles published between its inception in 1964 and January 2019. Articles evaluated the relationship between one of the Red Book principles and patient or organizational quality outcomes. Two reviewers synthesized and summarized information from these studies.

After identifying 5,332 studies involving the four principles, a total of 477 were selected for systematic review. Several primary studies also were included for assessment.


Individual articles covering 30 years of research on senior or executive leadership in health care were included in four systematic reviews. Evidence from these investigations showed clinical quality improved when senior leaders were engaged and committed to quality. Higher levels of incident reporting that reduced medical errors, better compliance with guidelines, improved efficiency and safety, and interventions targeted at improving specific health outcomes were some of the findings linked to the actions of executive leaders.

Providing resources or visibly engaging in quality and safety endeavors also fostered successful quality improvement efforts.

Surgical Quality Officer

Medline articles and systematic reviews of studies over 32 years related effective mid-level management in quality improvement with better patient and organizational outcomes. The evidence showed that a surgical quality officer positively affected quality improvement efforts and the way they were conducted.

Surgical Quality and Safety Committee

The evidence indicated that a quality and safety committee must have wide clinical representation, well-defined goals, and clear lines of communication and authority to ensure quality improvement efforts will be effective.

Culture of Safety and Reliability

Medline articles and studies covering a 20-year period showed that organizational culture improved patient outcomes and safety in the workplace. Among the most effective aspects of institutional culture were education programs, communication tools, leadership walk-arounds, and comprehensive unit-based programs.

"Principles related to leadership, resources, and culture help keep surgery safe and reliable. With these concepts in place, hospitals can deliver consistent, quality surgical care to patients and improve patient outcomes," said Dr. Fischer.
Other study authors include Q. Lina Hu, MD, MS (co-first-author); Annie B. Wescott, MLIS; and Melinda Maggard-Gibbons, MD, MSHS.

"FACS" designates that a surgeon is a Fellow of the American College of Surgeons.

Authors declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Citation: Evidence Review for the American College of Surgeons Quality Verification. Part I: Building Quality and Safety Resources and Infrastructure. Journal of American College of Surgeons. DOI:

About the American College of Surgeons

The American College of Surgeons is a scientific and educational organization of surgeons that was founded in 1913 to raise the standards of surgical practice and improve the quality of care for all surgical patients. The College is dedicated to the ethical and competent practice of surgery. Its achievements have significantly influenced the course of scientific surgery in America and have established it as an important advocate for all surgical patients. The College has more than 82,000 members and is the largest organization of surgeons in the world. For more information, visit

American College of Surgeons

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