By Daniel E. Hall, MD, MDiv, MHSc; Jason M. Johanning, MD; and Danielle Hagan, MSA

After recognizing a significant opportunity to improve the care provided to one of our nation’s most vulnerable populations, patient care teams at the Veterans Health Administration (VHA) developed a procedure called the Surgical Pause. This brief pause allows physicians and surgeons to take a step back and consider whether a surgery is really safe for a frail patient, as well as evaluate strengthening measures to prepare a patient for surgery. As a result of the program’s success, The Joint Commission and National Quality Forum have awarded the 2023 John M. Eisenberg National Level Innovation in Patient Safety and Quality Award to the Veterans Health Administration’s Surgical Pause initiative for its innovative efforts resulting in improved healthcare outcomes of frail veterans considering elective surgery.

Innovation in Patient Safety and Surgical Quality

The Surgical Pause initiative stands out as an innovative and novel approach in the complex healthcare landscape. By integrating the Risk Analysis Index (RAI) as part of the standardized patient assessment, the initiative provides a rapid, data-driven assessment of veterans' frailty—a key determinant of surgical risk—within 30 seconds. This approach shifts the paradigm from a one-size-fits-all approach concerned primarily with high-risk procedures to one that adapts preoperative evaluation to the specific needs of high-risk, frail patients.

• Focused Assessment: Targets the crucial elements of risk without unnecessary delay.
• Goal-Oriented Surgical Planning: Aligns interventions with each veteran's overarching life goals.
• Expertise Synergy: Leverages the collective insights of interdisciplinary teams for tailored care plans.

The Surgical Pause represents a significant advancement in patient safety and quality, and its efficacy is substantiated through measurable outcomes. The pilot programs at Omaha VA Medical Center drastically reduced six-month mortality rates from 25% to 8% and subsequent implementation in other facilities has been similarly successful. The initiative's efficacy is further supported by peer-reviewed studies, validating the RAI and the process improvements implemented through the Surgical Pause.

VA Under Secretary for Health, Dr. Shereef Elnahal, recognizes the value and impact of the award-winning initiative. "The Surgical Pause is an innovative, data-driven clinical practice that saves Veterans lives by predicting and preventing complications before they happen," noted Dr. Elnahal in a VA Press Release . "We are thrilled to be rolling out the Surgical Pause across the nation as a part of VA’s steadfast commitment to providing Veterans with high-quality, world-class healthcare they deserve."

Replication and System-Wide Impact

Implementing the Surgical Pause required addressing initial resistance and integrating the practice within existing protocols. The U.S. Department of Veterans Affairs (VA) approach to overcoming these challenges has involved comprehensive education campaigns, ongoing technical support, and establishing feedback mechanisms to refine and sustain the initiative.

• Strategic Communication: Key to persuading stakeholders of the initiative's value.
• Robust Training Programs: Critical for ensuring staff can apply the initiative.
• Adaptive Learning: Important for evolving the initiative based on real-world application.

The replicability of the Surgical Pause initiative across VA medical facilities and its potential application in other organizations is a testament to its versatile and adaptive design. With the combined support of the VHA Office of Healthcare Innovation and Learning’s Innovation Ecosystem and National Surgery Office, it has already been launched successfully in over 50 VA facilities, and its framework serves as a model for healthcare systems seeking to enhance patient safety and improve surgical outcomes for high-risk populations.

The Surgical Pause as a Blueprint for the Future

Looking to the future of healthcare, particularly in the rapidly evolving field of geriatric surgery, the Surgical Pause initiative serves as a blueprint for patient-centered, data-driven care. This practice, now formally adopted by the National Surgery Office and recognized by the Eisenberg Award, underscores VA's role as a pacesetter in developing and implementing healthcare innovations that can be adapted and adopted by other institutions.

Daniel E. Hall is a practicing Staff General Surgeon at the VA Pittsburgh Healthcare System with training in moral philosophy, theology, quality improvement and health services research with degrees from Yale and Duke. In addition to his work on the Surgical Pause, his team is characterizing trajectories of recovery after surgery and understanding the social determinants of surgical outcomes. He also serves as Medical Director, High Risk Populations & Outcomes for the Wolff Center and Associate Professor of Surgery, Anesthesia and Perioperative Medicine at the University of Pittsburgh.

Jason Johanning is a Professor of Vascular Surgery and serves as Medical Director of the VA Surgery Quality Improvement Program for the National Surgery Office.  As Chief of Surgery at the Omaha VA, Dr. Johanning conceived and implemented a novel frailty screening program resulting in significant and sustained improvements in surgical outcomes.  The frailty screening program has since been implemented in multiple settings both public and private replicating the initial quality improvement initiative.

Danielle Hagan is a Diffusion Specialist in the VHA Innovation Ecosystem and works with VHA frontline employees to replicate and scale innovative healthcare solutions across the organization to improve the experiences of veterans and their caregivers.  Danielle worked with Dr. Daniel Hall to expand the reach of the Surgical Pause and build an infrastructure to ensure the successful scale of the practice throughout VHA.