In order to provide proven and stronger quality information, the American College of Surgeons (ACS) has partnered with the Centers for Medicare & Medicaid Services (CMS) to allow ACS NSQIP® hospitals across the country the opportunity to report surgical outcomes to Hospital Compare, the CMS website that provides quality information to healthcare consumers. The program provides hospitals participating in the ACS NSQIP Adult Program Options the chance to voluntarily, publicly report on one or any combination of three National Quality Forum (NQF)-endorsed measures—elderly surgery, colon surgical and lower-extremity bypass outcomes.
Information on the Hospital Compare website will explain the rigors of ACS NSQIP so that patients better understand what the measures mean; the importance of accurate, risk-adjusted data; and how to use the information in making their care decisions. Because ACS NSQIP is based on the best available data—clinical, risk- and case-mix–adjusted, nationally benchmarked and audited 30-day patient outcomes—the program provides arguably the most valid and reliable look at surgical quality. It provides a better gauge of quality than many other public measures, many of which are based on compliance with process measures or based on administrative data.
Registration will take place in electronic format only. Hospitals interested in participating in this program are required to submit an Addendum. An Exhibit Form is also required for hospitals that share a CCN with another hospital. These documents only need to be submitted at the time of initial registration. Once these documents have been submitted, hospitals will be able to electronically select the measure(s) they wish to publically report to Hospital Compare. Your Authorized Institutional Signatory is responsible for submission of the Addendum and Exhibit Form. Measure selection can be completed by a designated hospital representative.
- Begin by visiting www.acsnsqip.org/cmsdatasharingweb.
- Create a new account.
- In order to create your account, you will need the following information:
- Hospital Federal Employer Identification Number (FEIN)
- Hospital CMS Certification Number (CCN)
- E-mail address of your Authorized Institutional Signatory
- This account is separate from your ACS NSQIP Workstation account. An e-mail confirmation of account creation will be provided within one hour of your submission. The e-mail will be sent from firstname.lastname@example.org.
- Once your account has been created, log in and electronically complete/submit the addendum and associated exhibit form (The exhibit form is only required for hospitals that share a CCN with another hospital).
- Only one account is required. The Authorized Institutional Signatory does not need to create a separate account if the addendum and/or exhibit form are forwarded to them. Instructions for sending these documents can be found once your account has been created.
- For the exhibit form, you will be required to list all hospitals that share the same CCN and their associated FEIN.
- Once the addendum and exhibit form (if required) have been submitted, you are eligible to select the measures.
- Please see the Measure Selection page within your account which provides the opportunity for your hospital to indicate the measure(s) they wish to publically report on the Hospital Compare website. The account creator is responsible for submitting the measure(s) selection. Measure selection will take place prior to each reporting period. The reporting periods in 2015 are April, July, October, and December.
- Once the SAR has been released, results will be posted on the Measure Selection page.
If you would like information about the availability of auxiliary aids and services, please visit the Medicare website.
Public reporting will continue to expand in the future. We hope your ACS NSQIP hospital will be among the quality leaders joining this important initiative to help better inform the public how to most accurately understand hospital quality.
For questions, please contact:
Gina M. Pope, RN, CNOR
Business Development Representative