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News | Aug. 4, 2022

WRNMMC first DOD facility to earn American College of Surgeons’ new quality verification status

By Bernard Little, WRNMMC Command Communications

The American College of Surgeons (ACS) has recognized Walter Reed National Military Medical Center (WRNMMC) as one of the first 25 hospitals verified through its inaugural Quality Verification Program (QVP). WRNMMC was the only Department of Defense facility achieving the ACS quality verification.
The ACS announced the 25 hospitals, 22 in the United States and three international facilities, earning the verification last month.
“The ACS QVP provides a proven, standardized method for establishing, measuring, and improving a hospital’s quality infrastructure across all surgical departments,” the ACS stated in the release announcing those facilities earning the recognition.
“The recognized QVP centers include a variety of institutions, such as community, large and mid-size academic, public safety net, military, and small/rural hospitals, among others. These facilities were selected to help ensure that ACS QVP can be adapted to unique hospital circumstances and provide customized, actionable feedback to a diverse range of hospitals,” the release added.
“A hospital that elects to participate in the QVP has made a commitment to quality and quality improvement that permeates every aspect of patient care,” added Navy Cmdr. (Dr.) Eric H. Twerdahl, a surgeon in the Division of Vascular Surgery at WRNMMC and the current surgical quality officer at Walter Reed Bethesda.
Twerdahl explained that to be verified, a facility “must, through self-reported information and a confirmatory site visit, demonstrate robust commitment to the 12 QVP standards.” These standards include:
• Leadership commitment and engagement to ensure surgical quality and safety
• A designated Surgical Quality Officer (SQO)
• A Surgical Quality and Safety Committee
• A culture of safety and high-reliability
• Standardized processes and sufficient resources for collective, analyzing, and reviewing clinically relevant data to monitor and identify quality and safety issues
• Continuous, data-driven quality improvement
• A standardized, documented process for formal retrospective case review
• A formal peer-review process to monitor and address quality and safety issues at the individual surgeon level
• Meaningful and thorough processes for credentialing and privileging
• Standardized and team-based processes throughout the continuum of surgical care
• Standardized, evidence-based, multidisciplinary management of specific diseases
• Compliance with hospital-level regulatory performance metrics
Twerdahl explained that although achieving ACS QVP required a team effort, “retired Air Force Col. (Dr.) Peter Learn, surgical quality officer emeritus, was singularly instrumental.” Learn also served as an associate professor of surgery at the Uniformed Services University.
The key principles of ACS QVP are driven by self-reported information, surgical quality data, interviews with key members of the hospital leadership team, and data surveillance and standardized processes and systems that find, fix, and prevent problems to improve the quality and safety of surgical patient care, Twerdahl explained.
“[ACS QVP] status sends a very explicit message to our teammates, our patients, and our military and civilian partners in the region and across the country that our hospital is committed to quality and quality improvement,” Twerdahl stated. “Walter Reed expects to play a leadership and mentorship role for other Military Health System facilities seeking verification,” he added.
The ACS launched the QVP in July 2021. “We are thrilled to recognize our first 25 verified hospitals and are excited about expanding QVP to more and more hospitals around the nation and around the world," said Dr. Clifford Y. Ko, director of ACS Division of Research and Optimal Patient Care. “Just as importantly, now that we have this first network of 25, they will be able to learn from each other and teach others how to embark on this quality journey,” Ko added.
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