Continuously improving our processes to ensure safe and high quality care is not only what the public demands of us; it is now tied to our reimbursement. Authorized by the Affordable Care Act, the Hospital Value-Based Purchasing (VBP) program is the beginning of a historic change in how Medicare pays healthcare providers and facilities—for the first time hospitals across the country will be paid for inpatient acute care services based on care quality, not just the quantity of the services provided. In order to succeed and sustain gains in reducing care-associated adverse events while continuing to fund our mission to provide high quality care, healthcare institutions must embrace standardized, evidence-based practices as well as purposeful engagement of the entire healthcare team. Human factors and in particular, unanticipated events in the operating room during high acuity surgery are a stark and often unnerving reality [19, 20]. Therefore, we as surgeons , partnering with the CSQO and hospital administration, must be responsible to develop a strong safety culture that demonstrates effective coordination of care, identifies gaps and engages caregivers who proactively and thoughtfully bring solutions forward to provide the highest quality of care for all patients [21].

Every department of surgery and healthcare institution is structured a little differently. Nonetheless, some form of departmental Quality Committee, that is aligned with the healthcare institution is essential. The true north for such a committee should be providing the highest quality of care for all surgical patients, which implies care that is safe, efficient, effective, patient centered, timely, and equitable [22]. It is the responsibility of the CSQO to ensure that all of these Institute of Medicine aims are fulfilled within a department and health system so that the delivery of quality care is given equal attention and prioritization. To that end, the departmental Quality Committee should have a representative from each surgical division within the Department. Meetings are typically monthly and often the timing may need to be creative to accommodate surgical schedules. Additional key members of the committee include representatives from the operating room—particularly nursing, the surgical intensive care unit, the surgical care unit, and pharmacy. Data managers and/or epidemiologists and hospital quality administrative support are essential. Other invited guests should be chosen depending on the topic being discussed. For example, infectious disease representatives and infection control staff would be appropriate when discussing wound infection rates. Residents and medical students should always be encouraged to attend. Risk managers and compliance representatives may be appropriate at times but should not dominate the conversations. Quality managers and data analysts that assist with data collection and process improvement should be considered a part of the committee and not simply facilitators of the process. Table 15.2 considering busy operating schedules, each divisional quality lead should have an alternate and at a minimum, each divisional lead should complete basic Quality and Patient Safety training prior to being nominated to the departmental committee. The reporting of the departmental quality committee should be to the Hospital or System level Quality and Patient Safety Committee, and the CSQO should be an active member of a larger hospital oversight committee. Similarly, the CSQO should identify a Co-chair of the Departmental Quality Committee to attend the system level meeting when he or she is unavailable to ensure a continued presence at the health system level.

As each hospital or medical center may be organized differently, the above Quality committee structure should be considered flexible. For example, if a hospital has multiple surgical departments, then a representative of each department should be a member of the committee, rather than divisional members. In addition, at large members are important to help message to the middle part of the organization.

Although the CSQO charge may vary from institution to institution, in addition to eliminating adverse events, he or she will often be asked to lead efforts to balance a sometimes conflicting set of responsibilities. This list includes, but is not limited to, educating surgeons and trainees about quality and process improvement, achieving compliance with a growing list of external mandates that may not always seem rational, standardizing and streamlining care pathways, ensuring appropriateness, and making difficult decisions about resources. The CSQO requires a unique skill set, including not only the ability to listen and a willingness to work for consensus, but also the authority and fortitude to make some decisions that may not always be greeted with enthusiasm. Ultimately, the CSQO is responsible for aligning the Department of Surgery with hospital or institutional initiatives. Often, hospital goals or key result areas are significantly impacted by surgical services and outcomes. Having the department understand how their performance impacts the institution as a whole is vital to sustained improvements. Clear definition of the reporting structure and quality oversight is key, and understanding that not only is the reporting fixed, but that the ultimate responsibility of the leadership and board can be leveraged is often very helpful. An example of one is provided in Fig. 15.1. Impacting mortality and reducing sentinel events, including retained foreign bodies and wrong site procedures, the CSQO may serve as the project leader or champion for programs aimed at process improvement [23–25]. Approaches such as team training or Crew Resource Management are really surgically driven programs that have been shown to improve outcomes [26–30]. Without the leadership and direction of the CSQO and key members of surgical departments and divisions, such programs are unlikely to be successful and could serve as a source of frustration for all surgeons involved. The CSQO should be the advocate for the individual surgeon when these initiatives are being rolled out while he or she is leveraging the institutional support to render the initiative successful [31]. Sentinel events often can only be addressed after thorough root cause or common cause analysis. To that end, the CSQO may serve as the lead physician on these workgroups and be responsible for devising and implementing countermeasures to prevent them from happening again. Inherent to this process is the sharing of often sensitive data when a surgeon or surgical team has been involved in a “never event” [32]. By focusing on the systems issues and sharing the fixes, the CSQO can further the culture of safety and continuous improvement, without compromising the integrity of the surgeon. Using the departmental Quality Committee, to share events and patient safety opportunities is an appropriate venue that is safe and productive. Opportunities that have been realized through careful analysis could be shared using standardized storytelling which could be distributed electronically or in poster format in resident rooms or the perioperative surgeon’s lounge as seen in Fig. 15.2 [33].

Over the past 25 years, measurement of healthcare processes and outcomes has been evolving and rapidly changing. Initially, the focus was on data collection and reporting. Of late, there is a push from business groups, state and national agencies, and most importantly, patients to ask questions about healthcare outcomes, cost, and patient experience. To address these questions at the surgical divisional or departmental level, there must be good and validated data. According to Provost and Murray, “Data are documented observations or results of performing a measurement process. Data can be obtained by perception or by performing a measurement process.” [34]. In order to leverage data and create ultra-safe environments for patients, not only are resources needed, but a relationship between departments, clinical and administrative, must be forged and maintained.