First of all let me describe what the American College of Surgeons National Surgical Quality Improvement Program is all about. The ACS NSQIP is the first nationally validated, risk-adjusted, outcome-based program to measure and improve the quality of surgical care across the US. Named ‘Best in the Nation” by the Institute of Medicine, the ACS NSQIP provides a prospective, peer-controlled, validated data base of preoperative to 30-day postoperative surgical outcomes based on clinical data. A 2009 Annals of Surgery study shows that each hospital participating in ACS NSQIP on average per year prevented 200-250 complications, saved 12-36 lives, and reduced millions of dollars in cost. There are nearly 500 hospitals participating in the program, not only from the US, but also from Canada and some other countries like Australia, Saudi Arabia, and Ireland.

On the first day of the 2013 ACS NSQIP convention, as I walked around the scientific poster exhibits, and attended the workshops and lectures, I was amazed at how large and well-organized the whole activity was. I got to see how comprehensive and seamless the database functioned; and how it was easily utilized to analyze various surgical outcomes within participating hospitals. It certainly required a lot of funding, personnel and effort; and I wondered whether we in the Philippines were ready to embark on a similar project.

It was also very evident to us participants that the ACS NSQIP model was indeed the future of surgery - where surgical outcomes are measured, monitored and analyzed, utilizing scientifically validated processes that are both transparent and formative. Pretty soon prospective patients will be able to check on the performance of hospitals and individual surgeons, comparing their results to national standards. There was, in the conference, a very palpable air of excitement and commitment to this vision.

The morning workshop focused on change management. Dr. Nestor Esnaola, MD, MPH,MBA,FACS and Beth Turrentine, PhD, RN handled the sessions quite effectively. They emphasized how each of us had to become surgeon champions for effective change within our respective institutions; - even as outmoded, inconsistent surgical practices persist, with their attendant risk for complications.

One activity that was quite interesting and enjoyable was the Paper Plane Game. We were grouped into 10 members each, with 1 assigned as pilot, 1 as recorder, and the rest as builders of paper planes. The objectives were to build as many paper planes as we could within 5 minutes, after which the pilot would try to fly each one accurately into a designated corner. The number of accurately flown planes over the total number made was then computed. We analyzed how communication, leadership and planning affected production processes. Quite an effective teaching model, I must say, and I am excited to try it out with my trainees.

The sessions also talked about the Six Sigma and LEAN methods to affect change, concepts I had encountered during my Leadership and Management Development Program at the Ateneo last year. Other phrases and concepts that stuck in my mind today included the following:

1. Use the “Unfreeze-Change-Refreeze” model for more 
effective, lasting change.
2. “Many hands make for light work” versus “ Too many 
cooks spoil the broth”
3. We all carry our faults in our back pocket, which 
everyone else - except us -can see … and so we must 
ever so often check our back pockets”
4. We can’t effectively change things alone. We need to 
build teams and recruit allies, keeping opposers in the 
loop but out of the way.
5. The Quality in Training Initiative entails teaching our 
trainees about surgical quality improvement methods 
now, even while they are still learning basic surgical 
skills.
6. Define Measure Analyze Improve Control (D-M-A-I-C)
7. The “Swarm Theory” - individual ants don’t accomplish 
much, but their collective ant colonies function and 
outlive the almost inconsequential individual
8. Pick the “low-hanging fruits” first for easy success … 
celebrate each small success in order to keep the team’s 
efforts motivated towards the “higher hanging fruits”.
9. Planning for change should take 60% of the time; the 
rest is spent on implementation.

As all these information swirled around me, I could not help but wonder how such concepts and models could be applied in the Philippines, particularly in the face of the inevitable propagation of surgical quality improvement initiatives worldwide. True, we have many problems in terms of logistics, funding, personnel and archaic practices. Certainly such programs will require collaboration between DOH, Philhealth, HMOs, and hospitals, both government and private; but such collaboration is not actually beyond our reach. One dichotomy we will need to resolve is whether to simply adopt and join ACS NSQIP, which will save us time, money, effort and personnel (at the expense of nationalist self-determination); or to create our own Philippine surgical quality improvement initiative, despite obvious challenges in funding and structural support.

I am happy in fact that there are established quality improvement pathways for colorectal surgery that have been validated, not just by ACS NQIP, but by other European programs. ERAS (Enhanced Recovery After Surgery) is now an accepted program for colorectal surgery in England, and I had the opportunity to read on it during my flight here. Indeed, ERAS for me is a “low-hanging” fruit which I can implement in the hospitals I am connected with, improving outcomes for my patients, but also allowing me to develop models and strategies to bring further change within the national framework. We can analyze our results, write about them, and then cascade them to other institutions, as well as other fields of surgery. Let’s see where that leads us afterwards.

Finally, I was fortunate to meet a Filipino surgeon also attending this year’s ACS NSQIP. His name is Jhun de Villa, who finished general surgery in Ilocos (and rotated in pediatric surgery in PGH, where we crossed paths), after which he emigrated to the US, retrained in general surgery, but now works quite effectively as the Surgical Performance Improvement Officer of the Department of Surgery, University of Florida. He has had much experience in implementing and propagating ACS NSQIP in his hospital. He will be a valuable resource for us Filipinos, as we develop our surgical quality improvement programs for our national organizations, governmental institutions, specific hospitals, and individual surgeons.

Till my next blog tomorrow….

Day 3 ACS NSQIP

Day 3 began with an early breakfast, “breakout” meeting to initiate the ACS NSQIP Enhanced Recovery After Surgery (ERAS) Collaborative Pilot Project. ERAS was actually developed in Europe, particularly for colorectal surgery, where it has significantly decreased post-operative recovery period and hospital stay. I had finished reading the manual on ERAS before arriving at the convention, so it was quite interesting for me to witness how plans were made to implement it in the ACS. Those present included Surgeon Champions and Surgical Clinical Reviewers from about 10 selected hospitals. It was a quick, preliminary meeting, but I could sense both the enthusiasm of the participants, as well as the multidisciplinary camaraderie that permeated the discussions. 

Dr. Clifford Ko himself moderated the event and led the discussions. It was quite inspiring to see him in action. At the end, he also introduced the next project to be piloted after ERAS, this time called RIOT or Return Into Oncologic Therapy. This also a topic I am quite interested in. Recent data has shown that patients, whose recovery after cancer surgery was delayed, subsequently had delays in the initiation of their chemotherapy, resulting in significant worsening of cancer outcomes. The hypothesis therefore is, like with ERAS, if the postoperative recovery can be shortened and made safe from complications, then perhaps adjuvant cancer treatment could be started earlier, with better long-term cancer survival. To emphasize the point on RIOT, the team from MD Anderson presented their experience on ERILS (Enhanced Recovery In Liver Surgery), where adjuvant chemotherapy after liver metastasectomy was an important component in long-term survival. Makes very good sense to me. 

Moving back to ERAS, the program emphasizes optimal return to normal function after surgery, with good functional quality and well-being (rather than just speed of recovery or discharge). It uses a multidisciplinary team approach, with focus on metabolic stress reduction, and promotion of rapid return to optimal function. It promotes normoglycemia and prevents insulin resistance by allowing high carbohydrate drinks up to 2 hours prior to surgery, with early resumption of diet immediately thereafter. Analgesia management should avoid the use of opioids that delay bowel activity, and use other options such as lidocaine drip or TAP (Transversus Abdominis Percutaneous regional block) Other elements are more familiar to most Filipino surgeons, such as early ambulation, deep breathing exercises, mouth washes, early removal of foley catheters, goal directed IV fluid management to prevent both over and under hydration, oxygen supplementation, DVT prophylaxis, etc.. What ERAS does is to combine and synchronize all these various elements to promote earlier functional recovery and reduce the metabolic stress response. 

NSQIP promotes the same concept, but provides a sophisticated data base to evaluate outcomes. Furthermore, the database not just focuses on colorectal patients, but also on other disciplines, such as vascular, hepatobiliary, breast, neurosurgery, head and neck, bariatric, and gynecologic surgery, among others. In that senses, NSQIP allows the development of multiple enhanced recovery programs across various disciplines. Finally, because NSQIP is a national database involving more than 500 US and foreign hospitals, it also provides individual users (whether hospital or surgeon) meaningful statistical feedback, and consequently the ability to benchmark against the national/international mean, or against the performance of other like-practitioners. 

After the breakfast collaborative meeting, I moved on to the other sessions, the first of which discussed the ROUTE bundle (Respiratory care; Oral care; Up from bed; Tilt bed up when lying; and Exercise program) to prevent post-operative pneumonia. It was pointed out that, over-all, pneumonia accounts for 40% of surgical mortality. Hence the need for programs such as ROUTE. Interestingly, oral care called for intensive promotion for daily brushing of the teeth, as well as twice daily chlorhexidine mouthwash.

The next session discussed another adverse and measurable outcome: hospital readmission within 30 days following discharge after surgery. Such readmissions reportedly occurred in 10 – 15% of colorectal surgery; 20% of all Medicare cases; costing them approximately 17 billion US dollars annually. Several bundles and programs were presented that addressed this issue, although their setbacks were also discussed. Indeed, one of the key messages on quality improvement was to “fail forward”; in other words not to aim for perfection, but rather to reach for small victories, and that even with initial small failures, the program was actually moving forward. 

Obviously all programs face hurdles and various challenges within different hospital cultures. Certainly, it has become an era of greater transparency within the US healthcare system; and HMOs and other third party payers are seeking ways, and providing incentives, to decrease complications and improve care. The term for it therefore is Iterative Quality Improvement, where mathematical or computational process are applied to objective outcomes parameters. There is also an important need for continuous innovation in the field of medicine, tempered by sound clinical research and evidence-based processes. Quality improvement and evidence-based practice go hand-in-hand.

The next session focused on Acute Care Surgery, where the US national trend has been the development of dedicated surgical teams to be “at the right place at the right time” for any emergency, whether trauma, acute abdomen, etc…The emphasis again is on achieving mastery in all areas of acute care, including critical care. Indeed, emergency laparotomies carry a 15% over-all-mortality, rising to 24% in patients over 80 years of age. Emergency operations have a 7-fold mortality rate and a 3-fold morbidity rate compared to elective procedures. 42% of emergency operations are septic on admission - a significant predictor of morbidity, and of mortality, which increases by 8% every hour there is a delay in even just the initiation of antibiotics.

The development of Sepsis Bundles and protocols has resulted in a 7 to 25% reduction in mortality. Acute care surgeons are at home in the ICU and tend to utilize it more than the other specialties. Surviving sepsis guidelines have been established, which includes a MEWS database (Modified Early Warning Score). Acute surgical care teams have developed capabilities to treat patients at the get-go, and to provide a continuum of care for critical patients. Goal-directed fluid replacement protocols have been established, including recommendations for the use of colloids and of keeping serum lactate at survivable levels. 

This trend is something Filipino surgical educators need to look closely at. I have often expressed the need to integrate trauma, acute surgical care and critical care into one comprehensive fellowship-training program. Such a program would fulfill the country’s requirements for surgeons highly skilled in trauma, which is still the number one surgical condition nationwide. 

As a busy surgeon often engaged with complex colorectal conditions, I recognize the unique and important role surgical intensivists perform for patients who are septic, with multiple co-morbidities, requiring close physiologic monitoring, with critical fluid and nutritional management, and continuous aseptic care of intravenous access lines. I feel fortunate that there are foreign-trained colleagues who can fulfill this role for me right now; but we certainly need local training programs in acute surgical care - with strong skills in critical care - to supply the future manpower needs for our country. 

Sadly there is a perception in the country that trauma and surgical intensive care are non-viable specialties with weak reimbursement processes. As such, trauma training programs, despite their importance, have had difficulty recruiting applicants for the past several years. The solution I see, to assure viability and sustainability of these specialty programs, is to incorporate non-traumatic surgical emergencies into their scope of practice. Certainly many of such emergencies will also need the critical care expertise of surgical intensivists. Patients with non-traumatic surgical emergencies also appear to have better paying capabilities than those with trauma, whether through third party payers, or directly out-of-pocket. Definitely our tertiary hospitals, as they upgrade their capabilities to meet 21st century needs, will require more and more the services of acute surgical care specialists. 

Furthermore, highly specialized surgeons, such as colorectal surgeons, hepatobiliary surgeons, neurosurgeons, cardiothoracic and vascular surgeons, bariatric surgeons etc… are all so busy managing their own elective cases that they will surely appreciate the complementary work of acute surgical care. In the same way that emergency cases get in the way of my own elective colorectal cases; the lecturer Dr. David Evans pointed out that for acute care surgeons like him, elective surgery gets in the way of their emergency operations and they would prefer not doing such elective cases anymore. There is in that sense a season and a place for everyone.

The last sessions I attended focused on colorectal surgery, the highlights of which follow:


10 tips for improving colectomy outcomes by Dr. Husein Moloo:

1. Know your own outcomes, preferably with the help of 
NSQIP.
• Be cognizant of Hawthorne effect.

2. Have a plan of action to deal with what you find in the 
data.
• Use DMAIC (Define-Measure-Analyze-Improve-
Control)
• Note that “A well defined problem is a problem 
half-solved.”
• Get help.
• Get educated. We need surgeons to buy –in.
• CUSP (Comprehensive Unit Based Safetey 
Programs) are used to, for instance, decrease SSI

3. The Hedgehog Concept:
• An intersection of the following:
o What you are passionate about
o What you can be best in
o What drives your economic engine
• This is an argument therefore for high volume, 
specialized care – and in my case, for my 
continuing passion for colorectal surgery

4. Avoid Surgical Dogmas
Example: Outmoded bowel prep

5. Consider the ERAS Program (Enhanced Recovery After 
Surgery) 

6. As much as possible, do laparoscopy when indicated 

7. Create a Team Environment
• Operating Room Team
• Oncology Team

8. Don’t forget SSIs (Superficial Surgical Site Infections)
• Use CUSP

9. Always aim for optimum patient satisfaction and 
experience
• As we develop colorectal team, make it 
caregiver-centric, not doctor-centric

10. Aim for excellence.
• NSQIP helps achieve excellence



Top 10 Tips in Proctectomy (Rectal Surgery) by Dr. Mary Kwaan

10. Have a Stoma Nurse

9. Use the Post-op Ileostomy Pathway, with
• Pre-op education
• Standardized teaching material

8. Use an omental pedicle flap to cover the pelvis during 
APR

7. Optimize and master the use of surgical staplers

6. Use rectal reconstructive techniques
• Colo J pouch and Ileal J pouch are best

5. MRI for rectal cancer
• Positive margins predits metastasis

4. Neoadjuvant radiotherapy works

3. Do mechanical bowel prep

2. Be a high volume surgeon
• More sphincter preservation
• Higher cancer survival

1. Practice TME (Total Mesorectal Excision)!

Other points for colorectal surgery:
O2 inhalation at 80% 48 hours after surgery
DVT prophylaxis 24 hours before and after, then
Maintenance heparin or fractionated or low 
molecular weight
Compression devices

The day ended with a Fellowship Dinner at the USS Midway, an iconic aircraft carrier now serving as a museum by the bay front of San Diego. Such an awesome marvel of engineering and warfare… I bought myself a Revell plastic model of the ship to build with my youngest son Jonah. I haven’t built a plastic model since high school.