Measuring Performance

Surgery Endorsement Maintenance 2010 

Project Status: Completed

Surgical Consensus Standards Endorsement Maintenance

Access the Endorsement Summary (PDF) | Access the Full Report

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.


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.


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



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
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
3. DeFrances. Lucas, and Golosinskiy.

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