Outcomes Data Collection

All American College of Surgeons Bariatric Surgery Centers will report outcomes on all    patients undergoing weight loss surgery at their facilities.

Level 1a and 2a centers are required to participate in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP).

Level 1b, 2b, and Outpatient Bariatric Surgery Centers will report their outcomes data to the American College of Surgeons Bariatric Surgery database.

ACS NSQIP

In 1990, the Veterans Administration Health System (VA) introduced the National Surgical Quality Improvement Program (NSQIP).  This became the first peer-controlled, reliable, bio-statistically rigorous, validated, risk-adjusted quality improvement in surgery.  NSQIP served  the VA system very well and for that reason, in 2000, the VA and the ACS began collaboration to employ NSQIP in the private sector by studying general and vascular surgery. This collab-oration produced the ACS NSQIP, now available to private hospitals.

ACS NSQIP is a database including preoperative, intraoperative, and 30-day postoperative    data.  Multiple logistic regressions identify the significant risk factors for morbidity and mor-tality allowing prediction of expected outcomes.  Comparing the expected outcome to the observed outcomes (O/E ratio) provides quantification of surgical quality and permits valid comparisons of outcomes between hospitals.

ACS NSQIP requires a surgeon leader in each participating hospital.  A trained, dedicated Surgical Clinical Nurse Reviewer (SCNR) collects and submits the required data. A carefully defined data collection process provides a statistically valid sample of each hospital's operations. The effectiveness of the program depends on the accuracy, quality, and reliability of the sub-mitted data.  The SCNRs receive initial and continuing training, as well as annual evaluation     of the quality of their work.

ACS NSQIP maintains a Web site for surgeons to examine their data and compare their per-formance with the averages of the hospitals in the program.  The Web site provides participants with continuously updated Clinical Performance Improvement Reports; Online Reports and Benchmarking; Postoperative Occurrence (complication) Reports; Wound Class Reports; Preoperative Risk Factors Reports; Mortality Reports; Length of Stay Reports; Procedure Reports; and Surgical Performance Measures Reports.  In addition, each hospital receives a semiannual written report with an analysis of their outcomes and a confidential comparison   with all other hospitals in the program.

The American College of Surgeons Bariatric Surgery Database

Level 1b, Level 2b, and Outpatient Bariatric Surgery Centers will report their outcomes          data to the American College of Surgeons Bariatric Surgery database using a Web-based        data entry system.  A designated nurse at the bariatric surgery service will enter the data using the established protocol.  The entered data will be subjected to quality control.  The data will    be encrypted and de-identified to protect the confidentiality of the patients, the hospital, the outpatient facility, and the surgeons.  When the hospital or outpatient facility receives the data reports, they can identify the patients and surgeons.  The hospitals and outpatient facilities will receive annual data reports.  Center verification visits will include audits of the data, which include chart reviews.  This data does not have the same rigor as ACS NSQIP and is not risk- adjusted.  It will not be used to make comparisons or for research due to the lack of rigor.      This data will only report on a center's outcomes towards the ACS accreditation process.

Data Monitoring

Level 1a and 2a centers (ACS NSQIP Participants)

ACS NSQIP participants can monitor their data on a 24/7/365 basis using the ACS NSQIP    Web site.  They can compare their data with the average of the other centers in the program. These centers will receive a semi-annual report of their risk-adjusted outcomes in confidential ranking with other centers in the program.  This data will also undergo confidential review by   the ACS NSQIP Advisory Committee and the American College of Surgeons Bariatric Surgery Center Committee.  If these reviews reveal trends or variances of concern, the concerns will be communicated to the hospital CEO, the surgeon director, and the program coordinator.  Each ACS NSQIP Center will have Inter-rater Reliability visits from a trained, experienced Surgical Clinical Nurse Reviewer.  This involves a medical record review to assess the reliability of the submitted data and the variability of data collection and submission.

Level 1b, 2b, and Outpatient Facilities (American College of Surgeons Bariatric Center Network Database Participants)

The hospital CEO, the bariatric surgery director, and the bariatric surgery coordinator will receive a report of their non-risk-adjusted outcome data annually.  The American College of Surgeons Bariatric Surgery Center Committee will review each hospital's de-identified data annually.  If these reviews reveal trends or variances of concern, the concerns will be commu-nicated in a special report to the hospital CEO, the bariatric surgery director, and the bariatric surgery coordinator.

Revised October 1, 2007 

Bariatric Surgery Center Network Program

Continuous Quality Improvement