1. NSQIP Admin Leads Meeting Agenda October 12 th 2011 1.CPT coding update – Angela Tecson 2.BC NCSQIP Collaborative MOU – Marlies van Dijk and Susan Scrivens 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 6.Kick Starting Surgical Improvement in BC: registration update – Marlies van Dijk 7.Surgeon Champion and SCR relationship – Marlies van Dijk 8.Questions? Updates? – Everyone

2. 1. CPT coding update – Angela Tecson

3. 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.

4. 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)

5. 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)

6. 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)

7. (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)

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

9. 4. Interest in BC issues log – VCH and Providence

10. 5. Culture survey initiative – Marlies van Dijk Update Call to Action webinar October 14 th at 12pm https://bcpsqc.webex.com

11. 6. Kick Starting Surgical Improvement in BC: registration update – Marlies van Dijk Total = 115 FHA = 28VCH = 21VIHA = 18 PHC = 11 IHA = 12 NHA = 6 PHSA = 2

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

13. 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.

14. Data Collection SCR (support Surgeon/ Anesthesia) Analysis SCR (support Surgeon/ Anesthesia) Dissemination Everyone! SCR/SC Action Teams Front line/ Multidisciplinary (Data support: SCR)

15. 8. Questions? Updates?