From blueprints to blastoff: Launching the GSV Quality Improvement Program

In 2016, the American College of Surgeons (ACS) laid out a blueprint to improve the quality of surgical care for older adults in the U.S.¹ Developing a quality improvement project centered on older patients undergoing surgery was driven by a number of factors, including the rapid growth in the number of Americans ages 65 and older. In fact, this population is expected to more than double in size from 46 million in 2015 to 98 million in 2060.² Surgeons are particularly affected by an aging population, as older adults account for more than 40 percent of surgical procedures performed.^3-5

In addition, studies have shown that the geriatric population may more often prioritize quality of life over quantity of life. Outcomes such as preserved function and independence, for example, may be more important than traditional postoperative outcome measures, such as morbidity and mortality.⁶ At the same time, older age has been shown to place patients at a greater risk for experiencing postoperative outcomes that may affect quality of life.^7-11

It also is important to note that the model for health care financing has shifted focus on a national level from volume-based to value-based care in an effort to create a system that is safer, more efficient, and patient-centered.¹² As a result of these factors, it became clear that there is a pressing need to identify the unique aspects of care for older adults undergoing surgery, and to create a system that could provide high-quality interdisciplinary surgical care to this vulnerable population.

Building on past success

Since its establishment in 1913, the ACS has played an extensive role in ensuring optimal surgical care through the creation of multiple quality programs in cancer, trauma, bariatric, and pediatric surgery. Building on the experience gained from these other quality programs, the ACS partnered with the John A. Hartford Foundation in 2015 to create the Coalition for Quality in Geriatric Surgery (CQGS). The CQGS includes an interdisciplinary group of more than 50 stakeholder organizations representing patients, caregivers, nurses and other health care professionals (such as pharmacists and social workers), physicians, payors, and health care regulatory bodies (see sidebar). The vision of the CQGS was to improve the surgical care and outcomes of older adults by establishing a quality improvement program with verifiable standards and data based on best evidence, with a focus on what matters most to the individual patient.

When the blueprint for improving geriatric surgical care was first published in the Bulletin in 2016, the CQGS was early in the process of engaging stakeholders and identifying the standards for optimal surgical care of the older adult. The Coalition has since worked diligently to develop these standards, which, over the subsequent three years, have been refined and piloted.

Setting the standards and piloting the program

Preliminary standards were developed in 2016 through a combination of extensive literature review, a series of hospital field visits, and meetings with engaged stakeholder organizations that rated the proposed standards on both validity and feasibility using a modified version of the RAND-University of California Los Angeles (UCLA) Appropriateness Methodology. This process started with 308 standards that stakeholders agreed represented a detailed and comprehensive collection of the key components of geriatric surgical care in the following key areas: goal-setting and decision making, preoperative optimization, immediate preoperative and intraoperative clinical care, postoperative clinical care, transitions of care, program management, and patient outcomes and follow-up.¹³

The 308 standards were ultimately reorganized into 92 standards, and the CQGS invited 15 hospitals to participate in a survey to determine which of the standards were already implemented, understand how easy or difficult the standards would be to implement if not already in practice, and identify and record standards that were confusing or difficult to interpret.¹⁴ Following completion of this survey in 2017, the information was used to refine the standards further into a core group of 33 standards that focused on the following four areas: goals-of-care and decision making, cognitive screening and delirium prevention, maintenance of function and mobility, and nutrition and hydration optimization.

From 2017 to 2018, the standards were presented, discussed, and pilot tested in eight hospitals representing diverse geographic locations, as well as hospital types and sizes. Formal site visits were conducted, which included chart review, interviews with key team members, review of hospital processes and policies, and an evaluation of certain physical parts of the hospital. The results of the pilot testing showed that each hospital was able to implement most of the standards. Several best practices for standard implementation were collected from the pilot sites, including creation of a preoperative checklist for important geriatric surgical screening tools, the use of telecommunication to bridge the gap between hospitals and post-acute care facilities, and others.

Launching the GSV Quality Improvement Program

The Coalition’s work over the last three years has culminated in the creation of the Geriatric Surgery Verification (GSV) Quality Improvement Program. The GSV Program will be unveiled formally at the 2019 ACS Quality and Safety Conference, July 19–22 in Washington, DC, with recognition of the stakeholders and participating pilot hospitals. A Preconference Session will take place July 19, which will focus on the GSV Program development, return on investment, implementation, and enrollment. The conference will include a Geriatric Track with five breakout sessions covering topics ranging from aligning goals-of-care, to moving the needle on geriatric outcomes, to palliative care. At this time, the final GSV standards (32 total, with two optional) will be formally released and interested hospitals will be able to obtain more information on how to become involved in the GSV Program.

Hospitals can enroll in the GSV Program starting at the ACS Clinical Congress 2019, October 27–31 in San Francisco, CA. It is important to note that the GSV Program is applicable to all of the more than 4,000 hospitals in the U.S., regardless of size, teaching status, or geographic location. The GSV Program will be helpful to any hospital that provides care to older adult surgical patients and would like to further optimize care for this vulnerable population through the creation of an interdisciplinary team and the implementation of standardized care processes.

Why should your hospital participate?

The following questions are intended to help surgeons and hospital administrators determine if the GSV Program would benefit their patients:

• Do you operate on patients ages 75 or older?
• Are there opportunities to provide better, more standardized, and more up-to-date care protocols for these patients?
• Do you find postoperative care for older adults sometimes challenging because of new evidence in the literature, new guidelines, or new quality metrics?
• Would your institution find it helpful to implement a program for older adults undergoing surgery that promotes the use of evidence-based standards, identifies infrastructure and protocols, and encourages effective use of data?

If you answered yes to any of these questions, then the GSV Program can help you improve the care you provide to older adults undergoing surgery. This quality improvement program has the potential to affect the entire surgical episode, from preoperative screening to identify vulnerable older adult patients, to implementation of guidelines to minimize postoperative delirium and reduce readmissions. The GSV Program highlights the importance of team-based interdisciplinary care, prioritizes what matters most to older adults and their families, and promotes an implementable, practical, geriatric patient-centered care program to improve surgical care and outcomes.

Over the last three years, the CQGS has taken the blueprint for improving quality in geriatric surgery and transformed it into a reality. Contact the GSV Program for more information, and join us in Washington, DC, this month as we introduce the ACS GSV Quality Improvement Program at the 2019 ACS Quality and Safety Conference.

References

1. Russell MM, Berian JR, Rosenthal RA, Ko CY. Improving quality in geriatric surgery: A blueprint from the American College of Surgeons. Bull Am Coll Surg. 2016;101(12):22-28. Available at: http://bulletin.facs.org/2016/12/improving-quality-in-geriatric-surgery-a-blueprint-from-the-american-college-of-surgeons/. Accessed May 23, 2019.
2. Mather M, Jacobsen LA, and Pollard KM. Aging in the United States. Popul Bull. 2015;70(2):1-20. Available at: https://assets.prb.org/pdf16/aging-us-population-bulletin.pdf. Accessed June 12, 2019.
3. Etzioni DA, Liu JH, Maggard MA, Ko CY. The aging population and its impact on the surgery workforce. Ann Surg. 2003;238(2):170-177.
4. Etzioni DA, Liu JH, O’Connell JB, Maggard MA, Ko CY. Elderly patients in surgical workloads: A population-based analysis. Am Surg. 2003;69(11):961-965.
5. Centers for Disease Control and Prevention. Number of discharges from short-stay hospitals, by first-listed diagnosis and age: United States, 2010. Available at: www.cdc.gov/nchs/data/nhds/3firstlisted/2010first3_numberage.pdf. Accessed May 7, 2019.
6. Hofman CS, Makai P, Boter H, et al. The influence of age on health valuations: The older olds prefer functional independence while the younger olds prefer less morbidity. Clin Interv Aging. 2015;10:1131-1139.
7. Berian JR, Mohanty S, Ko CY, Rosenthal RA, Robinson TN. Association of loss of independence with readmission and death after discharge in older patients after surgical procedures. JAMA Surg. 2016;151(9):e161689.
8. Lawrence VA, Hazuda HP, Cornell JE, et al. Functional independence after major abdominal surgery in the elderly. J Am Coll Surg. 2004;199(5):762-772.
9. Finlayson E, Zhao S, Boscardin WJ, Fries BE, Landefeld CS, Dudley RA. Functional status after colon cancer surgery in elderly nursing home residents. J Am Geriatr Soc. 2012;60(5):967-973.
10. Mohanty S, Liu Y, Paruch JL, et al. Risk of discharge to postacute care: A patient-centered outcome for the American College Of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator. JAMA Surg. 2015;150(5):480-484.
11. Robinson TN, Raeburn CD, Tran ZV, Angles EM, Brenner LA, Moss M. Postoperative delirium in the elderly: Risk factors and outcomes. Ann Surg. 2009;249(1):173-178.
12. Centers for Medicare & Medicaid Services. Quality Payment Program. Available at: https://qpp.cms.gov/. Accessed May 7, 2019.
13. Berian JR, Rosenthal RA, Baker TL, et al. Hospital standards to promote optimal surgical care of the older adult: A report from the Coalition for Quality in Geriatric Surgery. Ann Surg. 2018;267(2):280-290.
14. Hornor MA, Tang VL, Berian J, et al. Optimizing the feasibility and scalability of a geriatric surgery quality improvement initiative. J Am Geriatr Soc. 2019;67(5):1074-1078.