Frequently Asked Questions about ACS NSQIP

Hospitals must submit an application. After completing the application process, contracts are reviewed and executed. The invoice is paid, surgical clinical reviewers (SCRs) are registered for training, and NSQIP participation begins.

There is a surgeon champion who serves as the program mentor and advocate. They implement and run the program and lead the QI initiatives. The surgeon champion should have QI experience. 

In addition to the surgeon champion, a surgical clinical reviewer (SCR) is required. They are responsible for maintaining certification, meeting the hospital caseload requirement, and performing the 30-day follow-up. They also function as an educational resource. SCRs need to have QI experience, and a Registered Nurse (RN) with statistical knowledge is preferred. 

Sites may choose to sample any combination of the available targeted procedures that are pertinent to the site’s quality improvement efforts and goals. If a site chooses not to target any procedures, they can instead collect cases from any combination of the 10 existing surgical specialty areas.

Surgical Specialty Areas:

• General, Vascular, Thoracic, Cardiac, Orthopedics, Neurosurgery, Urology, Otolaryngology, Plastics, and Gynecology.

Sites with one full-time SCR:

• Estimated sampling volumes are approximately 40 cases per 8-day cycle and 1,680 cases per year.

Sites with more than one full-time SCR:

• These sites will have the capacity to target a greater number of procedures and capture more than 1,680 cases a year if desired. Sites with lower surgical case volumes that do not total 40 cases per 8-day cycle should include all eligible cases performed at their site.

Yes, ACS NSQIP has a small and rural hospital program. Contact a program manager at acsnsqip@facs.org to learn more about the case threshold, pricing, and requirements.

All inquiries regarding ACS NSQIP participation can be sent to acsnsqip@facs.org, and inquiries regarding ACS QVP verification can be sent to acsqvp@facs.org. One of our program managers will be happy to speak with you!

ACS QVP verification takes place in stages. To begin, hospitals submit clinical data. That submission is followed by 30-day follow up reviews. From the review, outcomes are identified, and performance is benchmarked. There is an implementation of QI initiatives, and then performance is reassessed.

The Focused option, which is optional, is complimentary with ACS NSQIP participation. For Comprehensive ACS QVP, there is an added cost to the ACS NSQIP subscription since it is a review of all surgical specialties.

First, hospitals must review the standards and online resources. Then, select QVP participation level (Focused or Comprehensive). Once participation level is decided, submit the online application, and complete the Pre-Review Questionnaire (PRQ). After completion, site visits are scheduled.

ACS NSQIP QVP guides sites on how to use data to drive QI. Additionally, ACS QVP is open to all NSQIP hospitals. The after-visit summary reports are provided to detail compliance with standards guidelines to holistically explain areas of improvement.  

Hospitals already participating in ACS NSQIP can take advantage of ACS QVP at any time. Hospitals NEW to ACS NSQIP typically wait 6 months for ACS QVP. This ensures their data abstracting practices are in place.