Why Join Now?

A focus on quality has captured the nation’s attention, as government-driven reform, demographics and economic trends create permanent changes in the delivery of healthcare. Payers want to review the quality of care they reimburse. Empowered patients demand information to assess the quality of their hospitals and surgeons. At the same time, an aging population and the ever more expensive cost of care increasingly stress existing payment structures. The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP®) can help your hospital stay ahead of the curve. Below are a few important developments.

New CMS Measure: Participation in a General Surgery Registry
Recently, the Centers for Medicare and Medicaid Services (CMS) announced a new measure to encourage participation in a general surgery registry and expressed its intention to move toward reporting based on clinical data and outcome measures.

According to the rule, announced in August 2011, hospitals will report their participation “in a Systematic Clinical Database Registry for General Surgery, in the Hospital IQR Program beginning with the FY 2014 payment determination.”

Quality Leadership on Display: Voluntary Participation in Hospital Compare
The American College of Surgeons (ACS) and CMS are working to allow ACS NSQIP hospitals to voluntarily report their outcomes on the publicly accessible Hospital Compare website. Because ACS NSQIP is based on the best available data – clinical, risk- and case-mix-adjusted, nationally benchmarked and audited 30-day patient outcomes – it provides a more accurate look at surgical quality than many other public measures, which are based on administrative data or compliance with process measures.

Participating hospitals will voluntarily report on three measures endorsed by the National Quality Forum: elderly surgery outcomes, colectomy outcomes and lower-extremity bypass. Hospitals can choose to report just one measure or any combination of the three. The Hospital Compare website will explain the rigor of ACS NSQIP data so that patients better understand what the measures mean, the importance of accurate, risk-adjusted data, and how to use the information in making their care decisions.

Surgical CUSP: ACS NSQIP Pilot Program with CUSP and Dr. Peter Provonost
Dr. Provonost developed the Comprehensive Unit-based Safety Program (CUSP), at Johns Hopkins University in 2001 to improve the culture of safety in intensive care units. CUSP focuses on educating and improving awareness of patient safety and quality of care, empowering staff to take charge to improve safety, building partnerships between units and hospital administration

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to improve organizational culture, and providing tools to investigate and learn from mistakes.

ACS NSQIP has the highest quality data. CUSP has a very successful track record of changing behavior in hospitals. Now, Johns Hopkins and ACS have received funding from the Agency for Healthcare Research and Quality (AHRQ) to combine both programs’ strengths into a Surgical CUSP pilot.

Surgical CUSP Fast Facts

  • The pilot will roll out in 2012 in 100 ACS NSQIP hospitals in 10 states.
  • Pilot hospitals will work together to implement specific quality improvement initiatives, including a teamwork program developed by the Department of Defense and AHRQ, and a modified version of the World Health Organization’s surgical checklist.
  • The goal is to capture learnings and develop an educational toolkit that can be used nationally to improve surgical care.
  • Pilot hospitals will focus on improving colectomy outcomes and preventing surgical site infections. In the future, Surgical CUSP will expand into other surgical procedures and complications.