Hospitals participating in the American College of Surgeons (ACS) National Surgical Quality Improvement (ACS NSQIP®) will have a new resource available to further improve surgical quality for patients beginning in January 2022: the ACS Quality Verification Program (QVP). Introduced in July 2021, ACS QVP is based on 12 program standards, adapted from core elements of the Optimal Resources for Surgical Quality and Safety, or “Red Book.” ACS QVP provides a proven, standardized method for establishing, measuring, and improving a hospital’s quality infrastructure across all surgical departments.
This collaboration, which will be announced Wednesday, October 27, during the virtual ACS Clinical Congress, provides ACS NSQIP hospitals with a Focused Level of participation in ACS QVP, called NSQIP QVP, in which they can have two surgical specialties benchmarked against the ACS QVP standards during a half-day site visit. NSQIP QVP is one of four options for hospitals to participate in ACS QVP.
“ACS NSQIP was previously the only major data registry program at ACS that wasn’t connected to a verification program. NSQIP QVP provides the verification component, which is key to improving quality. NSQIP QVP helps link NSQIP data to hospital-based surgical quality improvement efforts, helping hospitals use the data they have collected to improve surgical care,” said Clifford Y. Ko, MD, MS, MSHS, FACS, FASCRS, Director, ACS Division of Research and Optimal Patient Care, which administers ACS NSQIP.
NSQIP QVP is a new benefit that is included in the standard cost of ACS NSQIP. The College’s goal is for all ACS NSQIP sites to reach QVP-focused verification status by the end of 2027. Some of the hospitals that participated in ACS QVP as pilot sites are also ACS NSQIP-participating hospitals that saw the power of combining these two programs.
“Participating in the ACS QVP program as a pilot site accelerated our hospital along the quality journey and provided a roadmap for next steps. The combination of a quality structure as outlined in QVP and information available from NSQIP can catalyze improvement in quality for surgery patients,” said Caroline Reinke, MD, FACS, assistant professor of surgery, Atrium Health, Charlotte, NC.
NSQIP QVP will allow sites to undergo QVP Focused Verification on two surgical areas in which the site collects NSQIP data. After the focused areas are identified, sites will provide information on these two areas in pre-review questionnaires (PRQs) focused on the QVP standards. Once the PRQs are submitted, ACS will review the information prior to scheduling a site visit. After the site visit, the NSQIP-participating site will receive a detailed report on its strengths and areas for improvement.
As Kirsten Edmiston, MD, MPH, FACS, director, clinical excellence, surgery service line, Inova Health System, Fairfax, VA, explained, “Participation in the ACS Quality Verification Program accelerated our journey to deliver integrated high quality surgical care across Inova’s five-hospital health system. Together, the QVP and NSQIP data are tremendously valuable to identify opportunities, implement solutions, and improve patient care—overall driving clinical excellence.”
“In many ways the preparation and the survey itself served as an inventory for departmental resources and helped in marshalling our forces for the COVID onslaught which began in March 2020,” said John McNelis, MD, FACS, FCCCM, MHCM, chairman, department of surgery, Jacobi Medical Center, North Central Bronx Hospital, New York, NY. “As we emerged from COVID, the report has served as a template for our quality program throughout the department.”
“Combining ACS NSQIP and ACS QVP builds on the College’s longstanding commitment to surgical quality. The key principles of ACS QVP help hospitals identify problems and improve the quality and safety of surgical care for their patients,” said ACS Executive Director David B. Hoyt, MD, FACS.
A series of comprehensive literature reviews validating the principles underlying the QVP program have been published in the Journal of the American College of Surgeons. Read more about the first and second reviews.
For general information on the ACS Quality Verification Program, visit www.facs.org/qvp or contact [email protected]. For information on NSQIP QVP, visit www.facs.org/quality-programs/acs-nsqip or contact [email protected].