Provides administrative and clinical review and administrative support for the DoD's implementation of the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) program. This includes but is not limited to, clinical screening, data compilation documentation and entry into the DoD NSQIP data base of all eligible patient cases within the medical treatment facility. The SCNR also works closely with the members of the Department of Surgery to identify opportunities for clinical quality improvement. The program collects data on cases, such as demographics, surgical profile, preoperative, intra-operative and post operative mortality and morbidity outcomes for patients undergoing surgical procedures in both inpatient and outpatient settings. The nurse reviewer performs chart abstraction and/or quality improvement projects for the NSQIP.
- Responsible for the identification of surgical patients for inclusion in the program registry through the application of strict program inclusion/exclusion criterion and randomization protocol.
- Responsible for the reliable collection of pre-operative, operative, and post-operative data components for the program through the effective utilization of the hospital medical record system.
- Responsible for meeting the accrual requirement of cases per year through the correct application of the program's randomization protocol.
- Attends weekly Morbidity and Mortality conferences to ensure reliable data collection of postoperative occurrences.
- Demonstrates applicability of the methodology and the reliability of definitions utilized by reviewers within the program through Inter-Rater Reliability (IRR) testing.
- Responsible for identifying areas for streamlining and process improvement in the data collection process.
- Responsible for utilizing software applications available at the site for data collection and analysis.
- Responsible for the accurate and timely entry of data into the program's website and assuring the transmission of completed data.
- Responsible for reviewing weekly site accrual report on the website and responding to accrual report alerts.
- Contacts patients and/or families via telephone and/or written communications post-operatively for the purpose of identifying possible occurrences associated with surgical procedures performed at the hospital.
- Serves as an educational resource on the ACS NSQIP for internal and external audiences by developing educational material and delivering presentations.