Surgery safety measures are extending to the presurgery sphere. Hospitals, surgeons, and ambulatory surgery centers are working together under a Strong for Surgery program to teach facilities how to reduce post-surgical complications through engaging patients in activities that will improve their health before they undergo surgical procedures.

  • Strong for Surgery tools and checklists are evidence-based.
  • The shift is from only quality improvement in the surgical suite to quality improvement from the first moment a patient steps inside the door for a consultation.
  • The American College of Surgeons offers program information and tools for free on its website. (https://bit.ly/2TNBaEw)

Surgery safety measures have improved immensely over the past four decades. Physicians can use checklists, electronic data, and safety tools to ensure better outcomes. Now, there is a program that helps build on those safety successes.

Created at the University of Washington in 2012 and pilot-tested through 2013 at hospitals, Strong for Surgery can help surgeons improve care with evidence-based tools and a focus on preoperative visits, says Thomas K. Varghese, Jr., MD, MS, FACS, one of the creators of the program.

“We look at what we can do from the day we first see a patient in the clinic,” says Varghese, who today serves as the program director of the cardiothoracic surgery fellowship at the University of Utah and as an associate professor of surgery at the university’s medical school. “We shift the spotlight from quality improvement [QI] efforts on the day of surgery to engaging in QI efforts the first time we see patients in the clinic.”

With the United States’ aging population, it is important for surgery centers to engage in preoperative evaluation and focus on helping people improve their health before surgery, Varghese and colleagues suggested in a recent study.1

The Strong for Surgery program, embraced by the American College of Surgeons (ACS), is widening the lens on where standardization should happen around surgical care, says David R. Flum, MD, MPH, FACS, professor of surgery at the University of Washington and director of the UW Medicine Surgical Outcomes Research Center in Seattle. ACS believes it is important for surgeons and institutions to improve the preoperation space and clinical outcomes, Flum notes.

“The Strong for Surgery program is perfect for ambulatory surgery centers [ASCs], especially as more and more procedures move from hospitals to ASCs and more patients with risk factors move to [ASCs],” Flum says.

These changes put greater pressure on surgeons and their practices to engage in QI and quality control. ASCs do not have the big budgets or the QI infrastructure of health systems, but they are well-suited for specific target programs like Strong for Surgery, Flum offers.

The program helps an administrator look “across the whole care continuum for the patient undergoing surgery,” Flum says. “Strong for Surgery identifies areas for standardization to improve the care experience.” By 2016, ACS had adopted Strong for Surgery, which was active in 50 clinical sites across disciplines, including general surgery, colorectal, vascular, and all surgical disciplines. By 2018, the program had spread to 230 active sites. Any surgery facility can use the program’s tools for free at the ACS website.

“All we ask is that they register with us. It’s a free process, but we want to learn how they did — good or bad,” Varghese says. “By doing the registration process, it enables us to get them the implementation guide, training, conference calls, and make sure they’ve onboarded correctly.”

To crowdsource the program’s efforts and outcomes, surgery centers using Strong for Surgery will report what went well and what did not. “We want to know that story. The more sites we engage with, the more we learn,” Varghese says. There are several components to the program:

It is designed to target health changes patients can make before surgery. The classic example is smoking cessation. “We know that people who continue to smoke at the time of their surgical intervention have an increased infection rate and impaired wound healing rate,” Varghese says.

“For a patient having spine surgery, one of the greatest risks of spine surgical complications and failure of bone healing is whether they use cigarettes,” Flum adds. “Many surgeons tell patients to stop smoking, but giving surgeons tools to help patients stop smoking is one of the opportunities of the program.”

Varghese was involved in a study that revealed a financial benefit to directing patients into a preoperative smoking cessation program, which can help them reduce postoperative complications caused by smoking. The study authors found that such programs, on average, saved $304 in direct medical costs per patient.2

Strong for Surgery gives surgeons a checklist to assess patients’ smoking habits. The program also provides resources, tools, and techniques to help patients get on a smoking cessation pathway before they begin the surgical pathway. These tools give physicians an example of how to ask patients to stop smoking, Varghese says. “Instead of saying, ‘We won’t offer surgery to you if you continue to smoke,’ the physician could say, ‘If you need a successful outcome, you need to stop smoking, and here are the ways we can help you stop smoking,’” Varghese offers.

When the smoking cessation tactics were used with spine surgery patients, physicians reduced the rate of cigarette use prior to surgery from 30% to 11%, Flum says. “We think this has a lot of possibilities for other types of surgery.”

Tools assist with risk assessment and mitigation. For example, in risk stratification for smoking, clinicians can ask patients if they have ever smoked. If so, the user records patients’ smoking status (current or former smoker). Users also can ask about number of pack-years (packs per day multiplied by years smoking) and record the answer. If a patient says he or she smokes, program users advise the patient to quit and set a quit date within two weeks. Users also can refer these patients to one of several preferred cessation programs.

It is important to identify local resources. Local resources references both institutional (the site where surgery is performed) and community and state resources, Varghese says.

“These are typically identified at the time of our initial conversations with the site. The key to this is to get all stakeholders to arrive at a consensus on which intervention tool to use,” he says. “For example, there may be indeed several smoking cessation programs, sites, and interventions available.”

Standardization is difficult unless the participating site agrees on a consensus on which resource to use each and every time, he adds.

“A lot of what we do when we recruit sites for the program is to identify local resources,” Varghese says. “You may go into a site and say, ‘Here’s an incredible and robust smoking cessation program at your site. Have you thought about using that resource?’”

In Utah, there is a state-sponsored phone line that people can call when they wish to stop smoking. Other locations might offer smoking cessation counseling, support groups, or other methods.

“Some people prefer online interactive programs,” Varghese notes. “Figure out what helps with every patient or tell the patient that [a certain] program is the one we’ve found the most success with.”

ASCs using the Strong for Surgery program should engage surgeons and office staff. “This is especially important for the process of rethinking the preoperative process,” Flum advises. “Right now, pre-op doctors’ offices are a place where patients make a determination of whether you need surgery.”

In addition to helping patients make that decision, surgeons and their staff could help patients learn how they might improve their health before surgery and prevent complications. ASC staff, surgeons, and administrators could think of that period before surgery as a way to help patients optimize their health and maintain control of chronic illness symptoms, he adds.


  1. Dalton A, Zafirova Z. Preoperative management of the geriatric patient: Frailty and cognitive impairment assessment. Anesthesiol Clin 2018;36:599-614.
  2. Gaskill CE, Kling CE, Varghese TK Jr, et al. Financial benefit of a smoking cessation program prior to elective colorectal surgery. J Surg Res 2017;215:183-189.

Prehabilitation Checklist

The Strong for Surgery program includes a screening checklist for prehabilitation, which ACS defines as “a process of improving the functional capability of a patient prior to a surgical procedure.” Some of the items on the list include:

  • Does the patient report physical limitations or does he or she exhibit signs of frailty? If yes: Use either grip strength or the Timed Up and Go test for baseline assessment, and consider referral to a geriatrician;
  • Does the patient present with unstable cardiac disease? If yes: Consider referral for presurgery consultation with a cardiologist;
  • Does the patient report unstable pulmonary disease? If yes: Consider referral for presurgery consultation with a pulmonologist;
  • Does the patient show poor mobility and/or diminished endurance? If yes: Refer patient to physical therapy and start daily walking program.

(Learn more about this checklist at: http://bit.ly/2DmBSTz.)