National Surgical Quality Improvement Program (NSQIP)
Since 2009, The Mount Sinai Hospital has reported quality data through the National Surgical Quality Improvement Program (NSQIP), which is an outcomes-based, data-driven, and risk-adjusted surgical quality improvement program. By utilizing NSQIP, our surgeons are empowered to report outcomes to improve patient care and reduce healthcare costs. Reporting outcomes through NSQIP provides the following benefits:
- Tracks morbidities and mortalities
- Benchmarking Mount Sinai with other competing hospitals
- Comprehensive risk analysis comprehensive results and statistics on the specific variables NSQIP collects
- Extensive surgical clinical reviewer (SCR) training
- Annual conference
- Shared with attendings and other divisions within the hospital
There are more than 500 participating hospitals of varying sizes, and data abstraction is contingent on the size, as well as available resources for each hospital. This allows for adequate comparison among hospitals on topics such as surgical outcomes and standards of care. In fact, according to NSQIP, the program's impact on participating institutions "has the opportunity to prevent 250-500 complications, save 12-36 lives, [and] reduce costs by millions of dollars" on average for each year of participation in the program.
For the Department of Surgery to participate in NSQIP, there is an extensive training process for SCRs, whom work with their site's Surgeon Champion to collect surgical data for submission to NSQIP.
The process of reviewing patient medical charts allows for accurate data input and collection. All of the surgical cases are randomly selected and include all of the surgeons from Colon and Rectal Surgery; General Surgery; Metabolic, Endocrine and Minimally Invasive Surgery; Plastic and Reconstructive Surgery; the Surgical Intensive Care Unit (SICU); Surgical Oncology; and Vascular and Endovascular Surgery. There is an average of 80 surgical cases abstracted each week, which are entered into an online database and utilized for benchmarking Mount Sinai's surgical outcomes with other participating NSQIP hospitals' outcomes. Examples of variables which are collected for nearly all participating institutions include sepsis/septic shock, general/vascular surgical and mortalities, urinary tract infections, and pneumonia.
At routine intervals throughout the year, NSQIP produces a semi-annual report, which provides risk-adjusted outcomes data that compares the quality of care internally over time for The Mount Sinai Hospital, as well as against other participating hospitals. The semi-annual report is pivotal to the quality improvement process within the Department of Surgery. Any concerning trends are analyzed for a more in-depth review and corrective action. The Department of Surgery performs a comprehensive analysis of indicators which are deemed "needs improvement." If the variable cases and included cases are correctly classified under NSQIP guidelines, then quality improvement measures are implemented. All pertinent information is disseminated to staff within the Department of Surgery, in order to ensure transparency and implement applicable measures, if needed.
Office of Surgical Outcomes and Quality Improvement
Department of Surgery
5 East 98th Street, 15th floor
New York, NY 10029
Mount Sinai has achieved "Meritorious" status by the American College of Surgeons NSQIP for its quality outcomes in mortality, cardiac, respiratory, and more for all Surgery cases in 2013. Learn more