TQIP HPA (USA): Services Provided to Hospital

Services Provided to Hospital | Hospital Participation Requirements | Program Fees

Services provided to a hospital participating in the American College of Surgeons Trauma Quality Improvement Program (ACS TQIP®): 

Training and Education

• Annual TQIP Conference. The annual fee paid by the Hospital includes the registration fee for two people to attend the annual conference. Additional people may attend the conference at the registration cost set for each annual conference.
• TQIP Training Activities. TQIP provides periodic educational experiences, online training modules and various training tools. An unlimited number of individuals may access the online training at no additional cost.
• Conference Calls/Web Conferences. ACS may have conference calls and/or web conferences to conduct training on relevant topics such as the use of TQIP data for performance improvement and data quality issues and to present report results to participants.

Data Accrual and Quality

• The ACS will provide tools to the Hospital so it can identify and monitor data quality issues that may affect reports and other deliverables.
• ACS will monitor accrual rates and data quality to evaluate whether there are issues related to record submission. The Hospital will be notified of data issues through TQP Validator reports.

Clinical Performance Improvement Reports

The ACS TQIP® has developed a set of reports for use by the Hospital in support of Clinical Performance Improvement efforts. These reports will allow Hospital to view its data in summary and detail and to benchmark its results against all other participating hospitals.

For each reporting period, ACS will determine if data volume and quality are adequate for specific analyses and reports.

These reports include but are not limited to:

• Data analysis tools that allow the Hospital to closely review its own data
• Annual Reports including
  • Risk-adjusted outcomes
  • Aggregate report on Hospital and patient characteristics
• New Report Development as deemed appropriate
• TQIP Participant Use File

Customer Service Support

ACS will supply customer service and technical support to the Hospital including phone and email support—timely response to questions; quality assurance and monitoring of data submission process; and help desk support. 

Technical Services

ACS will maintain processes for data collection, validation, and other technical services. The data collection Data Center contains an interface module that handles the communication between the local sites (via Internet) and the central site. Through the central web site, ACS will provide the following capabilities:

• Multi-method malware prevention
• Data Protection by user account and password
• Web based data submission
• Standard XML data format
• Local and central data validation
• Data blinding to de-identify patients and medical centers by encrypting data based on Facility ID
• Data monitoring to measure data accrual and volume
• Online tool for reporting
• Database to store transaction data
• Multi-factor authentication (MFA)

These capabilities are subject to change as the ACS and our technical partners are committed to maintaining best standards that have been implemented across the industry.

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

• Commitment from the Hospital’s Trauma Medical Director or his/her designee to oversee ACS TQIP implementation and administration at the Hospital.
• Participation of the Trauma Medical Director or his/her designee on periodic conference calls.
• Funding for the Trauma Medical Director or his/her designee to attend the TQIP annual conference. The annual fee to ACS does not include travel costs.

Data Collection by a Trained Trauma Registrar/Data Abstractor:

• Hospital agrees to employ a qualified, dedicated registrar/abstractor to collect and submit data to the ACS TQIP. If Hospital uses an abstractor, all references to the registrar, and all obligations of the Hospital pertaining thereto, shall be read to extend and apply to the abstractor.  
• The Hospital will provide the registrar with:
  • Office space, adequate for protecting patient health information that may be available to the registrar;
  • Phone, fax, copier access;
  • Personal computer with access to the Internet (high-speed preferable); and  
  • Necessary access to medical records and patient information (paper or electronic) for collection of ACS TQIP data elements.
• The registrar must complete periodic educational experiences, available online training modules, any required or associated exams, and participate in ongoing training, conferences and conference calls and/or web conferences.
• Hospital agrees to provide funding (travel and accommodations) for the relevant staff to attend the TQIP annual conference.  
• In the event that the registrar is on extended leave or has chosen to leave the position during the program year, a backup registrar should be identified, trained, and be ready to assume the role of data collector.
• Hospital agrees to participate in the annual NTDS pilot when notified.

Data Quality/Submission:

• Maintain a trauma registry that is compliant with the National Trauma Data Standard (NTDS) and meets the current requirements of the NTDS. ACS does not supply the trauma registry or software required to establish and maintain the trauma registry.
• Keep registry data submissions current with the most recent release of the National Trauma Data Standard data elements and inclusion criteria.
• Provide data via the TQIP data submission process, in accordance with the NTDS patient inclusion criteria, the NTDS data dictionary, validation and format requirements, and within ACS deadlines.
• Maintain consistent and high-quality data compliance, as evidenced by regular data monitoring. In the event there are ongoing and/or unaddressed data quality and accrual issues the Hospital may not receive TQIP reports. The Hospital will be notified in advance of the decision to not provide reports.
• Make active use of all TQIP reports to continuously assess and improve the quality of data provided to TQIP.
• ACS TQIP will monitor data quality on an annual basis through data scrutiny and analysis, and use results of the monitoring to determine when an audit is needed.  
  • The Hospital agrees that ACS will conduct inter-rater reliability audits of TQIP data remotely or onsite when necessary.
  • The Hospital agrees to host on-site and remote data audits by ACS TQIP personnel to assess the quality of data.
  • The date and time of the audit will be set upon mutual agreement by ACS and the Hospital.
  • If conducted remotely, it will be the responsibility of the Hospital to ensure the medical record is redacted prior to review. 
• If the Hospital’s data show better than expected performance, the Hospital may, upon the ACS TQIP’s request, be asked to share systems, strategies, and information with other participants in the ACS TQIP.  (This sharing will not involve disclosure of identifiable patient information). 
• New measures may be introduced from time to time that will require new data elements, software updates, and additional training. These measures will be included in the NTDS data dictionary revision cycle. The Hospital must ensure maintenance of an up-to-date trauma registry based on the NTDS data dictionary.

The Hospital agrees to pay to ACS an annual fee for participation in the American College of Surgeons Trauma Quality Improvement Program (ACS TQIP®). Detailed below is a current Pricing Guide of options.

*Hospitals that participate in both the full Adult Quality Program and the full Pediatric Quality Program will be billed the respective Trauma Quality Program fees as two different line items.

ACS may adjust this fee from time to time and will provide at least 60 days’ advance notice of any adjustment in fees by publishing annual fees on our website.