UCSF Benioff Children’s Hospital San Francisco has been verified as a Level 1 Children’s Surgery Center by the American College of Surgeons (ACS) – an honor that was six years in the making.
UCSF Benioff Children’s Hospital San Francisco was the second children’s hospital in California to achieve Level 1 Surgery status, after UC Davis Children’s Hospital. To receive the designation, a hospital must demonstrate compliance with the ACS Children’s Surgery Verification program standards, and enroll in the ACS Pediatric National Surgical Quality Improvement Program (NSQIP), a multispecialty database used to measure surgical outcomes and improve care. UCSF enrolled in the Pediatric NSQIP in 2015.
“Becoming a Level 1 Surgery center reflects a great deal of planning, commitment, and hard work on the part of many staff and faculty and demonstrates our unwavering commitment to the patients and families we serve,” said Matt Cook, president of UCSF Benioff Children’s Hospitals. “We are excited to continue building upon our pediatric health system in order to provide the safest and highest quality patient-centered care.”
UCSF Benioff Children’s Hospital Oakland is an ACS-verified Level 1 Trauma Center, and recently hired a NSQIP pediatric surgeon champion and pediatric surgical quality analyst to facilitate its verification process as a Level 1 Surgery Center.
A Creative COVID Workaround
To meet the 136 standards required in the ACS application, the San Francisco facility assembled a Children’s Surgery Verification team and created a Perioperative Performance Improvement and Patient Safety (PIPS) Committee, which includes representatives from every pediatric surgical specialty, medical proceduralists, anesthesiology, neonatology, critical care medicine, hospital leadership, OR nursing, radiology, emergency medicine, and the Child Life Program.
Additionally, “the program structure gave way for the creation of new policies and procedures, building a data source platform and implementing changes to the current credentialing and privileging for specific providers,” said Ayanna Fritton, RN, Children’s Surgery Program Manager, who has helped to guide the program from infancy and through the application and evaluation process.
“The ACS standards go beyond the hospital walls into community outreach, patient transport and follow-up discharge care, always with the goal of joining these pieces with the in-hospital experience,” Fritton said. “This way, we are providing high-quality, coordinated care to all patients, including many who are medically complex.”
A two-day site visit is the ACS’s required last step in the application process. Every site visit has a three-person survey team comprising a pediatric surgeon, anesthesiologist and nurse, who review the hospital facility, clinical outcome data and quality improvement process. The original site visit was scheduled for May 2020, but was cancelled due to the COVID-19 pandemic.
UCSF’s Children’s Surgery Verification team got creative, volunteering to be a pilot site for the ACS to test their virtual site visit format. They made a series of hospital tour videos featuring the three critical care units, perioperative area, ED and radiology. It was narrated by Lan Vu, MD, UCSF associate professor of Surgery, medical director of surgical quality and physician champion of the Children’s Surgery Verification program.
Of more than 220 children’s hospitals across the country, only 38 were verified Level 1 Children’s Surgery Centers at the time of UCSF’s designation. ACS renews verification status every three years, and enrollment in the verification program is currently voluntary.
“We anticipate that verification status may dictate resource allocation and patient referrals in the future, similar to the established Trauma Center designation,” Vu said. “More importantly, the program supports UCSF’s mission to provide excellence in patient care.”