During the mid to late 1980s, the Department of Veterans Affairs (VA) came under much public scrutiny over the quality of surgical care in its 133 VA hospitals. At issue were the operative mortality rates in the VA hospitals and the perception in Congress that these rates were significantly above the national (private sector) norm. To address the gap, Congress passed Public Law 99-166 to address the gap, which mandated the VA to report its surgical outcomes annually:
- On a risk-adjusted basis to factor in a patient’s severity of illness; and
- Compare them to national averages.
The only problem was that these “national averages” did not exist.
1991–1993
Surgeons at the VA knew there were no national averages or risk-adjustment models for the various surgical specialties. Looking at their own infrastructure, however, with its advanced information systems and centralized authority and organization of hospitals, they realized they were in a unique position to create these data models.
As a result, the VA embarked upon the National VA Surgical Risk Study (NVASRS) in 44 VA medical centers. The foundation for their work was Lisa Iezzoni’s “algebra of effectiveness,” which states that outcomes of healthcare can be described by this equation:
Patient Factors + Effectiveness of Care + Random Variation = Outcome
For this equation to move from theory to practical application, the VA recognized it needed to build a statistically reliable database of patients’ preoperative risk factors and postoperative outcomes. It also had to create methods for accurate risk adjustment and to account for random events.
During this period, a dedicated nurse in each of the 44 medical centers collected preoperative, intraoperative, and 30-day outcome variables on more than 117,000 major operations. Using this data, the NVASRS was able to develop risk models for 30-day mortality and morbidity in nine surgical specialties. Additionally, the VA found that the risk-adjusted outcomes produced by the models matched the quality of systems and processes in the 44 hospitals. This work allowed, for the first time, a comparative measurement of the quality of surgical care in the nine specialties.
1994
The success of the NVASRS study encouraged the VA to establish an ongoing program for monitoring and improving the quality of surgical care across all VA medical centers, and the National Surgical Quality Improvement Program (NSQIP) was born. Over 110,000 major surgical cases have been added to the database each year, creating over 1 million surgical cases presently in the VA system.
Over time, as the VA focused on outcomes, the outcomes improved. The VA hospitals saw a 47% drop in postoperative mortality and a 43% drop in morbidity rates from 1991 to 2006.
1999
In 1999, the private sector became interested in NSQIP. Specifically, private sector hospitals wanted to know if the methodology used in VA hospitals was applicable outside the VA. They also wanted to know if the risk-adjustment models would hold true for the more heterogeneous private sector patient populations vs. the more homogenous VA system, whose patient population is predominantly male.
A pilot study, initiated in 1999, determined the feasibility of implementing NSQIP in non-VA hospitals. Surgeons at three nonfederal hospitals (Emory University, the University of Michigan, and the University of Kentucky) volunteered to participate in the pilot and to donate the time of a nurse coordinator to collect data. The pilot study included only general and vascular surgery. The three centers found that after the first complete year of analysis, both the data collection/transmission methods and the predictive and risk-adjustment models of NSQIP were applicable to their non-VA environments.
2001
In 2001, ACS launched a pilot program funded by the Agency for Healthcare Research and Quality (AHRQ) to show that NSQIP also reduced morbidity and mortality in private sector hospitals. Founded in 1913, the ACS aims to improve the care of surgical patients. This goal has always been the guiding force in ACS activities. The development of a national system to collect and report risk-adjusted event data for surgical services was of great importance to the American College of Surgeons, which represents 90,000 surgeons worldwide.
NSQIP functioned very well in the 18 private-sector hospitals that took part in the pilot program, and, in October 2002, the Institute of Medicine named NSQIP the “best in the nation” for measuring and reporting surgical quality and outcomes.
2004
In 2004, the ACS began enrolling additional private-sector hospitals into ACS NSQIP®. ACS NSQIP became the first nationally validated, risk-adjusted, outcomes-based program to measure and improve the quality of surgical care across surgical specialties in the private sector. ACS NSQIP is available to all private-sector hospitals that meet the minimum participation requirements, complete a hospital agreement, and pay an annual fee. Hospitals can benefit from participating in ACS NSQIP for many reasons; most importantly, the program can contribute to the reduction of surgical mortality and morbidity. Today, nine of the top 10 hospitals ranked as America’s Best Hospitals by U.S. News & World Report participate in ACS NSQIP.
2009
As hospitals gain more experience with ACS NSQIP, the program continues to evolve in response to learnings and changes in the healthcare sector. ACS developed four measures in 2009 in partnership with the Centers for Medicare and Medicaid Services (CMS) with the goal of creating practical outcomes-based measures that would help hospitals achieve significant quality improvements.
Participating ACS NSQIP Hospitals form regional and systemwide Collaboratives to share best practices and identify quality improvement projects. To date, there are more than 75 ACS NSQIP collaborative groups and more in development. Each collaborative receives technical support and guidance from ACS NSQIP in developing data-sharing strategies, designing specialized reports, and publicizing the group’s efforts. Collaboratives may be regional, health systemwide, or virtual.
2010
In 2010, ACS NSQIP rolled out new options tailored to a variety of hospital types and quality improvement focuses. ACS NSQIP now offers several different participation options. Also, in 2010, the ACS NSQIP Pediatric was introduced as an independent program and open enrollment was made available. Today, there are more than 150 pediatric programs participating in eight countries. Developed in partnership with the American Pediatric Surgical Association (APSA), the ACS NSQIP Pediatric option is the nation’s first and only risk-adjusted, clinical, outcomes-based program to measure and improve pediatric surgical care.
There are now nearly 700 hospitals participating in adult ACS NSQIP. ACS NSQIP hospitals are in 49 of the 50 states, as well as the District of Columbia, in this country, and internationally the program is being used at more than 150 hospitals in 18 different countries worldwide.
2013
ACS NSQIP released their first Collaborative Semi Annual Report (SAR) in December 2013 SARs. These reports (PDF and Excel data files) provide an indication of how the individual collaborative hospitals are performing relative to each other and how the collaborative as a whole is performing relative to all ACS NSQIP hospitals. Since 2013, there have been several enhancements to these reports.
2014
The program also continues to receive national honors as it was named a 2014 recipient of the John M. Eisenberg Patient Safety and Quality Award in the category of Innovation in Patient Safety and Quality from The Joint Commission and the National Quality Forum.
2019
The ACS NSQIP Ambulatory Patient Reported Outcomes (PROs) Project began in 2019 within the ACS NSQIP, aiming to scale routine health IT-enabled capture of PROs for quality improvement to the national level in ambulatory surgery, and to leverage the ACS NSQIP network of Collaboratives to spread its uptake. The project was partially funded through a grant awarded to the ACS from AHRQ and was a follow-up to the PROs Alpha Pilot Project that concluded in May 2018.
Officially launched in February 2020 with participation from 8 hospitals, the project employed validated measures known as Patient Reported Outcome Measures (PROMs), recognized for their relevance across ambulatory surgical procedures. 34 questions were sent to patients to measure domains such as global function, pain interference, fatigue, physical function, and shared decision making. At its peak, the project enrolled 64 sites.
The grant-supported phase of the project concluded in April 2023. Presently, 31 of the original 64 Pilot sites continue to collect PROMs through the system. The ACS is currently working to develop the full platform within the NSQIP Registry.
2022
ACS NSQIP hospitals became eligible to participate in the ACS Quality Verification Program (ACS QVP) as part of their annual NSQIP participation fee. ACS QVP provides a proven, standardized method for establishing, measuring, and improving hospital-wide quality infrastructure. Participating hospitals receive an in-depth assessment at hospital and specialty levels. It includes customized, actionable recommendations—such as leadership and safety culture. Using the framework of the 12 ACS QVP Standards, hospitals will be able to find, fix, and prevent problems across all surgical departments.
2023
ACS Quality Framework and Toolkit launched to help hospitals use their NSQIP data to drive quality improvement efforts. The ACS Quality Framework is broken down into 38 criteria across eight components and is designed to help ensure QI projects are comprehensive and effective. While it is not a methodology, it can be used in tandem with any quality improvement methodology. The Framework components and criteria are organized around three phases of quality improvement projects: Planning, Conducting, and Reflecting.
Also in 2023, the Quality Improvement Opportunity Report was released with each SAR for Adult NSQIP, providing performance appraisals for specific surgical groupings and outcomes. The intention is to give hospitals a simple description of their performance, identifying areas where they are doing well and where they are not doing well, compared to the average hospital, and to provide a framework for ranking surgical outcomes as viable targets for quality improvement.
