Connect

Children's Surgery Verification (CSV) standards by the American College of Surgeons (ACS) outline best practices that ensure optimal outcomes for pediatric patients who undergo a procedure under anesthetics. The first ACS site visit at UVA Health Children’s is scheduled Aug. 19-20. Being verified as a Level 1 Children’s Surgery Center means: 

• Systems quality monitoring of more than 6,000 pediatric procedures annually. 
• 24/7 access to pediatric-prepared physicians, nurses, and allied health team members. 
• Pediatric-friendly facilities. 
• Hospital-wide leadership support and resources to improve the care of children. 

Delivering the Highest Quality Care

Efforts to become verified were spearheaded by Eugene McGahren III, MD, UVA Health’s first Chief of Children's Surgery — and supported by a dedicated team of UVA Health Children's physicians and quality improvement (QI) leaders since 2018. The formal application was focused on the strengths of QI efforts; during this process, many gaps were identified and closed — reinforcing UVA Health Children's commitment to delivering the highest quality care to pediatric patients.  

The verification process started with the submission of regular data on performance markers to the ACS via the National Surgical Quality Improvement Program (NSQIP)® Pediatric. 

This program — through coding and nurse analysis — collects data on more than 150 variables including preoperative risk factors, intraoperative variables, and 30-day postoperative mortality and morbidity outcomes for patients undergoing major surgical procedures in the inpatient and outpatient settings. A year of data was required to have a verification application considered. 

One UVA Health Team

In summer 2021, UVA Health Children’s Surgery Program Manager Julie Gallaway, MHA, BSN, RN, CPN, created a gap analysis and developed a strategy to close gaps between hospital practices and CSV standards.

Supported by UVA Health University Medical Center CEO Wendy Horton, PharmD, MBA, FACHE; Chief Medical Officer Reid Adams, MD — Dr. McGahren, Gallaway, and Associate Chief Nursing Officer Karin Skeen, PhD, RN, NEA-BC, diligently worked with UVA Health Children's and UVA Health leaders. They aligned structures, processes, and resources to support consistent, high quality care delivery for pediatric surgical patients — regardless of where they are cared for within UVA Health with programmatic requirements.  

Unifying Vision

By June 2023, UVA Health Children’s was ready for an in-depth, ACS consultation including a mock site visit to highlight remaining gaps. With continued incremental improvements throughout UVA Health, a formal application was submitted in November 2024 to become a Level 1 Children's Surgery Center. From May through July 2025, Children's Surgery Quality team and Performance Improvement and Patient Safety (PIPS) Committee members prepared for that first ACS site visit, scheduled Aug. 19-20.  

The UVA Health Children’s Surgery Quality Team includes: 

• Ankush Gosain, MD, PhD, MBA, FACS, FAAP, Surgeon-in-Chief, UVA Health Children's 
• Eugene McGahren III, MD, Chair, PIPS Committee 
• Barbara Castro, MD, Lead Anesthesia Liaison to PIPS 
• Sandra Kabagambe, MD, NSQIP Pediatric Surgeon Champion 
• Julie Gallaway, MHA, BSN, RN, CPN, Surgery Program Manager 
• Shannon Horton, RN, NSQIP Pediatric Surgical Clinical Reviewer
• Carol Clark, RN, Quality Improvement Coordinator 
• Ibeth Westreicher, Administrative Assistant 

The team reminds us that partnership and attention are required to help ensure a successful application and site visit. Below is an overview of the agenda: 

Tuesday, Aug. 19 

• 11:30 a.m.-1 p.m. | Quayle Learning Center| Site introduction: The site visit begins with a presentation by Children's Surgery Quality leaders to introduce UVA Health Children’s to the site reviewers and share the completed QI work and future goals. Everyone who can join is invited to learn more about PIPS and its SV journey. 
• 1-3 p.m. | PI Process and Chart Review: This closed session consists of chart reviews for pre-selected patients. Reviewers are looking for evidence of postoperative surgeon engagement and use of supporting services such as Nutritionists, Child Life, PT/OT, and Speech. They’ll also review PIPS quality projects, looking for the ability to create measurable goals, sustainable processes, and accountability for outcomes. 
• 3-5 p.m. | Children’s Surgery Verification (CSV) Interviews: The CSV Program was developed from the recognition that standard practice and continuous quality improvement are the best ways to ensure optimal outcomes for pediatric patients. These standards include policy and protocols, in addition to holistic matters such as family-centered and developmentally appropriate care.
  
  The interview team will consist of a pediatric surgeon, pediatric anesthesiologist, and pediatric nurse — all invested in improving care for pediatric patients across the nation. They will ask investigative questions with the intent of helping us to create a strong, sustainable system to engage in open, honest discussion about current processes and learn how to improve the care we give. The goal: to optimize surgical outcomes of infants and children nationally by standardizing requirements for children’s-specific providers and resources to meet the needs of every child requiring surgical care.
  
  “In the last several years, we have made incredible strides in improving systems for pediatric patients and closed many application gaps. Interviewees are asked to be candid in their discussions to elicit feedback that will help us continue on this trajectory,” says Gallaway. 

Wednesday, Aug. 20 

• 8-10 a.m. | Site Tours: Engaging team members in conversation about pediatric preparedness and emergency procedures — reviewers will tour pre- and post-surgery areas of the facility: Outpatient Surgery Center Battle Building; Pediatric Emergency Department; Radiology suites; Main Operating Room (Peds Pre/Post); Neonatal Intensive Care Unit; Pediatric Intensive Care Unit; and ECMO.
  
  Additional preparatory materials are on the PIPS Committee Teams platform.

Next Steps

ACS feedback and approval are anticipated within three months of the site visit, followed by a one-year period to correct any deficiencies and three years to correct opportunities for improvement. 

Questions? Email ChildrensQuality@uvahealth.org.