ACS NSQIP Data Collection Overview

The ACS NSQIP collects data on 135 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. A site's surgical clinical nurse reviewer (SCNR) using a variety of methods including medical chart abstraction captures outcomes data.

The ACS NSQIP involves four basic steps that are rigorously followed to collect a medical center?s surgical data and then process it in order to improve patient outcomes.

Step 1: Capture the Data

A dedicated surgical clinical nurse reviewer is responsible for all data collection at the participating site. Trained by ACS NSQIP personnel on the intricacies of the program and on the systems used to capture and transmit the data to the central servers, this nurse reviewer collects the following variables on each surgical case.

• Demographics – 6 variables
• Surgical Profile – 11 variables
• Pre-operative Data – 44 clinical variables & 13 laboratory variables
• Intra-operative Data – 16 clinical variables & 3 occurrence variables
• Post-operative Data – 20 occurrence variables, 12 laboratory variables & 10 discharge variables

Required data variables are entered via web-based data collection to the acsnsqip.org website, portions of the data may be automatically extracted by a software program called QCMitt. The software program was developed to automatically extract portions of the required data variables from the participating hospital?s existing data systems.

Annual Data Audits -Each participating site's data are audited on an annual basis to ensure that cases are being selected correctly and that the data definitions are being appropriately applied. These audits identify opportunities to further educate nurses and staff, provide feedback to the entire program and to each site, and assure that sites are consistent in their reporting of data.

Step 2: Analyze the Data

The flow and accuracy of data are continually monitored to ensure that the random sampling methodology is being followed and that the online benchmarking reports are timely. Data are accepted continuously into the database (not quarterly or annually like other programs) so it is readily available for sites to review and consider. Additionally, nurses entering the data are provided with support tools to manage their work, and lead surgeons are kept continually informed about the status of case entry.

Step 3: Review Data

Medical centers enrolled in the ACS NSQIP have their data presented to them in two kinds of quantitative reports:

• Semiannual Reports – A comprehensive report is prepared twice a year for administrators and surgical services staff comparing their risk-adjusted surgical outcomes to other participating centers on a blinded basis for all operations combined and by sub-specialty. The report allows the center to compare its risk profiles and outcomes with those of peer medical centers and with national averages.
  
  Each year the ACS NSQIP Advisory Committee reviews the performance of all the participating medical centers. High and low outliers are identified, and the Committee reports back to those centers regarding their outlier status.
• Online Reports – Authorized users can view daily center-specific reports as well as those comparing their metrics to national averages. In this way they can monitor their continuous improvement on an ad hoc basic, between the more formal report cycles.
• Ad hoc Reports – As a participant of the program each site has four hours per month of a data analysis for ad hoc specialized reports.

STep 4: Act On The Data

Findings from these reports then form the basis for quality improvement action plans. Participating medical centers use this feedback to re-engineer their workflows, foster and improve internal education, and to develop clinical performance improvement initiatives.

Self-examination by these medical centers, in turn, produces additional feedback to the ACS NSQIP about surgical practices and potential reasons for below or above average performance.

Medical centers that have significantly improved their performance or sustained excellent performance over time are asked to communicate back to the ACS NSQIP as to the methods and procedures used. This feedback, combined with the data collected during various structured site visits produces a continually updated set of "best practices" that is disseminated to all the participating ACS NSQIP sites across the country in the published annual report.