The Opportunity

The rate of surgical procedures is increasing annually. In 2010, 51.4 million inpatient surgeries were performed in the United States, and 53.3 million procedures in ambulatory surgery centers were completed.¹ Ambulatory surgery centers account for 43 percent of all same-day surgery in the United States and are the fastest growing provider type participating in Medicare.²  

NQF has endorsed surgical measures through a variety of projects beginning in 2004 with the National Voluntary Consensus Standards for Cardiac Surgery. Most recently, NQF completed a surgery endorsement project in February 2015. A second phase of this endorsement project will be completed in November 2015. The NQF surgery portfolio currently includes measures focused on key surgical care processes and outcomes for surgical procedures such as pre-, intra- and post-surgical care, use of medications peri-operatively, and adverse surgical outcomes.

As part of NQF’s ongoing work with performance measurement for patients undergoing surgery, this project seeks to identify and endorse surgical performance measures for accountability and quality improvement that address a number of surgical areas including, but not limited to, cardiac, pediatric, bariatric, thoracic, vascular, orthopedic, neurosurgery, urologic and general surgery. This project will seek new performance measures in addition to conducting maintenance reviews of surgical measures previously endorsed using the most recent NQF measure evaluation criteria.

About the Project

This project is the third cycle of measure evaluation by NQF’s Surgery Standing Committee, and continues to build on the work of the previous Surgery Endorsement project, launched in 2013. This project seeks to identify and endorse new measures that can be used to assess surgical conditions at any level of analysis or setting of care, and review endorsed measures scheduled for maintenance.

Objectives

A multi-stakeholder Standing Committee has been established to evaluate newly submitted measures and measures undergoing maintenance review and make recommendations to endorse as consensus standards. This Committee will identify and recommend endorsement of new performance measures for accountability and quality improvement that specifically address a number of surgical topic areas, including, but not limited to: pre-, intra- and post-operative care processes across an array of procedure types, use of peri-operative chemo-prophylaxis and adverse surgical outcomes. Measures including outcomes, interventions and procedures associated with surgery and surgical care processes will be considered. Additionally, the Committee will evaluate consensus standards previously endorsed by NQF under the maintenance process.

NQF Process

Measures will be considered for NQF endorsement as national voluntary consensus standards. Consensus on the recommendations developed through NQF's formal Consensus Development Process (CDP, Version 1.9). This project involves the active participation of representatives from across the spectrum of healthcare stakeholder and will be guided by a Standing Committee.

Funding

This project is supported under a contract provided by the Department of Health and Human Services. For information about the availability of auxiliary aids and services for NQF’s federally funded projects, please visit: http://www.medicare.gov/about-us/nondiscrimination/nondiscrimination-notice.html.

Contact Information

For more information, please contact the project team at 202-783-1300 or via email at surgery@qualityforum.org.

Notes

1. National Hospital Discharge Survey: 2010 table, Procedures by selected patient characteristics - Number by procedure category and age
2. http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/ASC_HAI_MAP.pdf