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It is very important that you read the ACS NSQIP information packet and understand the hospital requirements to participate in the program. If your institution would like to participate in the program, please fill out this application in its entirety. A representative from the ACS NSQIP will contact you upon receipt of your information.
I. FACILITY IDENTIFICATION
Name of Hospital
Address (line 1)
Address (line 2)
City
State
  		 Zip Code
CEO (or equivalent) Name
Title
Email Address
Telephone Number
Fax Number
Hospital FEIN #
AHA ID #
(American Hospital Association ID Number)

 

  
Primary Legal Contact Name
Title
Address (line 1)
Address (line 2)
City
State
  		 Zip Code
Email Address
Telephone Number
Fax Number
II. PROGRAM CONTACTS
Designated Surgeon Champion Name
Title
Address (line 1)
Address (line 2)
City
State
  		 Zip Code
Email Address
Telephone Number
Fax Number
If the designated surgeon is not the Chief of Surgery, please provide the Chief of Surgery's name below
 
Primary Program Contact Name
Title
Address (line 1)
Address (line 2)
City
State
  		 Zip Code
Email Address
Telephone Number
Fax Number
III. HOSPITAL INFORMATION
Accreditation
JCAHO
AOA
Other, please identify accrediting body: 
Classification
Class I or General Hospital
Class II Hospital (Special Children/Women)
Class III Hospital (Special Medical/Psychiatric/Eye/Rehab/Substance abuse)
Class IV Hospital (Intensive Residential Treatment Facility)
Is your hospital a Trauma Center?  Yes  |  No
If yes, what level? 
Description
Public
Not for profit
For profit
Volume
A. How many licensed beds?
Less than 100  |  100-300  |  300-500  |  More than 500
B. Does your hospital meet the high volume case requirment of 1680 general and vascular cases annually? 
Yes  |  No (If No, answer C below)
 
C. If you answered No to B above,
Does your hospital meet the low volume case requirment of 900 general and vascular cases annually? 
Yes  |  No
Data Collection
ACS NSQIP collects data on general and vascular surgeries. The program plan is to expand data collection to include other surgical specialties. In order to prioritize the development of new models, please indicate for which surgeries your hospital is most interested in collecting data.
Bariatric
Gynecology
Neurosurgery
Ophthalmology
Oral
Orthopedics
Otolaryngology (ENT)
Pediatric
Plastic/Reconstructive
Podiatry
Thoracic
Trauma
Urology
Other, please specify:
Data Use
How do you plan to use the ACS NSQIP data? Check all that apply:
Quality Improvement
Marketing
Patient Education
Reimbursement Negotiation
Research
Teaching and training of clinical staff/residents
National Benchmarking
Multi-hospital system benchmarking, resource utilization
Don't know
Funding

Do you have budget approval and funding to hire a Surgical Clinical Nurse Reviewer to capture your site's clinical data?
Yes  |  No
IV. GENERAL INFORMATION
Referral Sources
ACS Clinical Congress
Direct Mail
Internet
VA/QC Metrix/COHO
Other, please specify:
Application
Which model are you applying for?   
Have you filed an application before?   Yes  |  No
Enrollment
On what date are you able to enroll in the program? 
V. COMMENTS
State any additional information you feel may be helpful to us in considering your application:
VI. CONFIRMATION
By clicking the Submit button below, I state that I have read the ACS NSQIP information packet and understand the hospital responsibilities to participate in the program. My institution would like to participate in the program; please consider this application.
 
 
American College of Surgeons National Surgical Quality Improvement Program
Copyright © 2006, ACS NSQIP. All Rights Reserved.