Frequently Asked Questions

Can any hospital join the ACS NSQIP?
Yes, any hospital that performs surgery may join the ACS NSQIP. The requirements are that a dedicated Surgical Clinical Nurse Reviewer (SCNR) be hired to capture and review the data, that a surgeon champion or leader be identified to lead the program at the hospital, and that the hospital agree to the program protocols and meet minimum case standards.

Does it cost anything to join the program? If so, how much?
There is an annual participation fee of $35,000 for sites participating in the ACS NSQIP. This fee covers all of the management and administration of the program, training of the site’s surgical clinical nurse reviewer, an annual on-site audit, and on-going support. Additionally, the fee includes the use of online web tools for data submission, online site-specific reports and national benchmarking tools, and semi-annual program reports including O/E ratios. Data automation and software programs to support the nurse, continuing education credits for your nurses who successfully complete the online training, and four hours of ad-hoc/specialized data analysis and reporting per month are also included. All participation fees must be paid prior to beginning participation in the program.

Can I view the benchmarking data without joining the ACS NSQIP?
No, you must be a participant, contributing data on a timely and regular basis in order to have access to the national benchmarking data.

What happens if there isn’t unanimous support of the program among our administration and surgeons?
Certainly the introduction of any new program and data analysis will be most successful if the stakeholders are well informed about the program. Qualified staff members are available to help you to educate your colleagues about the ACS NSQIP by visiting your site to deliver informational lectures, to describe the statistical methodology, and to demonstrate the online reports and benchmarking tools. We can also provide you with written materials explaining the program and its benefits for use in your efforts to build support for the program within your institution. If your site would like to host a visit, we ask that the cost of the travel be covered by your institution.

How intrusive is the program to surgeons?
There is no requirement of individual surgeons beyond making pertinent patient records available to the surgical clinical nurse reviewer as may be required to capture data. ACS NSQIP data is reported by specialty, not by specific surgeons. If a site chooses to review and report surgeon-specific data, they may do so using the online reports or their ACCESS database, however, the ACS NSQIP does not analyze or report this data.

Can we get out of the program at any time?
You may discontinue participation with the program at any time. There is, however, no pro-rated return of the annual participation fee and your identity-stripped data remains in the ACS NSQIP data warehouse, which is overseen by the ACS NSQIP Advisory Committee and the American College of Surgeons.

How long does it take to set up the program?
As soon as a participation agreement is signed with the American College of Surgeons, the fee is paid and a dedicated surgical clinical nurse reviewer is hired, you will be able to enroll the SCNR in the mandatory initial training session. Once the SCNR is trained, you may begin to collect and submit data. This process can take anywhere from a few weeks to a few months and is highly dependent upon a site’s ability to secure funding and identify and hire a SCNR.

What are QCMitt and The Nurse Workstation?
QCMetrix, the company that developed the ACS NSQIP Web-based data collection tool, has also developed other tools to streamline participants’ efforts in the program. QCMitt is a data automation tool that allows a medical site to extract ACS NSQIP data from its internal systems and transmit it to a remote data capture interface, which in turn is integrated into the core ACS NSQIP database. QCMitt’s automated processes relieve the data-entry burden of the SCNR and improve the quality of the data being captured.

The Nurse Workstation is a productivity tool allowing a clinical provider the means to coordinate the data collection process with the on-going management of their ACS NSQIP data. It extends a participant’s use of their data for outbound communications, patient follow-up, ongoing analysis, and more—fully within the guidelines of HIPAA. By providing a centralized console, The Nurse Workstation increases the nurse reviewer’s productivity by streamlining the gathering and organization of data.

Do QCMitt and The Nurse Workstation come with the program or are they extras?
QCMitt and The Nurse Workstation are both made available to participating sites at no additional fee. A participating site’s IT personnel must work with the QCMetrix IT experts to install and test these tools and to provide onsite support as may be required. The ACS NSQIP participation fee includes a set number of hours by the QCMetrix staff to help sites with these tools.

If we use QCMitt, does that mean we don’t use the www.acsnsqip.org website?
QCMitt will eliminate the need for the site’s surgical clinical nurse reviewer (SCNR) to re-enter any data that can be captured electronically from other internal data collection systems. As all required data elements cannot be automatically captured, however, the SCNR will still need to use the www.acsnsqip.org website to enter data that cannot be captured electronically. This will vary from site-to-site depending on how automated the patient information is at a given site’s facility. Sites will also continue to use the website to view their online reports.

What’s the level of our IT effort in setting up QCMitt to automatically collect the data?
The data schema of QCMitt has been tested and successfully implemented by numerous sites in the ACS NSQIP. The level of IT effort is highly influenced by the systems currently in place at your site and the IT personnel available to identify where the data resides in a site and to apply the schema of the QCMitt.

How long before we start to see meaningful data for our site?
Because the ACS NSQIP captures data prospectively, it takes most sites approximately 6-12 months to have captured enough data to begin to be able to make meaningful comparisons to other sites and to have a statistically significant O/E ratio. Factors such as how many SCNRs the site has and the presence/absence of data automation will also affect the volume and subsequent speed from which a site will have enough data to draw any conclusions.

What’s the ideal background for the Surgical Clinical Nurse Reviewer?
The ideal candidate for the position of SCNR is someone who has a BS in Nursing or an advanced degree (MSN, NP, PA) with clinical experience in the OR, SICU or Cardiac Surgery divisions of a hospital. Familiarity with hospital information systems, hospital operations, and quality improvement techniques is helpful as well. Candidates with no clinical background are highly discouraged.

Is 100% of the SCNR’s time taken by the program or is there room for other tasks?
At the start of a site’s participation in the ACS NSQIP, the learning curve is relatively steep, and past experience has found that it does take 100% of the SCNR’s time and effort. As the SCNR becomes more experienced in the program and in identifying the sources of the required data at a site, then more time is freed up for additional duties.

How many cases can one Surgical Clinical Nurse Reviewer capture?
One SCNR is expected to enter a minimum of 1,680 cases or the maximum cases that meet the program’s inclusion criteria if the site performs fewer than 1,680 cases per year. With data automation and an experienced SCNR, our experience has been that the number of cases one nurse can manage is approximately 2,000 to 2,300. Certainly, the more automated the hospital’s medical records are, the more cases can be entered.

Who has access to the ACS NSQIP data?
Only participants of the ACS NSQIP have access to the data. The site-specific detail reports may only be accessed by the individual participating site; no hospital may view another hospital’s detailed data.