Surgery Endorsement Maintenance 2010

Call for Intent
July 2024

Surgery Endorsement Maintenance 2010

NQF is initiating a consensus development project seeking endorsement of measures for Surgery Endorsement Maintenance 2010
If, after reviewing this Call for Intent, your organization believes it has one or more measures that address the scope and objectives of this project as described below and would like NQF to evaluate them for possible endorsement, please submit a call for intent to submit candidate standards by 28 September, 2010 to complete this process.
NQF has recently converted to electronic submission of materials. To submit your intent, log in with your NQF username and password and complete the form for each intended measure submission. If you have not created an NQF account, please follow the instructions on the log-in page.
The rate of surgical procedures is increasing annually. In 2006, 46 million in-patient surgeries in the United States were performed , and 53.3 million procedures in ambulatory surgery centers were completed in 2006. 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. 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.

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.

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.
This Consensus Standards Endorsement Maintenance project consists of two activities:

1. Evaluation of new measures related to surgical procedures. NQF will solicit new measures for general surgery and surgical specialties, including but not limited to: cardiac, thoracic, vascular, orthopedic, neurosurgery, and other specialty surgical areas. This call encompasses pre-operative evaluation, post-operative care, diagnostic studies and treatments associated with these surgeries.

Submitted measures may be:
a. structure, process, outcome, or composite measures;
b. applicable to any care setting and ideally applicable to multiple care settings; and
c. applicable to any age, including children as appropriate.

2. Maintenance of endorsement for NQF-endorsed voluntary surgical consensus standards that were endorsed prior to June 2008.

Due to the number of measures, the project will be conducted in two phases:

Phase 1 – cardiac surgery, including pre-operative evaluation, post-operative care, diagnostic studies, and treatments associated with these surgeries.

The Call for Measures for Phase 1 will begin on September 29, 2010.

The online submission forms for measures undergoing maintenance and new measure submissions will be available September 15, 2010.

Phase 2 – general surgery and surgical specialties including but not limited to thoracic, vascular, orthopedic, neurosurgery, and other sub-specialty surgical areas.

The Call for Measures for Phase 2 will begin November 15, 2010.

The online submission forms for measures undergoing maintenance and new measure submissions will be available September 15, 2010.

Both newly submitted measures and consensus standards for maintenance review will undergo the nine-step Consensus Development Process (CDP), including review against the most recent NQF evaluation criteria. In addition to ensuring currency of specifications and evidence for the focus of the measure, endorsement maintenance provides the opportunity to harmonize specifications, to ensure that an endorsed measure represents the “best in class,” and to seek input from those who have implemented existing NQF-endorsed® measures undergoing maintenance review.

Measure developers are asked to specify how “e-ready” their measures are, and to the extent possible, NQF will work with measure developers to submit measures that include electronic specification for electronic health records (EHR) that would align with the American Recovery and Reinvestment Act’s Health Information Technology for Economic and Clinical Health Act (ARRA- HITECH) requirements.
The candidate measures will be considered for NQF endorsement as voluntary consensus standards. Agreement around the recommendations will be developed through NQF’s formal CDP. This project will involve the active participation of representatives from across the spectrum of healthcare stakeholders and will be guided by a multi-stakeholder Surgery Steering Committee.

Any organization or individual may submit measures for consideration. To be evaluated, candidate consensus standards must be within the scope of the project and meet the following general conditions as specified in the measure evaluation criteria:

A. The measure is in the public domain or an intellectual property agreement is signed.
B. The measure owner/steward verifies there is an identified responsible entity and process to maintain and update the measure on a schedule that is commensurate with the rate of clinical innovation, but at least every three years.
C. The intended use of the measure includes both public reporting and quality improvement.
D. The requested measure submission information is complete. Generally, measures should be fully developed and tested so that all the evaluation criteria have been addressed and information needed to evaluate the measure is provided.

*Measures without testing results as outlined in the Scientific Acceptability of Measure Properties may be eligible for time-limited endorsement if all of the following conditions are met:
• An incumbent measure does not address the specific topic of interest in the proposed measure;
• A critical timeline must be met (e.g., legislative mandate);
• The measure is not complex (e.g., composite, requires risk adjustment); and
• The measure steward verifies a timeline and committed resources to conduct testing within 12 months if granted time-limited endorsement.
This project is supported under a contract provided by the Department of Health and Human Services.
For more information, contact Alexis Forman at (202) 783-1300 or via e-mail at