It’s the kind of study with relatively expected results: A program that takes data and uses it to improve performance shows that participating organizations, over time, do better than their counterparts who don’t participate.1

But when you talk to study author Clifford Ko, MD, MS, MSHS, FACS, the director of quality programs at the American College of Surgeons (ACS), he’ll explain to you that while a solid majority of participants in the National Surgical Quality Improvement Program (NSQIP) do show lower mortality, morbidity, and surgical site infections than their non-participating counterparts — 69%, 79%, 71% compared to 62%, 70%, and 65% — that still means that there are 20-30% of participating hospitals that are not showing lower rates in those areas despite eight years of participation.

“We were hoping to find what we found,” Ko says, “But we don’t know why we have these results. Do they improve and get bored and go back to old habits? Is their heart just not in it anymore?”

What is different about this study is the length of time they looked over — eight years — using the same measurement system as a previous study that found improvement in 80% of the participants over a three-year period — “That’s still 20% not improving,” Ko notes. “I think that this is a very realistic look at the surgical world. We see that complication rates are improving more than mortality rates, and that’s what hospitals tell us they see,” he says. “I’m a surgeon at UCLA, and when I look at records, I find it’s easier to spot problems with complications that we can solve than with mortality. So this data is definitely representative of what is happening with hospitals.”

It’s also representative of what is happening in just 400 of the 600 hospitals that participate in the NSQIP in a country with more than 5000. “The hospitals that sign up for NSQIP are early adopters,” he says. “They spend the money, hire the data collector and want to work on these issues. They may not be representative of all hospitals, but I think they are a good representation of the ones in the program.”

Even with this voluntary system, though, it’s obvious that not every participant puts everything into the opportunity, says Ko. Getting others to agree to participate in the kind of protocols that NSQIP has created without a mandate? It won’t happen, says Ko. Nor will a mandate.

Still, over time, the information that NSQIP has gleaned has led to changes in the way surgery is done, and will continue to do so, he says.

Surgical-site infections remain the most common complication and one of the most complex problems to fix, he says. “It’s multifactorial, and any one thing that can go wrong can lead to an infection. So you have to look at a lot of things to figure out what isn’t right. To do that takes good data, accurate data. You need a multidisciplinary team, a good culture, and an ability to try different solutions until you get a result.” NSQIP hospitals provide that, he continues.

But he understands that not every hospital will want to put the money and time into that particular endeavor. “We have to prioritize, and each hospital is different,” he says.

For more information on this topic, contact Clifford Y. Ko, MD, MS, MSHS, FACS, Director of Quality Programs, American College of Surgeons, Chicago, IL. Email:


  1. Ko CY, Cohen ME, Liu Y, Hall BL. Improved Surgical Outcomes for ACS NSQIP Hospitals Over Time. Annals of Surgery. DOI: 10.1097/SLA.0000000000001192