NQF Endorses Additional Surgical Measures 

Washington, DC – the National Quality Forum (NQF) Board of Directors has endorsed an additional nine quality measures on surgical care performed in hospitals and in outpatient facilities. The set of measures – part of NQF’s Surgery Endorsement Maintenance, Phase 2 Addendum report – addresses a wide range of surgeries and surgical support processes, including pancreatic resection, cardiac and vascular mortality rates, and antibiotic prophylaxis. The set also includes a new measure evaluating patient experience of care following surgical procedures.

For this addendum report, NQF evaluated measures that were pending endorsement under the Surgery Endorsement Maintenance Phase II work due to harmonization issues and further review of a measure focused on assessing patient experience through the Consumer Assessment of Healthcare Providers and Systems (CAHPS®) surgical care survey. In all, 13 measures were evaluated against NQF’s endorsement criteria, with nine receiving endorsement status.

“These additional measures support surgical quality improvement efforts that will advance higher-quality care delivery, better outcomes, and improved patient satisfaction,” said Janet Corrigan, PhD, MBA, president and CEO of NQF. “The CAHPS® surgical care survey measure in particular has the potential to improve patient satisfaction, as it is the first NQF-endorsed surgical care measure that assesses care quality from the patient’s perspective.”

The CAHPS® surgical care survey focuses on an increasingly important area for the quality measurement community: patient experience. Data from the survey – which touches on patients’ thoughts on how well they were prepared for surgery, how well they believed the surgeons communicated, and what information they were given to help them recover from surgery, among other questions – should help providers better understand and ultimately improve patient care and experience.

The endorsed measures include those 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.

NQF is a voluntary consensus standards-setting organization. Any party may request reconsideration of any of the nine endorsed quality measures listed below by submitting an appeal no later than May 31 (to submit an appeal, go to the NQF Standards Directory). 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 

• 0128: Duration of antibiotic prophylaxis for cardiac surgery patients (Society of Thoracic Surgeons)
• 0357: Abdominal aortic aneurysm (AAA) repair volume (IQI 4) (AHRQ)
• 0359: Abdominal aortic aneurysm (AAA) repair mortality rate (IQI 11) (risk adjusted) (AHRQ)
• 0365: Pancreatic resection mortality rate (IQI 9) (risk adjusted) (AHRQ)
• 0366: Pancreatic resection volume (IQI 2) (AHRQ)
• 0529: Prophylactic antibiotics discontinued within 24 hours after surgery end time (CMS)
• 1523: In-hospital mortality following elective open repair of AAAs (Society for Vascular Surgery)
• 1534: In-hospital mortality following elective EVAR of AAAs (Society for Vascular Surgery)
• 1741: Patient experience with surgical care based on the Consumer Assessment of Healthcare Providers and Systems (CAHPS) ® surgical care survey (American College of Surgeons)

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.