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November 5, 2020 – Original Press Release


ACS NSQIP

The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP®) has UNC Hospitals among the recognized 89 of an eligible 607 hospitals participating in the adult program for achieving meritorious outcomes for surgical patient care in 2019.

UNC Hospitals was recognized and deemed “Meritorious” across the “All Cases” and the “High-Risk Cases” categories.

ACS NSQIP Semiannual Report: UNC Site Summary

These outcomes data reflect UNC’s and UNC Urology’s surgery ACS NSQIP performance benchmarked against the full 719 participating sites for 2019.

UNC 2019 ACS NSQIP Numbers
UNC Hospital performance across all surgical cases was ranked as ‘Exemplary‘ in the following categories: Mortality, Cardiac, Ventilator > 48 hours, Sepsis, and ROR (Return to Operating Room). The only category across all surgical cases performed at UNC Hospitals that were labeled as ‘Needs Improvement‘ was Readmission.

UNC Hospitals’ Urology surgical cases (chart below) performed ‘As Expected‘ in all major categories; achieving ‘Exemplary‘ metrics for cases involving Renal Failure.
UNC Urology 2019 ACS NSQIP Numbers


* Determined by Outlier status or Adjusted Quartile status.
** Predicted Observed Rate is the model-adjusted observed rate.
Data: American College of Surgeons National Surgical Quality Improvement Program, 2020. ACS NSQIP® Semiannual Report: Site Summary – UNC Hospitals January 1, 2019 – December 31, 2019

About the ACS NSQIP

ACS NSQIP-participating hospitals are required to track the outcomes of inpatient and outpatient surgical procedures; these outcomes are then analyzed by the ACS and reported back to hospitals. The results will inform patient safety initiatives within the hospital and impact the quality of surgical care.

The ACS NSQIP recognition program commends a select group of hospitals for achieving a meritorious composite score in either an “All Cases” category or a category that includes only “High Risk” cases. Each composite score was determined through a different weighted formula combining eight outcomes. Outcomes in the following eight clinical areas were evaluated:

  • Mortality
  • Cardiac: cardiac arrest and myocardial infarction
  • Pneumonia
  • Unplanned Intubation
  • Ventilator use for more than 48 hours per patient
  • Renal Failure
  • SSI: superficial incisional SSI, deep incisional SSI, and organ/space SSI
  • UTI: urinary tract infection

ACS NSQIP Scoring

The 89 hospitals achieved a distinction based on an outstanding composite quality score. Risk-adjusted data from the July 2020 ACS NSQIP Semiannual Report, which presents data from the 2019 calendar year, were used to determine which hospitals demonstrated meritorious outcomes.

Seventy-two hospitals were recognized on the “All Cases” list and 72 hospitals were recognized on the “High Risk” list; the 72 hospitals represent 10 percent of the 719 calendar-year 2019 ACS NSQIP hospitals.

50 hospitals are recognized on both the “All Cases” and “High Risk” lists, 20 other hospitals are on just the “All Cases” list, and 19 other hospitals are on the “High Risk” list only—yielding 89 hospitals in total.

A full listing of the recognized hospitals is available online.

ACS NSQIP Validated Methodologies

ACS NSQIP is the only nationally validated quality improvement program that measures and enhances the care of surgical patients.

This program measures actual surgical results 30-days postoperatively as well as risk adjusts patient characteristics to compensate for differences among patient populations and acuity levels.

The goal of ACS NSQIP is to reduce surgical morbidity (infection or illness related to a surgical procedure) and surgical mortality (death related to a surgical procedure) and to provide a firm foundation for surgeons to apply what is known as the “best scientific evidence” to the practice of surgery.

Furthermore, when adverse effects from surgical procedures are reduced and/or eliminated, a reduction in health care costs follows.

ACS NSQIP is a major program of the ACS and is currently used in nearly 850 adult or pediatric hospitals.

About the American College of Surgeons

The American College of Surgeons is a scientific and educational organization of surgeons that was founded in 1913 to raise the standards of surgical practice and improve the quality of care for all surgical patients.

The College is dedicated to the ethical and competent practice of surgery. Its achievements have significantly influenced the course of scientific surgery in America and have established it as an important advocate for all surgical patients.

The College has more than 82,000 members and is the largest organization of surgeons in the world. For more information, visit www.facs.org.