VA ‘Surgical Pause’ Initiative Wins Eisenberg Patient Safety Award

The Joint Commission and National Quality Forum (NQF) have announced the recipients of the 2023 John M. Eisenberg Patient Safety and Quality Awards, including a Veterans Health Administration surgery initiative that reduced six-month mortality for at-risk patients.

The Eisenberg Awards recognize major achievements by individuals and organizations that improved patient safety and healthcare quality. Launched in 2002, the awards honor the late John M. Eisenberg, M.D., M.B.A., former administrator of the Agency for Healthcare Research and Quality (AHRQ) and a founding member of NQF’s board of directors.



Each year, awards are presented for national-level innovation, local-level innovation and individual achievement. The 2023 awardees are:
• National Level Innovation in Patient Safety and Quality: The Surgical Pause – Veterans Health Administration
• Local Level Innovation in Patient Safety and Quality: Creating a Culture of Quality for Cardiovascular Care in Michigan – BMC2
• Individual Achievement: Eduardo Salas, Ph.D., Rice University

“Each year, the Eisenberg Awards showcase innovative healthcare quality and patient safety efforts that have had a significant demonstrable impact on improving patient outcomes and reducing avoidable healthcare harms,” said Dana Gelb Safran, Sc.D., president and chief executive officer of NQF, in a statement. “The work of this year’s individual and institutional recipients embodies the legacy of Dr. Eisenberg, who was a visionary pioneer and change maker committed to translating research into real-world delivery system improvements that ensure safe, reliable, and effective care for every patient in every setting. The Joint Commission and NQF are proud to recognize these outstanding innovators as we continue to honor Dr. Eisenberg’s enduring contributions to our field.”

Veterans Health Administration (VHA) is recognized for its initiative the Surgical Pause, which reduced six-month mortality of patients determined to be “frail” from 25 percent to 8 percent at three VA medical centers. Under the initiative, providers implemented routine frailty screening with the Risk Analysis Index to identify patients at the highest risk of postoperative complications, loss of independence, and mortality. For patients found to be frail, a brief “pause” permits further evaluation. For patients who pursue surgery, multidisciplinary care plans are implemented to reduce frailty-associated risks before surgery, shifting the paradigm and effort to strengthening the frail patient and mitigating potential complications before they happen. Further analysis of more than 50,000 patients found that one-year mortality declined by 4.2 percent. As a result of this success, the Surgical Pause has been replicated across more than 50 medical centers across VA and the private sector.

BMC2 (Blue Cross Blue Shield of Michigan Cardiovascular Consortium) is a statewide quality improvement collaborative that develops and administers a portfolio of quality improvement interventions for patients who undergo percutaneous coronary interventions (PCI), vascular surgical procedures, and transcatheter valve procedures in Michigan. As a result of the initiative Creating a Culture of Quality for Cardiovascular Care in Michigan, BMC2 participant sites:
• Improved documentation of radiation use from 73.1 percent in 2019 to 85.5 percent in 2021. BMC2 sites are outperforming national rates, which were 57.5 percent in 2019 and 74.3 percent in 2021.
• Achieved an overall 43 percent decrease in cases with high-dose radiation exposure (2.8 percent in 2018 to 1.2 percent in 2021) for hundreds of patients and catheterization laboratory staff members.
• Reduced opioid pill prescribing. Data showed improvement in the rate of patients with a prescription for fewer than 10 opioid pills, increasing from 62 percent in 2018 to 91 percent in 2021.

NQF said that Eduardo Salas, Ph.D., of Rice University, is recognized for his body of work across 40 years designing, developing, and evaluating evidence-based principles and tools to help healthcare organizations create a culture of teamwork and safety. Most notable is his development of TeamSTEPPS (Team Strategies & Tools to Enhance Performance & Patient Safety), a coordination and teamwork framework that has been adopted by 70 percent of U.S. hospitals to help reduce medical errors.

Salas is a prolific scholar and has published more than 420 journal articles in top-tier journals and two books, edited 36 books and 247 book chapters, and has bestowed hundreds of presentations. His work has been cited more than 132,000 times.

“Congratulations to Veterans Health Administration, BMC2, and Eduardo Salas, for their tremendous achievements worthy of the 2023 John M. Eisenberg Patient Safety and Quality Awards,” said Jonathan B. Perlin, M.D., Ph.D., president and CEO of The Joint Commission enterprise, in a statement. “We envision a future where all people always experience the safest, highest quality healthcare across all settings. The accomplishments by the 2023 Eisenberg awardees serve as examples of inspirational, yet replicable efforts enabling healthcare organizations to drive real improvements to patient safety and quality.”

In August 2023 The Joint Commission and NQF announced a strategic affiliation, with NQF joining the Joint Commission enterprise while maintaining its independence in convening and developing consensus-based measures, implementation guidance, and practices that benefit all stakeholders.