American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

New Approach to Surgical Measurement: Phases of Surgical Care

The American College of Surgeons (ACS) is currently in development of a new framework to measure surgical care across the care continuum, encompassing five phases:

  • Preoperative
  • Perioperative
  • Intraoperative
  • Postoperative
  • Postdischarge

These measures are intended to align with the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 requirements by covering all phases of surgical care as a measure set or, possibly, a composite. These measures have been developed based on variations in surgical care and are clinically relevant and meaningful to surgical care.

The Problem with Current CMS MIPSMeasures

The ACS firmly believes the current measure approach is narrow, complex, costly, and sluggish. The measures available to surgeons in the Centers for Medicare and Medicaid Services (CMS) Merit-based Incentive Payment System (MIPS) are often irrelevant to surgical care because a single set of measures is very difficult to translate to an individual general surgeon due to the diversity of procedures general surgeons perform. Procedures vary from surgeon to surgeon based on their patient population, subspecialty, and geographical location. As a result, the current approach has likely slowed down the engagement of providers thereby hindering the ability to drive improvement.

New Approach to Measuring Surgical Care

The ACS believes that registry-based quality measures, which encompass five phases of surgical care: preoperative, perioperative, intraoperative, postoperative, and post-discharge, along with care coordination will be meaningful and important to both surgeons and surgical patients. Future work would expand further to consider patient engagement, shared decision making and patient reported outcomes.

Every surgical patient in each specialty walks through the phases of surgical care, and each of these phases involves key processes, critical care coordination with primary care physicians and anesthesia, as well as the technical side of surgical care that relates to safety, outcomes and preventing avoidable harms. As we move toward value-based surgical care system, a framework that values these phases is required. These metrics are different from measures in the current PQRS program because they broadly apply to almost all surgeons, span across the various phases of surgical care, and when measured together they can have a real impact at the point of care.

The ACS has defined the following set of measures to span across the various phases of surgical care that align with a patient’s clinical flow. This framework broadly applies to surgical care for cross-cutting comparisons and was constructed to allow for more detailed, procedure-specific metrics to be added when necessary.

Phases of surgical care measures:

  • Surgical Plan and Goals of Care (Preoperative Phase)
  • Identification of Major Co-Morbid Medical Conditions
  • Preventive Care and Screening: Tobacco Screening and Cessation Intervention
  • Preoperative Key Medications Review for Anticoagulation Medication
  • QPP 358: Patient-Centered Surgical Risk Assessment and Communication
  • Patient Frailty Evaluation
  • Participation in a National Risk-Adjusted Outcomes Surgical Registry
  • Perioperative Composite
  • Intraoperative Timeout Safety Checklist
  • Intraoperative Surgical Debriefing
  • Optimal Postoperative Communication Plan and Patient Care Coordination Composite
  • Resumption Protocol
  • Unplanned Reoperation within the 30 Day Postoperative Period
  • Unplanned Hospital Readmission within 30 Days of Principal Procedure
  • Surgical Site Infection (SSI)

Comment Letters

ACS Comment to the NQF MAP: Surgical Phases of Care

ACS Comment to CMS Measure Development Plan

ACS Comment to the National Quality Forum’s Measure Application Partnership (MQF MAP) Measures Under Consideration for 2017

ACS Comments to the Request for Information Regarding Implementation of the Merit-Based Incentive Payment System, Promotion of Alternative Payment Models, and Incentive Payments for Participation in Eligible Alternative Payment Models