Participation Requirements
To participate in ACS NSQIP, hospitals must be willing to commit to the following program requirements:
Submit a completed ACS NSQIP Application Form.
Designate a surgeon champion:
- Choose the chief of surgery or a designated surgeon
to oversee ACS NSQIP implementation and
administration at the medical center. Responsibilities
of the surgeon champion include initial and ongoing
support of the surgical clinical nurse reviewer
(SCNR) and the promotion and advancement of the
program at your institution. In addition, the surgeon
champion will need to participate in conference calls
and attend the ACS NSQIP Annual Conference.
Secure funding to hire the necessary number of SCNRs to meet the hospital's participation needs:
- The program's experience is that one full-time SCNR
is capable of capturing 1,680 cases annually. This
capability is dependent on how a site is organized and
how easily accessible the required data is for the SCNR
to collect. A hospital may require additional SCNRs
for a variety of reasons including but not limited to:
Meeting the case volume requirements
Enhancing quality improvement initiatives utilizing ACS NSQIP data
Assigning data collection responsibilities
to more than one SCNR
Execute a Hospital Participation Agreement and pay the annual fee:
- Fee information is outlined in the ACS NSQIP Fee Schedule.
- For more information regarding the contract or the fees, e-mail ACS NSQIP at acsnsqip@facs.org or call 312-202-5000 and request to speak to an ACS NSQIP coordinator.
Hire qualified SCNRs to collect and submit data to ACS NSQIP :
Be a licensed nurse or physician's assistant.
Successfully complete the ACS NSQIP training program and participate in ongoing training, testing, and conference calls.
Attend the Annual ACS NSQIP National Conference.
Agree to adhere to the ACS NSQIP data submission and reporting guidelines:
- Meet the surgical case volume requirements.
- Collect and submit data in a timely and consistent manner as outlined in the Operations Manual.
- Obtain complete 30-day follow-up on a minimum of 80 percent of all submitted cases through the generation of a 30-day follow-up letter and/or telephone calls to patients and periodic searches of public death records.
- Allow ACS NSQIP to conduct an Inter-Rater Reliability audit at the hospital within six to nine months of the hospital's start of data collection and thereafter according to the program's audit policy.
Hospitals may participate in ACS NSQIP in the following ways:
MULTISPECIALTY
High Volume
Hospitals with a high volume of surgical cases may
participate in the multispecialty module by collecting
approximately 20 percent of their surgical case volume.
In addition to general and vascular surgery, hospitals
participating in this module will include cases from the
following surgical subspecialties: gynecologic, neurologic,
orthopedic, otolaryngologic, plastic, cardiac, thoracic, and
urologic surgery. All 10 subspecialties must be collected
unless the hospital does not offer the specialty at its facility.
Hospitals must capture approximately 20 percent of their
surgical volume in each subspecialty using the eight-day
cycle. If 20 percent of the hospital's surgical volume is
less than 1,680 cases annually, the hospital must submit a
higher percentage of cases to reach a minimum of 1,680
cases annually. The sampling criteria are as follows:
Assume that approximately 75 percent of a hospital's
reported surgical subspecialty case volume will
meet the ACS NSQIP inclusion criteria.
Hospitals are required to submit 20 percent
of the cases that meet program criteria.
[(Hospital's Reported Cases) × 75%] × 20% = Required Sample
A minimum total of 1,680 cases across
all 10 subspecialties is required.
An Online calculator is available to help
hospitals determine the number of cases required to participate in this module. Online Calculator
Reduced Volume
Hospitals with a low volume of surgical cases that
cannot meet the required 1,680 cases annually may
participate in the multispecialty module by entering
their maximum number of cases that meet the program
inclusion criteria. At a minimum, a hospital would
need to enter approximately 22 cases every eight-day
cycle. The participation year is based on 46 cycles, and
cases must be submitted for 42 cycles, which computes
to a minimum of 900 cases submitted annually. This
alternative is only available to hospitals that demonstrate
they cannot meet the required 1,680 cases annually.
GENERAL AND VASCULAR SURGERY ONLY
High Volume
Hospitals with a high volume of general and vascular
surgery cases may collect a sample of general and
vascular surgery cases using the eight-day cycle. The
first 40 consecutive cases are captured in each eight day
cycle. The participation year is based on 46 cycles,
and cases must be submitted for 42 cycles, which
computes to 1,680 general and vascular surgery cases
submitted annually. High-volume operations, such as
inguinal hernia repair, are limited in each cycle. Reduced Volume
Hospitals with a low volume of general and vascular
surgery cases that cannot meet the required 1,680
cases annually may participate in the general and
vascular surgery module by entering their maximum
number of cases that meet the program inclusion
criteria. At a minimum, a hospital would need to enter
approximately 22 general and vascular surgery cases
every eight-day cycle. The participation year is based
on 46 cycles, and cases must be submitted for 42 cycles,
which computes to a minimum of 900 cases submitted
annually. This alternative is only available to hospitals
that demonstrate they cannot meet the required
1,680 general and vascular surgery cases annually.
SAMPLING METHODOLOGY
- Many hospitals are not able to capture all of their surgical cases that meet the program's inclusion criteria. Therefore,
a systematic sampling system called the eight-day cycle was developed in order to prevent bias in choosing cases for
assessment. The SCNR uses the eight-day schedule to select completed cases from the hospital's operative log. The
schedule works as follows: if the first cycle begins on a Monday, it continues through to the following Monday (an
eight-day period of time). The next cycle begins on Tuesday and continues through to the following Tuesday, and
so on. There are 46 eight-day cycles in one year and the program requires that data be submitted for 42 of those
cycles. The process ensures that cases have an equal chance of being selected from each day of the week. Case
selection and case mix are monitored by the program on a weekly basis to ensure that the sampling is appropriate.
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