National Surgical Quality Improvement
Program – Ontario
Expression of Interest Form
Expressions of Interest must be received by January 20, 2015.
They must include the following documents:
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A completed Expression of Interest form
Letters of support from your Hospital CEO and Chief of Surgery
Confirmation of review of Participation Agreement and addendums with ACSNSQIP and Transfer Payment Agreement with HQO
Please submit your Expression of Interest form to NSQIP@hqontario.ca
Prior to completing this form
 Please download the Expression of Interest Information Package
 Email NSQIP@hqontario.ca to notify us of your interest in participating in the
run-in phase of the National Surgical Quality Improvement Program – Ontario.
We will respond within two business days and send you the following
documents:
1. A draft Participation Agreement and addendums with ACS-NSQIP
2. A draft Transfer Payment Agreement with HQO
NSQIP – Participation & Selection Criteria
PARTICIPATION CRITERIA
Please note that this Expression of Interest is not a call for proposals. However, while we do not require the
submission of extensive applications, we do look for confirmation that inquiring hospitals are committed to
the deliverables identified below.
Complete and submit Expression of Interest by January 20, 2015, including:
Signed Expression of Interest Form
Letter of Support from CEO
Letter of Support from Chief of Surgery
Review sample agreements (obtained by contacting NSQIP@hqontario.ca):
Participation Agreement and addendums with ACS-NSQIP
Transfer Payment Agreement with HQO
All agreements must be signed by March 31, 2015
Acknowledgement of Participation includes the following
Implement NSQIP-ON across surgical programs:
Participating hospitals will have the ability to choose between 3 program options (Small/Rural;
Procedure Targeted, Essentials) designed for all hospitals and quality improvement goals, regardless
of hospital type, patient population or type/number of procedures performed.
Implementation will, at a minimum, occur with General Surgery
All surgeons from the specialties selected agree to participate
Each hospital will be required to collect and report data through the American College of Surgeon’s
National Surgical Quality Improvement Program (ACS NSQIP)
Develop a Quality Improvement plan for continuous improvement based on NSQIP results involving
all stakeholders, including hospital CEO, Chief of Surgery, Surgeon Champion and hospital NSQIPON team.
Engage in collaborative learning with a network of colleagues across the province:
Participate in training/webinars/meetings. To facilitate improvement, each hospital’s elected NSQIPON team (SCR, Surgeon Champion, and team) will receive formal training on how to use their NSQIP
results and how to implement surgical quality and process improvement initiatives
Share NSQIP data and quality improvement lessons and solutions with the NSQIP-ON Network
participants
As part of NSQIP-ON your hospital will have access to NSQIP-ON learning community. The learning
community will be a support tool for all members within participating organization and you will have
access to newly developed quality action initiatives to assist your organization to foster improvements.
Participate in formal evaluation of NSQIP-ON Network. For the purposes of program evaluation and
development of QI supports for hospitals, participating hospitals acknowledge that ACS will provide
HQO access to de-identified, aggregated, risk-adjusted data reports. Details on the policy for access
and use of this data will be provided by HQO.
Meet participation requirements and program deliverables, particularly during the first 3 months:
Participating hospitals are required to hire or designate a Surgical Clinical Reviewer (SCR) by April 1,
2015. Training will be provided (see EOI Information package for details).
A Surgeon Champion must be designated for each hospital (see EOI information package for
details).
Sustain investments for ongoing participation in NSQIP-ON beyond October 2016:
Financial support will be provided to each hospital to facilitate participation until October 2016. This
will include NSQIP license fee, Surgeon Champion stipend and Surgical Clinical Reviewer funding
support (see EOI information package for details).
Organizations will be responsible for program costs following the run-in period (detailed HQO Funding
support will be provided to organizations as outlined in the Funding agreement)
Develop a Sustainability plan for continued involvement in NSQIP-ON
Develop program contingency plans to ensure continued success (i.e. Surgical Champion/SCR
vacation/turnover)
Please note that NSQIP-ON is committed to engaging as many hospitals as possible during the
run-in period. Consequently, if there are delays in the submission of an Expression of Interest or
the signing of agreements, a new hospital will be identified for participation.
NSQIP-ON Selection Criteria
Agree to Participation Criteria
Letter of Support from CEO
Letter of Support from Chief of Surgery
Agree to sign 1) Participation Agreement and addendums with ACS-NSQIP and 2) Transfer Payment
Agreement with HQO
Identify a Surgeon Champion, and to sustain the role past October 2016
Agree to hire a Clinical Surgical Reviewer, and to sustain the role past October 2016
Agree to implement across surgical programs, including (at a minimum) General Surgery. All
surgeons and disciplines participating in the selected specialty are required to participate
Agree to collect and submit data to ACS-NSQIP
Agree that HQO will have access to reports provided by ACS-NSQIP that include de-identified,
aggregated, risk-adjusted data. Details on the policy for access and use of this data will be provided
by HQO.
Agree to engage in local QI based on reports from ACS-NSQIP
Agree to participate in NSQIP-ON Network and to share data, change ideas and results with peers
who are participating in the Learning Community
Agree to participate in the evaluation of NSQIP-ON Network
Agree to include a sustainability plan in participation design
NSQIP-ON Expression of Interest
Completion of this Expression of Interest form indicates that your hospital/organization is committed to
participating in NSQIP-ON and is:
• Committed to implementing NSQIP-ON across surgical programs
• Committed to engaging in collaborative learning with a network of colleagues across the province
• Able to meet the participation requirements and program deliverables, particularly during the first
three months.
Upon receipt of your completed Expression of Interest, NSQIP-ON will begin the review process and will
notify your hospital once acceptance has been confirmed. Please note that we may contact you if
clarification of any points is required.
Hospital Name:
Site (if applicable): Please note that this form will need to be filled out for each site separately.
Hospital Address:
LHIN:
Hospital type:
Academic/teaching
Community
# of beds (site): ________________
Rural
Surgical Case Load (site): ________________
Please note that during the run-in period we are looking for representation from all three types.
NSQIP-ON Options – Indicate which NSQIP program option you have chosen (refer to Expression of Interest
Information Package, p. XX for guidance).
Essentials
Small/Rural
Procedure Targeted
Indicate what surgical specialties that will be participating in NSQIP-ON:
General Surgery (required)
Gynecology
Neurosurgery
Orthopedics
Plastic Surgery
Urology
Vascular
Other
estimated annual volume: ____________________
estimated annual volume: ____________________
estimated annual volume: ____________________
estimated annual volume: ____________________
estimated annual volume: ____________________
estimated annual volume: ____________________
estimated annual volume: ____________________
estimated annual volume: ____________________
Main Contact for NSQIP-ON application process:
Name:
Job Title:
Contact Phone:
Contact E-mail:
Secondary Contact:
Name:
Job Title:
Contact Phone:
Contact E-mail:
Surgeon Champion (if identified at time of EOI submission):
Name:
Contact E-mail:
Contact Phone:
Expression of Interest Date of Submission:
Please indicate whether or not you agree with the following statements regard the resources and
processes in place within your organization:
Question
Strongly
Agree
Agree
Disagree
Strong
Disagree
N/A
Unsure
People and processes are in place to
identify, analyze and act upon adverse
events and near misses to prevent
future occurrences
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QI project results are regularly
communicated to clinical staff
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The hospital has a process in place to
routinely educate clinicians and staff
about new initiatives and protocols
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The hospital has IT support available,
as needed, for the ON-NSQIP team
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Please answer the following questions regarding how widely the following quality improvement
strategies are used in surgical departments within your hospital:
Across all
surgical
specialties
In proposed
surgical
specialties
By few or no
surgical
specialties
Unsure
Tracking of surgical outcomes such as
length of stay, readmissions & mortality
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Tracking of process measures
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Collection of patient satisfaction/patient
experience information
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Benchmarking with other hospitals
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Benchmarking among
departments/units/programs within
hospital
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Management “walk-arounds” to identify
quality problems or issues
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Using best practices from other
industries
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Collaboration with other hospitals
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Evidence-based practice
guidelines/clinical pathways
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Patient Advisory Council or similar group
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Use of advanced practice nurse to
coordinate care
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Question
Please describe any financial or in-kind contributions from your hospital (e.g. QI, IT etc) to support
implementation of NSQIP-ON, including continued participation beyond the run-in period (i.e. past
October 2016).
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Signatures:
Print Full Name
Signature
Hospital CEO
Chief of Surgery
Surgeon Champion
Should you have any questions about this Expression of Interest form, the participation
requirements, or the selection criteria, please feel free to contact NSQIP@hqontario.ca