American College of Surgeons
Dedicated to improving the care of the
surgical patient and to safeguarding standards
of care in an optimal and ethical practice
environment
What NSQIP Is
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 Web-Based data collection software
 Quality improvement tool
 Risk-adjusted, outcomes-based data
 Clinically Validated data
 Benchmarking
Current
Participants
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Number of Participating Sites by State and Region (273)
CANADA 4
October 31,2010
3
MIDWEST 78
4
3
8
6
1
20
5
1
22
4
34
2
3
6
9
13
2
33
2
5
6
4
5 2
10
2
2
NORTHEAST
67
8
10
1
1
3
WEST 57
10
ABU DHABI 1
4
2
LEBANON 1
6
SOUTH 65
1
2
Product
Features
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








Clinically Rich Data
Web-Based Workstation
Private & Secure Data Encryption
Semi Annual Reports & Other Real-Time Reports
Online Return of Investment (ROI) Calculator
Best Practices (Expert panel rated guidelines)
Case Studies
Online Risk Calculator
Participant Use File (PUF)
Program
Staffing
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 Surgeon Champion (SC)
 Program Mentor/Advocate
 Lead Quality Improvement Initiatives
 Participate in Monthly SC Conference Calls
 Surgical Clinical Reviewer (SCR)
 Collect Data
 Online/On-going training; CEU’s & Certification - provided by the
ACS
Data
Collection
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 Demographics
 Surgical Profile
 Pre-operative Data (risk factors)
 Intra-operative Data
 Post operative Data (outcomes)
Data
Collection
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Case Selection
 Sampling of all operations requiring
 General anesthesia
 Spinal anesthesia
 Epidural anesthesia
 Inpatient and Outpatient Surgical Procedures
 excluding trauma and transplant
Data
Collection
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Sampling Methodology
 A randomized sampling system called
the 8-day cycle
 Process ensures that cases have an equal
chance of being selected from each day of the
week
Data
Collection
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Clinical vs. Administrative Data
Clinical Data tends to tell us more…
NSQIP
Admin
% Missed by Admin
Total Complications
28%
11%
61%
SSI
13%
1%
97%
Wound Disruption
6%
1%
83%
UTI
6%
0%
100%
Mortality
3%
3%
0%
Risk
Adjustment
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Observed vs. Expected O/E Ratios

O/E ratio = par on a golf course –
the score that is expected

An O/E ratio is a mathematical construct accurately showing the
risk-adjusted outcome for a specific site

‘O’ represents the total number of observed postoperative events
(deaths or complications)

‘ E’ represents the number of expected events based on the
preoperative risk and other factors in a given patient population

An O/E ratio < 1 means that the site is performing better than
expected, while a ratio > 1 indicates an excess of adverse events
Risk Adjustment
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O/E ratios show that risk adjustment has a profound effect in determining the
true performance of a medical center
01
01
04
04
08
Rank by
unadjusted
Mortality
Observed
Only
A
B
08
12
12
16
16
20
20
24
24
28
28
32
32
36
40
44
B
Rank by
risk-adjusted
Mortality
Observed/Expected
36
A
40
44
Changes in Medical Center Rank (O/E Ratio) After Risk Adjustment For 30-Day Mortality
Audits
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Data Needs to be Believed:
Validation with Audits
10%
2005
2006
2007
2008
3.15%
2.26%
1.99%
1.56%
0%
Inter-Rater Reliability (% Disagreement)
Shiloach JACS 2009
Reporting
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Real-Time and Semiannual Reports
 Real-time, continuously updated benchmarked
online reports




Pre-programmed library of reports
Real-time data
Not risk adjusted
Able to benchmark with all or like sites
 Semiannual benchmarked report
 Risk Adjusted
 Available 1st and 3rd quarters
Reporting
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Real-Time Reports
 Workflow Reports
 Site-Level Reports
 Database Statistics
 Data Analysis
 ACS Reports
Reporting
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Reporting
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How are our outcomes? SSI? Pneumonia? UTI?
Reporting
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How are our outcomes? SSI? Pneumonia? UTI?
Reporting
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How are our outcomes? SSI? Pneumonia? UTI?
Reporting
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Further drilling down on the data
Reporting
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Real Time Analyses
i.e,Mortality in Colectomy cases with or without UTI
Reporting
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Semiannual Report
Risk adjusted for hospital-to-hospital patient mix differences.
Reporting
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Over 40 Risk Adjusted Outcomes
 30-Day Mortality & Morbidity/ Serious Morbidity O/E Ratios in
All Patients
 30-Day Morbidity/Serious Morbidity O/E Ratios in patients >65
 Cardiac Occurrences
 Pneumonia
 Unplanned Intubation
 Ventilator Dependence >48 hours
 DVT/PE
 Renal Failure
 Urinary Tract Infection/UTI O/E Ratios
 Surgical Site Infection/Deep & Organ Space O/E Ratios
 Colorectal 30-Day Death or Serious Morbidity O/E Ratios
Interpretation
of Results
Reporting
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Observed to Expected (O/E) Ratio
Represents the hospital’s outcomes compared to the other ACS NSQIP hospitals, adjusted
for inter-hospital differences in patients’ characteristics, comorbidities, and preoperative
laboratory values
LOW OUTLIER: If the upper bound of the O/E confidence interval is <1.0,
the hospital’s outcomes are statistically better than expected. Thus, the
hospital’s outcomes are “Exemplary.”
O/E
Ratio
Overall (Multispecialty) 30-Day Morbidity O/E Ratios
1/1/2007 - 12/31/2007
Low Outlier
99% Confidence interval
High Outlier
2
1
AS EXPECTED
9999
9999
9999
9999
9999
9999
9999
9999
9999
9999
9999
9999
9999
9999
9999
9999
9999
9999
9999
9999
9999
9999
9999
9999
9999
HIGH OUTLIER: If the lower bound of the O/E ratio
is >1.0, the hospital’s outcomes are statistically
worse than expected. Thus, the hospital’s
Report Identification Number
ACS NSQIP Hospital ID Number
outcomes “Need Improvement.”
9999
0
Return on Investment
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NSQIP Improves Outcomes and
Saves Money
Return on Investment
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Does Surgical Quality Improve using the
ACS NSQIP?
 82% of NSQIP hospitals had decreased
surgical complications
 66% of NSQIP hospitals had decreased
mortality
 Each hospital is projected to avoid between
250-500 complications per year – on average
Return on Investment
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 Example …
 If 250 complications are avoided
 And each complication costs $10,000
 The potential savings is $2,500,000
Return on Investment
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 Beaumont Hospital saved $2.2 million and
reduced average LOS by 6.5 days by reducing
SSI. In 2009, the hospital estimates it prevented
nearly 300 SSI’s.
 Surrey Memorial Hospital reduced SSI’s over 4
years for savings of $2.54 million
 Henry Ford Hospital reduced LOS for annual
savings of $2 million
Return on Investment
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 Henry Ford Hospital reduced their length of stay
by an average of 1.54 days after reviewing data
from all patients who underwent a general,
vascular, or colorectal procedure translating into
an annual savings of $2 million.
 Surrey Memorial Hospital avoided an estimated
$380,000 in costs over a four-month period
through initiatives to reduce the number of
urinary tract infections.
Return
on Investment
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ROI Calculator
Complication
Cost Per
Case
Ventilator >48 hrs
$
UTI
27,654
Averted Events
X
Cost
Savings
17
=
$
$ 12,828
X 12
=
$ 153,936
Cardiac Arrest
$
15,079
X
4
=
$
60,316
Pneumonia
$
22,097
X
24
=
$
530,328
Unplanned Intubation
$
21,025
X
7
=
$
147,175
Deep SSI
$
20,012
X
15
=
$
300,180
Total
470,118
$1,662,053
Return on Investment
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Non-Monetary Benefits …
 Valid National benchmarking for surgical outcomes
 Provides proactive, value-oriented performance
measurement before it’s dictated by outside agents
 Improves local market position through publicly visible
improvement programs
 Optimizes cross-departmental partnerships and collaboration
through shared knowledge
 Helps build high performance surgical teams and employee
retention, (i.e. nurses)
 Offers CME’s for Surgeon Champions and CEU’s for SCR’s
Best
Practice Guidelines
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 Complete yet concise resource for
health care providers and QI
professionals
 Evidence-based
 Expert panel-rated
 Framework to:
 Prevent postsurgical complications
 Prioritize/direct QI efforts aimed at
reducing incidence/impact of
postsurgical complications
Best
Practice Case Studies
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 Kaiser Sunnyside Medical Center used NSQIP data to optimize
glucose and temperature control in the operating room
 Advocate Good Samaritan Hospital used NSQIP data to improve
postoperative Renal Outcomes
 Scripps Green Hospital used NSQIP
data to reduce surgical site infection
rates in vascular surgery
 Morristown Memorial Hospital used
NSQIP data to prevent surgical site
infections
The
Options
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Four Adult NSQIP options
1.
2.
3.
4.
NSQIP Classic
NSQIP Essentials
NSQIP Small &Rural
NSQIP Procedure Targeted
The
Options
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Regardless of Which Option, All
Hospitals Will Receive:
 Semi Annual Reports
 Real Time Online Reports (including new
SPCs)
 National Benchmarking
 NSQIP Best Practices/Guidelines
 NSQIP Improvement Case Studies
 Additional Items (e.g. Risk Calculator, Public
Use File)
The
Options
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For All Options, the Rigor and Validity
of ACS NSQIP is Unchanged
 Risk Adjustment
 30 Day Post Surgical
Outcomes
 Clinical Data
 SCR Training
 SCR Certification
NSQIP
Classic
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
General/Vascular = 1,680 cases per
year,
8-day sampling cycle

Multispecialty = 20% total case volume
by specialty, 8-day sampling cycle

1 FTE
NSQIP
Essentials
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
General/Vascular = 1,680 cases per year,
8-day sampling cycle

Multispecialty = 20% total case volume by
specialty, 8-day sampling cycle

1 FTE
NSQIP
Small & Rural
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

Small Hospital: < 1,680 cases per year
OR
Rural Hospital: ZIP code is defined within
RUCA data codes

100% collection of cases across all specialties

Collection of core variables for QI purposes

1 FTE (or less depending upon case volume)
NSQIP
Procedure Targeted
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
Larger hospitals targeting high-risk/high volume
procedures

Hospital selects procedures

Selection may be CPT code-driven

Minimum of 1,680 cases per year:
- 15 “Core” cases per 8-day cycle
- 25 “Procedure Targeted” cases per 8-day cycle

Minimum 1 FTE (or more depending on volume)
NSQIP Procedure Targeted
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Nine Subspecialties


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


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General Surgery
Vascular
Gynecologic
Urologic
Plastic & Reconstructive Surgery
Otolaryngology
Orthopedic Surgery
Neurosurgery
Thoracic Surgery
NSQIP
Procedure Targeted
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30+ Procedures
Pancreatectomy▪ Colectomy ▪ Ventral Hernia Repair ▪
Bariatric ▪ Proctectomy ▪ Hepatectomy ▪ Tyroidectomy ▪
Esophagectomy ▪ Appendectomy ▪ Cartoid Endarterectomy ▪
Cartoid Artery Stenting ▪ Open AAA Repair ▪ EVAR ▪ Open
Aortoiliac Bypass ▪ Endo Aortoiliac Repair ▪ Lower Extremity
Open Bypass ▪ Lower Extremity Repair Endovascular ▪
Hysterectomy ▪ Myomectomy ▪ Reconstructive Procedures ▪
TURP ▪ Bladder Suspension ▪ Radial Prostatectomy ▪
Radical Nephrectomy ▪ Radical Cystectomy ▪
Muscle/Myocutaneous Flap ▪ Reduction Mammoplasty ▪
Breast Reconstruction ▪ Abdominoplasty ▪ Thyroidectomy ▪
Total Hip Arthroplasty ▪ Total Knee Arthroplasty ▪ Spine
Surgery ▪ Hip Fracture ▪ Brain Tumor Procedure ▪Spine
Procedure ▪ Lung Resection
Pricing
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Classic
Essentials
Small &
Rural
Procedure
Targeted
Pediatrics
Base Price
$29,000
$27,000
$10,000
$29,000
$29,000
System or
Collaborative
Discount
($3,500)
($3,500)
-
($3,500)
($3,500)
Three - Year
Contract
Discount
($1,500)
($1,500)
-
($1,500)
($1,500)
Pediatric
Discount
Annual Fee
$24,000
$22,000
$10,000
$24,000
($2,000)
$22,000
Recognition
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Meets MOC Part 4 - Evaluation of
performance in practice through tools
such as outcome measures and quality
improvement programs, and the
evaluation of behaviors such as
communication and professionalism.
Recognition
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Institute of Medicine named NSQIP
“the best in the nation”
for measuring & reporting surgical quality and
outcomes.
Summary
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

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Risk adjusted Data
Clinically Robust Data
Validated Data
Best Practices Tools, Guidelines, and Case
Studies
 Proven! (improve quality AND decrease
costs)
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Tresha Russell
Business Development
Representative
tresharussell@facs.org
312-202-5441
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Thank you