Surgical Improvement Program

The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) is a nationally validated, risk-adjusted, outcomes-based program designed to measure and improve the quality of surgical care. It uses data gathered from medical charts by clinically trained personnel and includes demographics, preoperative risk factors, and intraoperative through 30-day postoperative outcomes data.

Hershey Medical Center currently participates in three ACS NSQIP programs:

  1. Adult NSQIP Procedure Targeted Option:  Collects data on high-risk, high-volume surgeries which include Colectomy, Proctectomy, Bariatric, Ventral Hernia Repair, Esophagectomy, Pancreatectomy, Hepatectomy, Cystectomy, Prostatectomy, Nephrectomy, Breast Reconstruction, and Muscle Flaps.  Hershey Medical Center has participated in Adult NSQIP since 2007.
  2. Pediatric NSQIP:  Started in January of 2010, and measures the quality of surgical care for children under the age of 18 across multiple specialties.  Currently, 57 Children's Hospitals participate in Pediatric NSQIP.
  3. Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP):  A joint program of the ACS and the American Society for Metabolic and Bariatric Surgery (ASMBS) established in 2012 for the purposes of reporting from a national registry, providing accreditation, and setting standards for quality care in bariatric surgery.

Data variables collected for Adult NSQIP, Pediatric NSQIP, and MBSAQIP programs:
(link to PDF attachments)

ACS NSQIP provides data reports in several formats:

  1. Semiannual Reports:  A comprehensive risk-adjusted report released twice a year using hierarchical modeling reported as odds ratios (OR) for each participating hospital.
  2. Online Reports:  Continuously updated site-specific reports comparing our unadjusted data to national averages.
  3. Participant Use Data File (PUF):  An aggregate file containing national HIPAA-compliant patient level data, for the purpose of data analysis by researchers to improve the quality of surgical patient care.  NOTE: Please contact Gail Ortenzi at before writing research articles using NSQIP data, to discuss NSQIP variable definitions and suitability for publishing.

More information about ACS NSQIP is available at,, and