National Surgical Quality Improvement Program (NSQIP)

Oakville Trafalgar Memorial Hospital (OTMH) is participating in the National Surgical Quality Improvement Program (NSQIP). OTMH joined the program in April of 2015 with a specialized focus on reducing the incidence of Urinary Tract Infections (UTIs) and Surgical Site Infections (SSIs) following surgical procedures.

As an outcomes-based, peer-controlled program, the NSQIP measures the quality of surgical care by evaluating the recovery and overall health of randomly selected patients 30 days post-surgery. The data collected at this time is evaluated alongside that which was collected over the course of the patient’s hospital stay. Evaluating patients after this time period is important as 50 per cent of surgery-related complications occur post-discharge.

Frequently Asked Questions–NSQIP

Q: What is the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP)?
A: The ACS-NSQIP is an outcomes-based, peer-controlled program designed to measure the quality of care provided to surgical patients in medical facilities. Various data points are collected from surgical patients and evaluated and compared with those in other surgical programs, as well as other hospitals. The NSQIP focuses on the rate of post-surgical complications in patients.

Q: Why was the NSQIP created?
A: The NSQIP was created with one goal in mind – to improve the quality of care provided to all surgical patients. By tracking, evaluating and comparing information, the network of NSQIP participants work together to collectively improve patient care.

Q: Which patients participate in the program?
A: The selection of patients evaluated as a part of the NSQIP is done totally at random. Any surgical patient coming in for surgery may be chosen to participate in the program. Patient participation in the anonymous collection of data is not voluntary, but answering any follow-up questions is voluntary.

Q: Is participation in the ACS-NSQIP confidential?
A: Yes. All participants (patients and surgeons) in the program are given a unique identification number known only to the Surgical Clinical Reviewer (SCR), who is a Registered Nurse in Surgery at the hospital. All information sent to the ACS-NSQIP is void of any identifying information for both patient and surgeon.

Q: What is Oakville Trafalgar Memorial Hospital’s (OTMH) role in the NSQIP?
A: OTMH has been selected as one of 34 Ontario hospitals to take part in the NSQIP. At OTMH, the program has a specialized focus on the incidence of Urinary Tract Infections (UTIs) and Surgical Site Infections (SSIs) following surgical procedures at the hospital.

Q: What does OTMH hope to get out of its participation in the NSQIP?
A: OTMH has set a target of 40 per cent reduction in both UTI and SSI rates in surgery patients between October 1, 2015, and September 30 2016. Currently, the incidence rate of UTIs in the hospital’s surgical patients sits at 2.7 per cent. Ideally, OTMH will see these rates drop to 1.62 per cent by the end of September 2016. The incidence of SSIs in the hospital’s surgical patients currently sits at 2.4 per cent. Ideally, OTMH will see these rates drop to 1.5 per cent by the end of September 2016.

Q: Why does the evaluation of patient data take place 30 days post-surgery?
A: Statistically speaking, 50 per cent of surgery-related complications actually occur post-discharge. As such, evaluating patients once they have been sent home is crucial to the accurate measurement of complication rates.