The National Surgical Quality Improvement Program (NSQIP), as administered by the American College of Surgeons, became available to private sector hospitals across the United States in 2004. The program works to improve surgical outcomes by providing high-quality, risk-adjusted data to surgeons at a given hospital to stimulate discussion and define target areas for improvement. Although the NSQIP began in the early 1990s with Veterans Administration hospitals and expanded to private sector hospitals nearly 5 years ago, the "how to" process for NSQIP implementation has been left to individual institutions to manage on their own. The NSQIP was instituted at a large tertiary hospital in 2005, identifying through experience 12 critical steps to help surgeons and hospitals implement the NSQIP.