NQF Endorses Surgical Measures 

JAN 31, 2012

CONTACT: Erin Weireter

NQF Endorses Surgical Measures

Washington, DC – the National Quality Forum (NQF) Board of Directors has approved for endorsement 24 quality measures on surgical care performed in hospitals and in outpatient facilities. The measures – part of NQF’s Surgery Endorsement Maintenance, Phase 2 project – address a wide range of surgeries and surgical support processes, including coronary artery bypass grafts, carotid artery stenting, pediatric cardiology volume and mortality rates, and cataract surgery.

“With the rate of surgical procedures – especially those performed outside of hospital settings – increasing annually, it’s more important than ever for NQF to support surgical quality measurement efforts,” said Janet Corrigan, PhD, MBA, president and CEO of NQF. “This set of measures will help support high-quality surgical care in a wide variety of settings and populations.”

The endorsed measures include measures that have undergone NQF maintenance as well as newly submitted measures for initial endorsement. The ongoing evaluation and updating of endorsed measures ensures the currency and relevance of NQF’s surgical care portfolio.

“These measures are a welcome addition to the surgical care portfolio endorsed by NQF,” said Arden Morris, MD, MPH, associate professor of surgery at the University of Michigan Medical School and co-chair of the Surgery Endorsement Maintenance Steering Committee. “They have undergone a rigorous review by a panel of providers, measurement experts, and consumer representatives, and will help healthcare stakeholders track and improve surgical care quality across clinical settings.”

For this project, NQF sought measures related to general surgery and surgical specialties, including but not limited to thoracic, vascular, orthopedic, neurosurgery, and other subspecialty surgical areas. In all, 40 measures were evaluated against NQF’s endorsement criteria, with 24 receiving endorsement status.

“There is an increased need for surgical measures that address care delivery across a range of conditions and settings,” said David Torchiana, MD, chairman and chief executive officer of the Massachusetts General Physicians Organization and co-chair of the Surgery Endorsement Maintenance Steering Committee. “This measure set is the result of that need, and will help providers ensure surgical patients receive the high-quality care they deserve.”

NQF is a voluntary consensus standards-setting organization. Any party may request reconsideration of any of the 24 endorsed quality measures listed below by submitting an appeal no later than February 29 (to submit an appeal, go to the NQF Measure Database). For an appeal to be considered, the notification must include information clearly demonstrating that the appellant has interests directly and materially affected by the NQF-endorsed recommendations and that the NQF decision has had (or will have) an adverse effect on those interests.

Endorsed Measures 

  • 0134: Use of internal mammary artery (IMA) in coronary artery bypass graft (CABG) (STS)
  • 0300: Cardiac surgery patients with controlled postoperative blood glucose (CMS)
  • 0127: Preoperative beta blockade (STS)
  • 0284: Surgery patients on beta blocker therapy prior to admission who received a beta blocker during the perioperative period (CMS)
  • 0117: Beta blockade at discharge (STS)
  • 0273: Perforated appendix admission rate (PQI 2) (AHRQ)
  • 0265: Hospital transfer/admission (ASC Quality Collaboration)
  • 1519: Statin therapy at discharge after lower extremity bypass (LEB) (SVS)
  • 1540: Postoperative stroke or death in asymptomatic patients undergoing carotid endarterectomy (SVS)
  • 1543: Postoperative stroke or death in asymptomatic patients undergoing carotid artery stenting (CAS) (SVS)
  • 0339: RACHS-1 pediatric heart surgery mortality (AHRQ)
  • 0340: Pediatric heart surgery volume (PDI 7) (AHRQ)
  • 0352: Failure to rescue in-hospital mortality (risk adjusted) (CHOP)
  • 0353: Failure to rescue 30-day mortality (risk adjusted) (CHOP)
  • 0351: Death among surgical inpatients with serious, treatable complications (PSI 4) (AHRQ)
  • 0515: Ambulatory surgery patients with appropriate method of hair removal (ASC Quality Collaboration)
  • 1550: Hospital-level risk-standardized complication rate (RSCR) following elective primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) (CMS)
  • 1551: Hospital-level 30-day all-cause risk-standardized readmission rate (RSRR) following elective primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) (CMS)
  • 1536: Cataracts: Improvement in patient’s visual function within 90 days following cataract surgery (AAO/Hoskins Center for Quality Eye Care)
  • 0528: Prophylactic antibiotic selection for surgical patients (CMS)
  • 0126: Selection of antibiotic prophylaxis for cardiac surgery patients (STS)
  • 0264: Prophylactic intravenous (IV) antibiotic timing (ASC Quality Collaboration)
  • 0527: Prophylactic antibiotic received within 1 hour prior to surgical incision (CMS)
  • 0301: Surgery patients with appropriate hair removal (CMS) (reserve status)

NQF operates under a three-part mission to improve the quality of American healthcare by:  

  • building consensus on national priorities and goals for performance improvement and working in partnership to achieve them;  
  • endorsing national consensus standards for measuring and publicly reporting on performance; and  
  • promoting the attainment of national goals through education and outreach programs.