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The Opportunity
The rate of surgical procedures is increasing annually. In 2006, 46 million inpatient surgeries in the United States were performed,1 and 53.3 million procedures in ambulatory surgery centers were completed.2 With this rise there has been a rapid increase in the number of ambulatory surgery centers. In 2007, there were 4,964 Medicare-certified ambulatory surgery centers, which was a 64 percent increase from 2000.3 NQF has endorsed a number of consensus standards for surgical procedures and care of surgical patients over the past six years. An evaluation of all NQF-endorsed surgical measures and consideration of new measures will ensure the currency and relevance of NQF’s portfolio of voluntary consensus standards.
As the quality measurement enterprise has matured, better data from clinical registries and electronic health records can support the demand for meaningful performance measures. There has also been a shift to focus on outcomes and composite measures.
In 2004, NQF endorsed 21 consensus standards for cardiac surgery under the National Voluntary Consensus Standards for Cardiac Surgery project, the largest number of surgical measures endorsed in a single NQF project. NQF has endorsed consensus standards applicable to surgery in a number of other projects, including National Voluntary Consensus Standards for Hospital Care: An Initial Performance Measure Set and National Voluntary Consensus Standards for Hospital Care 2007: Additional Performance Measures.
About the Project
The project began in September 2010.
Objectives
This project seeks to identify and endorse measures for public reporting and quality improvement that specifically address the care of the surgical patient and surgical procedures. NQF will solicit measures applicable to any healthcare setting and utilizing any data sources. Measures that are harmonized across settings (e.g., outpatient and hospital) are preferred.
Measures will be solicited for the following topics in two “phases”:
Phase 1 cardiac surgery, including pre-operative evaluation, postoperative care, diagnostic studies, and treatments associated with these surgeries. The Call for Measures for Phase 1 closed on October 28, 2010.
Phase 2 general surgery and surgical specialties including but not limited to thoracic, vascular, orthopedic, neurosurgery, and other subspecialty surgical areas. The Call for Measures for Phase 2 closed on December 14, 2010.
Additionally, as part of this process, surgical consensus standards that were endorsed by NQF before June 2008 will be evaluated under the maintenance process. Endorsement maintenance provides the opportunity to harmonize specifications and to ensure that an endorsed measure represents the “best in class.”
NQF Process
The candidate consensus standards will be considered for NQF endorsement as voluntary consensus standards. Agreement around the recommendations will be developed through NQF’s formal Consensus Development Process (CDP, Version 1.8). This project, like all NQF activities, involves the active participation of representatives from across the spectrum of healthcare stakeholders and is guided by a multi-stakeholder Surgical Steering Committee.
Funding
This project is supported under a contract provided by the Department of Health and Human Services.
Related NQF Work
Contact Information
For more information, contact Melinda Murphy, RN, MS, NE-BC, or Alexis Forman, MPH, at 202-783-1300 or via e-mail at surgery@qualityforum.org.
Notes
1. DeFrances CJ, Lucas CA, Buie VC, Golosinskiy A, 2006 National Hospital Discharge Survey, National Health Statistics Reports, no 5, Hyattsville, MD: National Center for Health Statistics; 2008. Available at http://www.cdc.gov/nchs/data/nhsr/nhsr005.pdf.
2. Cullen KA, Hall MJ, Golosinskiy A, Ambulatory Surgery in the United States, 2006, National Health Statistics Reports, no 11, Hyattsville, MD: National Center for Health Statistics; 2009. Available at http://www.cdc.gov/nchs/data/nhsr/nhsr011.pdf.
3. DeFrances. Lucas, and Golosinskiy.
This NQF project seeks to identify and endorse measures that specifically address care of the surgical patient and surgical procedures for public reporting and quality improvement applicable to all settings of care. In addition, NQF-endorsed® surgical consensus standards that were endorsed prior to June 2008 will undergo maintenance review.
The Call for Nominations for Steering Committee members closed on October 28, 2010.
For more information on the Steering Committee formation process, please refer the Call for Nominations. (PDF)
In an effort to further identify expertise for inclusion on the Steering Committee, NQF called a 10-day additional nominations period for the Surgery Endorsement and Maintenance 2010 project.
The additional Call for Nominations for Steering Committee members closed on November 19, 2010. For more information on the Steering Committee formation process, please refer the Additional Call for Nominations (PDF) document.
The 21-day review period for submitted nominees closed on January 6, 2011. Members and the public were able to provide feedback on the proposed roster and identified gaps in the committee representation. NQF has identified and has worked to ensure representation from purchasers, thoracic surgery and ophthalmology.
Surgery Endorsement Maintenance 2010 is a phased project, encompassing two separate Calls for Measures, Phase 1 and Phase 2. To date, NQF issued a Call for Candidate Standards for Phase 1 and Phase 2 of this project.
This project includes maintenance review of 43 surgical consensus standards. As a part of the maintenance review process, NQF sought comments on the implementation and use of these measures, particularly all stakeholders’ experiences with the measures. For additional information, refer to the Call for Implementation Comments document.
The Steering Committee began meeting in January 2011 to evaluate the submissions and prepare the draft report.
Phase 1 measures to be reviewed (PDFs):
Cardiac: CABG
- 0113 Participation in a Database for Cardiac Surgery (Revised)
- 0114 Post-operative Renal Failure (Revised)
- 0115 Surgical Re-exploration (Revised)
- 0119 Operative Mortality for CABG (Revised)
- 0129 Prolonged Intubation (Ventilation) (Revised)
- 0131 Stroke/Cerebrovascular Accident (Revised)
- 0134 Use of IMA in CABG (Revised)
Cardiac: Valve Replacement/Repair
- 0120 Operative Mortality for AVR (Revised)
- 0121 Operative Mortality for MV Replacement (Revised)
- 0122 Operative Mortality MV Replacement+CABG Surgery (Revised)
- 0123 Operative Mortality for AVR+CABG Surgery (Revised)
- 0124 Surgical Volume
- 1501 Operative Mortality for MV Repair (Revised)
- 1502 Operative Mortality for MV Repair+CABG Surgery (Revised)
Esophageal Resection and Transfusion
- 0360 Esophageal Resection Mortality Rate (IQI 8)
- 0361 Esophageal Resection Volume (IQI 1)
- 1526 Transfusion Consent
- 1527 RBC Transfusion Indication
- 1532 Plasma Transfusion Indication
- 1539 Platelet Transfusion Indication
- 1541 Blood Administration Documentation
- 1542 Preoperative Anemia Screening
- 1547 Preoperative Blood Type Testing and Antibody Screening
Cardiac: CABG and Prophylaxis
- 0116 Anti-Platelet Medication at Discharge (Revised)
- 0118 Anti-Lipid Treatment Discharge (Revised)
- 0130 Deep Sternal Wound Infection Rate (Revised)
- 0217 Surgery Patients with Recommended VTE Prophylaxis Ordered
- 0218 Surgery Patients who received VTE prophylaxis within 24 Hours (Revised)
- 0300 Cardiac Patients with 6am Postoperative Serum Glucose (Revised)
- 1479 Patients on Lipid-Lowering Medication
The Surgery Endorsement Maintenance Workgroup B met via conference call on February 11, 2011.
The Surgery Endorsement Maintenance Workgroup B will meet via conference call on April 28, 2011.
The Surgery Endorsement Maintenance Workgroup C met via conference call on February 11, 2011.
The Surgery Endorsement Maintenance Workgroup C met via conference call on April 27, 2011.
The Surgery Endorsement Maintenance Workgroup A met via conference call on February 16, 2011.
The Surgery Endorsement Maintenance Workgroup A met via conference call on April 22, 2011.
The Surgery Endorsement Maintenance Workgroup D met via conference call on February 17, 2011.
The Surgery Endorsement Maintenance Workgroup D met via conference call on April 20, 2011.
The Steering Committee met February 28-March 1, 2011 to review Phase 1 measures. The meeting was held in Washington, DC.
The Steering Committee met via conference call March 31, 2011.
The Steering Committee met May 4-5 to discuss Phase 2 measures at the Embassy Suites DC Convention Center, 900 10th Street, NW, Washington, DC.
Phase 2 measures reviewed (PDFs):
Cardiac, Appendectomy and Pancreatic Resection
- 0117 Beta blockade at discharge
- 0127 Preoperative beta blockade (REVISED)
- 0265 Hospital transfer/admission (REVISED)
- 0273 Perforated appendix admission rate (PQI 2)
- 0284 Surgery patients on beta blocker therapy prior to admission (REVISED)
- 0364 Incidental appendectomy in the elderly rate (IQI 24) (risk adjusted)
- 0365 Pancreatic resection mortality rate (IQI 9) (risk adjusted) (REVISED)
- 0366 Pancreatic resection volume (IQI 2) (REVISED)
- 1480 Patient(s) 18 years of age and older on a beta-blocker at admission
- 1519 Statin therapy at discharge after LEB (REVISED)
Cardiac and Vascular
- 0357 Abdominal aortic aneurysm volume (AAA) (IQI 4) (REVISED)
- 0359 Abdominal aortic artery (AAA) repair mortality rate (IQI 11) (risk adjusted) (REVISED)
- 1523 In-hospital mortality following elective open repair of AAAs (REVISED)
- 1531 Follow-up assessment of stroke or death after carotid revascularization (REVISED)
- 1534 In-hospital mortality following elective EVAR of AAAs (REVISED)
- 1540 Postoperative stroke or death in asymptomatic patients undergoing carotid endarterectomy (REVISED)
- 1543 Postoperative stroke or death in asymptomatic patients undergoing carotid artery stenting (REVISED)
- 1548 Surveillance after endovascular abdominal aortic aneurysm repair (EVAR)
General, Ophthalmology, Orthopedics and Pediatrics
- 0301 Surgery patients with appropriate hair removal
- 0339 RACHS-1 pediatric heart surgery mortality (REVISED)
- 0340 Pediatric heart surgery volume (PDI 7) (REVISED)
- 0351 Death among surgical inpatients with serious, treatable complications (PSI 4) (REVISED)
- 0352 Failure to rescue in-hospital mortality (risk adjusted) (REVISED)
- 0353 Failure to rescue 30-day mortality (risk adjusted) (REVISED)
- 0515 Ambulatory surgery patients with appropriate method of hair removal
- 1536 Cataracts: Improvement in patient's visual function (REVISED)
- 1549 Cataracts: Patient satisfaction (REVISED)
- 1550 Hospital-level RSCR following elective primary THA and TKA (REVISED)
- 1551 Hospital-level 30-day all-cause RSRR following elective primary THA and TKA (REVISED)
- 1741 Patient Experience with Surgical Care Based on the Consumer Assessment of Healthcare Providers and Systems (CAHPS)® Surgical Care Survey (REVISED)
General, Prophylaxis and Wound Dehiscence
- 0125 Timing of antibiotic prophylaxis for cardiac surgery patients (REVISED)
- 0126 Selection of antibiotic prophylaxis for cardiac surgery patients
- 0128 Duration of prophylaxis for cardiac surgery patients
- 0264 Prophylactic intravenous (IV) antibiotic timing (REVISED)
- 0367 Post operative wound dehiscence (PDI 11) (risk adjusted)
- 0368 Post operative wound dehiscence (PSI 14) (risk adjusted)
- 0527 Prophylactic antibiotic received within 1 hour prior to surgical incision SCIP-Inf-1
- 0528 Prophylactic antibiotic selection for surgical patients
- 0529 Prophylactic antibiotics discontinued within 24 hours after surgery end time
The Steering Committee met on June 21.
The Steering Committee met on August 3 via conference call. This meeting was open to members and the public.
The Steering Committee met on August 4 via conference call. This meeting was open to members and the public.
The Steering Committee met via conference call on September 13, 2011. This meeting was open to members and the public.
The Steering Committee met via conference call on November 29. This meeting was open to members and the public.
Project staff hosted a pre-voting webinar on August 16, 2011 with a
member of CSAC and a co-chair from the committee. Members and the
public had another opportunity to voice their opinions about the
Phase I measures and ask the Committee co-chair questions. This meeting was open to members and the public.
The draft report has been revised based on the comments received during the Public and Member Comment and consultation with the Steering Committee. The member voting period closed on August 30, 2011.
Project staff hosted a pre-voting webinar with a member of CSAC and a co-chair from the committee. This meeting was open to members and the public.
The draft report has been revised based on the comments received during the Public and Member Comment and consultation with the Steering Committee. The member voting period closed on December 5, 2011.
The CSAC met on September 12 to consider the endorsement of 18 measures from the Surgery Endorsement and Maintenance project - Phase 1.
Review the CSAC meetings
CSAC will consider the nine Surgery Endorsement Maintenance Phase II Addendum Report measures for endorsement.
Review the CSAC Meetings
The Board chose to endorse the Surgery Phase 1 measures.
No appeals were filed during this time.
No appeals were filed at this time.
The appeals period closed on May 31, 2012. No appeals were filed during this time.
