Throughout the United States, there has been a call to action to improve the quality and safety of surgical care while decreasing costs. In the state of Washington, clinicians have taken a unique approach to surgical quality improvement (QI) with the Strong for Surgery initiative. “Strong for Surgery is a physician-led initiative that identifies and evaluates evidence-based practices to optimize patient health prior to their surgery,” explains Thomas K. Varghese Jr., MD, MS. “We’re working with stakeholders from across the state to raise awareness of key factors in preoperative care that can improve postoperative outcomes.”

A Unique Collaborative

In 2006, the Surgical Care and Outcomes Assessment Program (SCOAP) was initiated as a peer-to-peer collaborative among hospitals in Washington. SCOAP is a grassroots, voluntary, clinician-led collaborative that includes doctors, statewide insurers, policymakers, and professional organizations of nurses, physicians, nurse anesthetists, and hospitals as well as the Washington state chapter of the American College of Surgeons. Hospitals participate in SCOAP by submitting detailed clinical information about patients undergoing surgical and interventional procedures at their sites. In return, hospitals receive reports that benchmark their performance in care delivery and outcomes.


With SCOAP, data are linked from multiple sources (eg, medical records, payers, and surveys) to help participating hospitals assess the longer-term impact of care and complications on patients and the healthcare system. The program includes a set of interventions for standardization—tools like checklists, order sets, and training—to drive performance improvement and clinician education. “SCOAP engages surgeons to determine the processes-of-care metrics that go into an ideal operation,” explains Dr. Varghese. “It tracks risk-adjusted outcomes that are specific to a given operation and offers interventions to correct under-performance. By benchmarking performance and implementing hospital quality initiatives, SCOAP has improved outcomes and saved millions of healthcare dollars.”

As a result of the success of SCOAP, a program called CERTAIN was then developed. “CERTAIN was created in response to the growing need to be able to monitor the risks, benefits, and value of new healthcare treatments and technologies,” Dr. Varghese says. This has resulted in a “learning healthcare system,” one that participates in continuous evaluation of healthcare technologies and interventions.

Real World Applicability

Dr. Varghese says that efforts are needed to move beyond QI and toward performing “real world” assessments of risks and benefits. “QI alone—while important and worthwhile—cannot accomplish these assessments,” he says. QI registries are often limited and cannot capture long-term care and outcomes. In addition, they do not always cross care delivery sites or include patient perspectives. They tend to be extremely labor intensive and may be limited in dissemination and generalizability.

CERTAIN builds an automated flow of electronic health information and creates a novel approach to incorporating patient perspectives into research. “It gives us an opportunity to connect with long-term care facilities, payers, and other community stakeholders,” says Dr. Varghese. “With initiatives like the Patient Voices Project, patients are surveyed on their views about surgeries and other interventions they receive. This data is then integrated into research development and disseminated to other participants.”

The lessons learned from SCOAP and CERTAIN have laid the foundation for the Strong for Surgery initiative. “Strong for Surgery offers interactive tools to make patient care more consistent,” Dr. Varghese says. “We provide checklists to optimize patient health before surgery and recommend strategies that enhance doctor–patient communication.” He notes that Strong for Surgery does not replace existing QI initiatives. Rather, it provides a means to tailor initiatives to the needs of each participating institution.

Preoperative Interventions

Several pre-surgical checklists have emerged as a result of Strong for Surgery, including topics such as preoperative nutrition (Table 1) and smoking cessation (Table 2). Checklists have also been created for medication use and glycemic control. “Strong for Surgery offers additional ways to translate the importance of preoperative risk factors into successful surgeries,” Dr. Varghese says. “Pre-surgical checklists help ensure that all patients are screened for risk factors and directed to appropriate resources. Use of these checklists ensures consistency in delivering best practices, helps communication between team members, and serves as an opportunity to educate patients about ways they can improve their health before surgery.”

The tools offered by Strong for Surgery are intended to help hospitals, clinicians, and patients implement best practices toward optimizing patient health, says Dr. Varghese. “By putting checklists into every doctor’s office across the state, we’re taking the focus of surgical safety beyond the operating room. Surgical preparedness has become part of the basic conversation about planning for surgery, and we’re ensuring that patients take part in that process.”


Strong for Surgery. Available at:

Surgical Care and Outcomes Assessment Program (SCOAP). Available at:

CERTAIN Learning Healthcare System in Washington State. Available at:

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