NQF Releases Statement Detailing Appeals Board Decision on SEP-1 Endorsement Status 

Washington, DC – National Quality Forum’s (NQF) Appeals Board met on April 29, 2022, to adjudicate a measure endorsement appeal, the first the organization has received in the last seven years. The measure, NQF #0500 Severe Sepsis and Septic Shock: Management Bundle(SEP-1), developed by Henry Ford Hospital, was initially granted NQF endorsement in 2008, and the intent of this measure is to promote efficient, effective, and timely delivery of high-quality sepsis care.

The Appeals Board unanimously upheld the December 2021 Consensus Standards Approval Committee (CSAC) endorsement decision. Prior to the appeals determination, both the appellant and the measure developer shared respective statements. Following responses to clarifying questions regarding the appeal, two votes were held to determine whether the issues presented met the eligibility criteria for an appeal:

• Were there procedural errors reasonably likely to affect the outcome of the original endorsement?
• Is there new information or evidence, which was unavailable at the time the CSAC made its endorsement decision, that is reasonably likely to affect the outcome of the original endorsement decision?

The Appeals Board determined by two, 5-0 votes (PDF) that the eligibility criteria for the appeal were not met. Based on these votes, no further appeal discussion was advanced, and the measure remains endorsed.

This determination concludes this part of the multistakeholder consensus-building endorsement process; a process designed intentionally to garner highly diverse stakeholder perspectives. While measure endorsement determinations are rarely appealed, this proceeding demonstrates the value and importance of a robust, voluntary, consensus-based process that is open, transparent, and supports thorough due process.

“The important considerations at the heart of the sepsis measure appeals process reflect the foresight and wisdom of the Presidential Commission recommendation that called for the creation of NQF. Consensus-based decision making is hard, demanding rigorous process and respectful dialogue between everyone present at the table. Despite highly divergent perspectives, what is undeniable is everyone’s shared motivation to make evidence-based decisions in the best interest of patient care and safety. I am heartened by all stakeholders’ commitment to establishing measurable performance standards to protect patients from harm and improve health outcomes,” said Dana Gelb Safran, ScD, President & CEO, NQF.

NQF would like to thank the Appeals Board, the 25 members of our Patient Safety Standing Committee, the measure developers, the appellant organizations, the CSAC, our Member Organizations, and all who engaged in this process.

Sepsis remains a measurement priority to keep patients free from harm and promote high value care. According to the Centers for Disease Control and Prevention (CDC), 1.7 million adults in America develop sepsis and nearly 270,000 Americans die as a result of sepsis annually. Research also suggests that 1 in 3 patients who dies in a hospital has sepsis, costing nearly $27 billion. Ensuring patient safety was a founding principle for NQF, and these statistics underscore why it remains critical to reduce the occurrence and severity of sepsis. Clinicians and pharmacists working on the front lines experience daily the devastating toll of sepsis on patients and their families. These providers are fully committed to improving sepsis care and outcomes.

While the Appeals Board unanimously determined that no procedural errors affected the endorsement decision, as an organization dedicated to continuous process improvement, NQF takes the appellant’s concerns seriously and is undertaking a thorough review to identify improvements to further strengthen the consensus development process.

The Appeals Board vote is the final decision on this measure as part of the spring 2021 maintenance review cycle. The next endorsement review of NQF #0500 Severe Sepsis and Septic Shock: Management Bundle will be in 2024 unless an early maintenance review is requested.

Background: In January 2022, six organizations jointly appealed to the Consensus Standards Approval Committee (CSAC) endorsement decision for NQF #0500. This measure was first submitted for endorsement in 2008, and since then, it has been reviewed three times for maintenance endorsement, appealed once, and undergone two ad-hoc reviews (i.e., early maintenance reviews). The measure has maintained NQF endorsement since 2008.

About National Quality Forum
The National Quality Forum (NQF) works with members of the healthcare community to drive measurable health improvements together. NQF is a not-for-profit, membership-based organization that gives all healthcare stakeholders a voice in advancing quality measures and improvement strategies that lead to better outcomes and greater value. Learn more at www.qualityforum.org.