NSQIP Admin Leads Meeting AgendaOctober 12th 2011

1. CPT coding update – Angela Tecson2. BC NCSQIP Collaborative MOU –

Marlies van Dijk and Susan Scrivens3. Query re: Hospital versus Surgical LOS – VCH and Providence4. Interest in BC issues log – VCH and Providence5. Culture survey initiative – Marlies van Dijk6. Kick Starting Surgical Improvement in BC: registration update

– Marlies van Dijk7. Surgeon Champion and SCR relationship – Marlies van Dijk8. Questions? Updates? – Everyone

1. CPT coding update – Angela Tecson

2. BC NCSQIP Collaborative MOU – Marlies van Dijk and Susan Scrivens

1. Each Participating Health Organization directs and authorizes ACS to provide SQAN with access to its risk-adjusted ACS NSQIP Data through staff of the BCPSQC.•Allows for the identification of the hospital sites of the Participating Health Organization.•ACS will not provide SQAN with site-identifiable non-risk-adjusted ACS NSQIP Data or reports.

2. ACS will provide a semi-annual report to SQAN •Compares non-site-identifiable risk-adjusted O/E ratios of hospital sites of the Participating Health Organizations. •ACS will also provide SQAN a semi-annual report comparing site-identifiable risk-adjusted O/E ratios of hospital sites of the Participating Health Organizations.

BC NCSQIP Collaborative MOU (continued)

3. ACS will enable the Participating Health Organizations to post a confidentiality notice on the NSQIP website•Alerts and reminds NSQIP users of their confidentiality obligations with respect to the ACS NSQIP Data.

BC NCSQIP Collaborative MOU (continued)

4. Each Participating Health Organization acknowledges and agrees:(a) SQAN will be submitting a report to BC Health Services Purchasing Organization (“HSPO”) twice per year on the risk-adjusted ACS NSQIP Data only. The data component of the report comes from NSQIP.(b) SQAN will collaborate with the Participating Health Organizations to ensure that each Participating Health Organization has the opportunity to provide the commentary on its own data as part of the HSPO report.

BC NCSQIP Collaborative MOU (continued)

(c) SQAN will not disclose risk-adjusted or non-risk adjusted ACS NSQIP Data to any third party without full agreement of each of the Participating Health Organizations.(d) SQAN will provide background on the improvement activities that have been undertaken to provide support.

BC NCSQIP Collaborative MOU (continued)

3. Query re: Hospital versus Surgical LOS – VCH and Providence

4. Interest in BC issues log – VCH and Providence

5. Culture survey initiative – Marlies van Dijk

• Update• Call to Action webinar October 14th at 12pm

https://bcpsqc.webex.com

6. Kick Starting Surgical Improvement in BC: registration update – Marlies van Dijk

Total = 115

FHA = 28VCH = 21VIHA = 18

PHC = 11

IHA = 12

NHA = 6PHSA = 2

Register here:http://www.bcpsqc.ca/events/sqan-events.html

7. Surgeon Champion and SCR relationship – Marlies van Dijk

Ellner, Scott J. 2011. “Hospital puts ACS NSQIP® to the test and improves patient safety” Bulletin of the American College of Surgeons 96(9): 9-11.

Data CollectionSCR

(support Surgeon/Anesthesia)

AnalysisSCR

(support Surgeon/Anesthesia)

Dissemination

Everyone!SCR/SC

Action TeamsFront line/

Multidisciplinary(Data support:

SCR)

8. Questions? Updates?