In February 2006, the department began participating in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP). The program is a national, validated, outcomes-based, risk-adjusted, peer controlled program designed to measure and enhance the quality of surgical care. It involves collecting data on 40 preoperative risk factors, 20 postoperative morbidities, and mortalities on patients undergoing major general and vascular surgical procedures.

Forty cases are selected from the surgical log every eight days to provide an appropriate sampling. A data validity and reliability audit was performed by NSQIP on 25 of these medical records, selected by them, from cases submitted between February and November 2006. The audit demonstrated an overall disagreement score of 0.45%, which is considered excellent.This score is a testament to the dedication of Randi Altmark, RN, BSN, CNOR, our Surgical Clinical Nurse Reviewer (SCNR) and a former Jefferson OR nurse, and her predecessor, Kathleen Hartman, RN, BSN.

As of January 1, 2007, 1000 Jefferson cases with 30-day follow up have been submitted and are available for analysis. We recently received our Observed/Expected (O/E) outcomes ratios relative to comparable participating institutions. The findings from these reports are encouraging and will be used to form the basis for quality improvement action plans.

Herbert E. Cohn, MD
Anthony E. Narducci Professor of Surgery and Chair of Quality