American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

Hospital Participation Requirements

Requirements for a hospital's participation in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP®): 

A.  ACS NSQIP Program Administration and Oversight at the Hospital

  • Commitment from the hospital's chief of surgery or delegated surgeon to serve as Surgeon Champion (SC) and to oversee ACS NSQIP implementation and administration at the Hospital.
  • Participation of the SC on program conference calls.

B.  Data Collection by a Trained Surgical Clinical Reviewer (SCR)

  • Hospital agrees to hire a qualified, dedicated SCR to collect and submit data to the ACS NSQIP.
  • This SCR will be dedicated to the ACS NSQIP and will be provided with necessary access to medical records and patient information (paper or electronic) for collection of ACS NSQIP data elements.
  • The SCR must successfully complete the ACS NSQIP training program, any required or associated exams, and participate in on-going training, conferences, and conference calls.
  • In the event that the SCR is on extended leave or has chosen to leave the position during the program year, Hospital is expected to identify a back-up SCR ready to participate in training to assume the role of data collector.

C.  Payment of Annual Fee

An annual fee paid to the American College of Surgeons will cover the cost of participating in ACS NSQIP:

  • Web-Based Workstation
  • XML Uploader
  • Data verification and encryption
  • Data analysis
  • Report production
  • Inter-rater reliability determination and audits
  • Training and support for one SCR
  • Online benchmarking
  • Interim and semiannual reports

D.  Data Quality/Reporting

The implementation of the data acquisition and transmission protocol as outlined in the ACS NSQIP Operation Manual. This includes:

  • Meeting the data accrual requirements as described in the ACS NSQIP Hospital Participation Agreement, Section 3 "Contribution of Data".
  • Maintaining high quality of data collection.
  • Obtaining complete 30-day follow-up on all participating patients through the generation of a 30-day follow-up letter and/or phone calls to patients and periodic death searches of public records.
  • Facilitating and hosting Inter-rater Reliability Audits by ACS NSQIP personnel to assess the quality of data.

Please note: During inter-rater reliability audits, the ACS NSQIP will validate the hospital's data sampling methodologies. If discrepancies exist, the hospitals will be contacted directly to discern the reason for any discrepancies and the hospital will need to submit a plan of action for correcting them. Failure to meet data collection requirements may result in the exclusion of the data collected by the Hospital from the semiannual reports.