UAB Hospital has earned The Joint Commission’s Gold Seal of Approval® for Advanced Certification in Spine Surgery (ACSS) by demonstrating continuous compliance with its performance standards. The Gold Seal is a symbol of quality that reflects a health care organization’s commitment to providing safe and effective patient care.
The certification is awarded in collaboration with the American Academy of Orthopaedic Surgeons. It recognizes organizations that promote consistent communication and multi-specialty care across the continuum – from pre-surgical consults with the spine surgeon through the procedure, rehab, and follow-up visits with the surgeon.
To be eligible for the ACSS, organizations must implement evidence-based care and clinical practice guidelines and participate in the American Spine Registry, a national quality improvement registry for spine care. Organizations also must collect performance data on surgical site infection rates, new neurological deficits, unplanned return visits to the operating room, and pre- and post-operative patient-reported outcomes.
“This certification by The Joint Commission is an important accomplishment for our patients, our departments, and our institution,” said Professor of Neurosurgery Mark Hadley, M.D.
Onsite review
Before receiving the ACSS, UAB Medicine underwent a rigorous onsite review in 2023. During the visit, a Joint Commission reviewer evaluated compliance with related certification standards, including patient safety and infection prevention protocols, operating room return rates, neurological deficits post-surgery, hospital readmission rates, and handoff communication protocols. The Joint Commission standards are developed in consultation with health care experts and providers, measurement experts, and patients. The reviewer also conducted onsite observations and interviews.
The journey to achieving ACSS was marked by a comprehensive preparation process. One key component of the preparation process was the implementation of a spine enhanced recovery protocol. This set of interventions is designed to optimize patient outcomes by standardizing perioperative care, reducing hospital stays, and improving recovery times.
A comprehensive pre-surgery educational booklet was developed to equip patients with the knowledge and resources needed to understand their procedure, the recovery process, and how to actively participate in their care. Educational efforts were not limited to patients. UAB implemented hospital-wide education initiatives to ensure that all staff members were informed about the new protocols and their roles in supporting the spine surgery program.
The spine program also established a continuous process improvement framework, which focuses on regularly reviewing and refining surgical protocols, patient care procedures, and outcome metrics to maintain the highest standards of care.
To help ensure patient satisfaction, UAB implemented rigorous pre-surgical screening processes and a patient satisfaction survey tailored specifically to the spine surgery experience. As a result, patients receive the benefits of reduced complication risks and enhanced overall outcomes.
Standardized order sets
Also, a multi-specialty team of experts in anesthesiology and perioperative medicine, physical therapy, nursing, pharmacy, infection prevention, and ambulatory services developed and implemented standardized order sets. These helps ensure consistency and adherence to evidence-based practices across the patient care continuum.
Dr. Hadley and Assistant Professor of Orthopaedic Surgery Sakthi Rajaram, M.D., serve as co-medical directors of the spine surgery program at UAB. They work closely with medical and administrative staff to maintain a comprehensive, patient-centered approach to treating spinal diseases – both medically and surgically.
As co-medical directors, Drs. Hadley and Rajaram are responsible for the overall quality, appropriateness, efficiency, and effectiveness of the clinical care provided through the spine program. Together, they develop and implement clinical policies and guidelines, evaluate clinical activities and performance, and ensure compliance with all regulatory, accrediting, and credentialing standards.
Dr. Hadley says the commitment of all spinal surgery colleagues in the departments of Neurosurgery and Orthopaedic Surgery has helped lead to safer, more consistent, and more comprehensive patient care.
“Our comprehensive strategy offers more standardization when possible, better timing and delivery of care, safeguards against medical errors, improved patient outcomes, and shorter lengths of stay,” Dr. Hadley said. “It also allows for long-term outcome analyses, to better assess our collective and individual efforts and potentially identify additional improvements in care delivery.”