Vanderbilt University Hospital has received the American College of Surgeons (ACS) Quality Verification Program (QVP) focused verification, a national recognition of the hospital’s strong infrastructure and data-driven processes to deliver high-quality, safe surgical care to patients.
QVP-verified hospitals undergo a rigorous assessment of their surgical quality and safety practices, including a site visit by an external peer review team. During VUH’s virtual, two-day site visit in February, a dozen standards were examined for two areas — colorectal surgery and elective general surgery. Many interviews with individuals involved in surgical care were conducted during the visit.
“This is the highest national verification a hospital can achieve that clearly signifies that we have the infrastructure in place and protocols consistently implemented to ensure our patients receive the best possible surgical care,” said Lee Ann Liska, MBA, President and Chief Operating Officer of VUH. “The QVP verification lets patients know VUH is dedicated to quality and safety and that our hospital adheres to the most rigorous surgical quality standards.
“From the moment a patient is evaluated for a possible surgical intervention until they are managed during their follow-up care, we have evidence-based processes in place to deliver a high-quality, safe surgical experience. Our health system also has robust data collection to ensure the protocols we’ve put in place deliver the positive outcomes we expect for our patients.”
The QVP site review included an examination of all stages of perioperative care:pre-operative (when an individual’s surgical risk is assessed and health optimized), immediate pre-operative, intraoperative, post-operative and post-discharge. Standards evaluated include commitment and engagement of leadership, program scope and governance, protocols, data collection and surveillance, and quality improvement.
“Vanderbilt University Medical Center is a robust, remarkably well-resourced organization and surgical program that has thoroughly embraced a culture of excellence, quality, safety and high reliability,” reviewers noted in their post-visit report. “Leadership in surgery, anesthesiology and perioperative operations is exceptional in both vision and capability.”
“This certification underscores the commitment of the Vanderbilt surgical and perioperative community to patient safety and quality of care,” said Roger Dmochowski, MD, MMHC, Vice President and Executive Medical Director of Perioperative Services at VUH. “This certification also manifests the commitment to the unique care of each patient and the continuous pursuit of excellence associated with that commitment.”
Eunice Huang, MD, MS, vice chair for Surgical Quality and Patient Safety in the Section of Surgical Sciences at VUMC, joined the health system in 2021, the same year the ACS began the QVP. After becoming familiar with VUH’s infrastructure and processes, she felt the hospital was ready to go through the verification review.
“It was important to work toward this QVP verification, because we do a lot of quality improvement work here,” said Huang. “It’s part of our DNA and part of our culture. Patients are always first here, and quality is a big component of that.
“It was helpful to have an external entity that is recognized throughout the world as the expert in surgical quality come in, look at our system and validate areas in which we are very strong, and also provide the opportunity to consider some efficiencies or learning from other institutions that are also very high quality.”
The hospital’s enhanced recovery after surgery (ERAS) program, which VUH implemented more than a decade ago, was especially praised by the QVP reviewers. The goals of ERAS are to help patients recover from surgery more quickly, leave the hospital earlier and experience fewer side effects from pain management.
The site reviewers reported, “The ERAS program is exceptional in every way. It is comprehensive, nimble, data-driven and thorough.”
Because of the marked evidence of its success, ERAS has now been implemented in 11 adult surgical specialties at VUH, from colorectal surgery to elective spine surgery. ERAS protocols have also been applied in pediatric surgery programs at Monroe Carell Jr. Children’s Hospital at Vanderbilt.
While the QVP focused verification concentrated on VUH, the process also stands to benefit the Regional Hospitals that are part of the Vanderbilt Health system, Huang noted.
“Our strategy is that, with this verification, we will have defined standards and processes that we deem as best practice,” she said. “We hopefully can take this to our Regional Hospitals to achieve similar outcomes, understanding that we likely will have to redesign some of the infrastructure to meet their specific needs.”
Huang added that the QVP verification demonstrates VUH’s longstanding commitment to providing top-quality, patient-centered surgical care.
“Everyone involved in any aspect of surgical care at VUH is to be commended for this,” she said. “That includes our Environmental Services personnel who keep our spaces clean, sterile processing techs, perioperative space managers, nurses, surgical techs, surgeons, anesthesiologists, clinic staff, case managers — everyone.”
The VUH team leading the QVP verification included Christopher Dornbusch, lead project manager in the Section of Surgical Sciences; Joel “Trey” Bradley III, MD, assistant professor of Surgery in the Division of General Surgery; Aimal Khan, MD, assistant professor of Colorectal Surgery in the division of General Surgery; Mary DeVault, MSN, RN, senior director of Quality and Safety for Perioperative Services; and Barbara Martin, RN, MBA, director of Quality, Safety & Risk Prevention.
Verification site visits for ACS QVP-participating hospitals occur approximately every three years. ACS is a scientific and educational organization of surgeons with more than 90,000 members. Its mission is to raise the standards of surgical practice and improve the quality of care for all surgical patients.
