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

Hospital Requirements

To join the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP®) a hospital must ensure adequate staffing for high-quality data collection and analysis.

Key Roles in Your Hospital

Surgeon Champion

As the resident ACS NSQIP “expert,” the Surgeon Champion is a source of information about ACS NSQIP to hospital staff. This person:

  • Holds regular meetings with the Surgical Clinical Reviewer (SCR), quality staff and department heads to review ACS NSQIP reports and address any issues. Shares learnings, best practices and case studies with hospital staff
  • Participates in an annual ACS NSQIP meeting and quarterly conference calls

Surgical Clinical Reviewer (SCR)

The ideal candidate for the SCR position has a bachelor’s degree in nursing or an advanced degree (MSN, NP, PA) with clinical experience in the operating room (OR), surgical intensive care unit (SICU) or cardiac surgery divisions of a hospital. In some cases, non-nurses with clinical and medical records experience can successfully serve as SCR. The SCR is required to successfully complete an ACS NSQIP training program and participate in ongoing training, conferences (including the annual ACS NSQIP meeting) and calls. For more information visit the SCR training and resources page.

The SCR:

  • Collects clinical data on variables, including preoperative risk factors, intraoperative variables and 30-day postoperative mortality and morbidity outcomes for patients undergoing major and minor surgical procedures in both inpatient and outpatient settings.
  • Validates and submits the data through a secure, Web-based system.
  • Conducts data audits, as instructed.
  • Meets regularly with the Surgeon Champion and quality team to review results.

Financial Costs of ACS NSQIP

  • Annual fee paid to the American College of Surgeons.
  • Salary and benefits for dedicated Surgical Clinical Reviewer.

Data Collection and Quality Requirements

  • Follow data acquisition and transmission protocol set out in the ACS NSQIP Operating Manual to ensure completeness and accuracy.
  • Communicate with surgical patients via a 30-day follow-up letter or phone call, and conduct periodic death searches in public records to obtain complete 30-day follow-up data.
  • Participate in regular audits, conducted by ACS NSQIP staff, to test data quality.