Program Overview

The ACS National Surgical Quality Improvement Program (ACS NSQIP) is the first nationally validated, risk-adjusted, outcomes-based program to measure and improve the quality of surgical care. The program employs a prospective, peer controlled, validated database to quantify 30-day risk-adjusted surgical outcomes, which allows valid comparison of outcomes among all hospitals in the program. Participating hospitals and their surgical staff are provided with the tools, reports, analysis, and support necessary to make informed decisions about improving quality of care. The program involves the following key components:

Data Collection

ACS NSQIP collects data on 136 variables, including preoperative risk factors, intraoperative variables, and 30-day postoperative mortality and morbidity outcomes for patients undergoing major surgical procedures in both the inpatient and outpatient setting. The data are collected, validated, and submitted by a trained Surgical Clinical Reviewer (SCR) at each site.

Data Monitoring & Validation

Once trained, the SCR submits data to ACS NSQIP through a secure Web-based system with built-in software checks and user information prompts to ensure completeness, uniformity, and validity of the data. Data automation tools are also available to lower the data entry burden on the SCRs and to improve the quality of data being captured. In addition, Inter- Rater Reliability (IRR) audits are conducted to ensure the data are examined on a routine basis.

Report Generation

Hospitals enrolled in ACS NSQIP have their data presented to them via comprehensive semiannual reports and real-time, continuously updated, online benchmarking reports. Both sets of reports allow participating sites to continually monitor their quality improvement efforts and to compare, on a blinded basis, their surgical outcomes with those of peer hospitals and with national averages.

The www.acsnsqip.org Web site offers 24/7 access to user-friendly, real-time reports that allow hospitals to view their non risk-adjusted data and compare these data with national averages. Flexible reporting enables participating sites to produce reports by surgical subspecialty, specific procedures, and individual surgeons (de-identified).

Click here to learn more about the program’s reporting capabilities and to view some sample reports.

Data Analysis

Using stepwise logistic regression, risk-adjusted 30-day morbidity and mortality outcomes are computed for each participating hospital. Outcomes are reported as observed versus expected (O/E) ratios and are distributed in the semiannual report. If the O/E ratio and the upper bound of the O/E confidence interval is <1.0, the hospital's outcomes are statistically better than expected. Thus, the hospital's outcomes are “Exemplary.” If the O/E ratio and the lower bound of the O/E confidence interval is >1.0, the hospital's outcomes are statistically worse than expected. Thus, the hospital's outcomes “Need Improvement.”

Focus On Systems

It is important to note that ACS NSQIP focuses on the systems at its participating centers, not on the individual providers of surgical care. Online reports are available for each site to view its surgeon-specific data; however, ACS NSQIP does not perform any statistical analysis of individual surgeon data or physician-specific benchmarking comparison data. Any site that wishes to perform additional in-depth analysis of its own physician performance data may download its hospital-specific MS Access database.

Feedback

ACS NSQIP provides feedback and information to participants through IRR audits, one-to-one support services, online training and testing, SCR and Surgeon Champion conference calls, and the Annual ACS NSQIP National Conference. In addition, ACS NSQIP committees monitor the development of the program and encourages participants, surgical specialty groups, and other quality improvement organizations to share their experience and expertise with the program.

RECOGNITIONS

• Institute of Medicine named NSQIP “the best in the nation” for measuring and reporting surgical quality and outcomes.
• The Joint Commission now provides merit badges on their Quality Check website for hospitals that participate in the ACS NSQIP.
• American Board of Surgery (ABS) Requirement: Participation in a national, regional or local surgical outcomes database, such as ACS NSQIP, or quality assessment process satisfies number four of the Maintenance of Certification requirements.