Prompted by the need to assess comparatively the quality of surgical care in 133 Veterans Affairs (VA) hospitals, the Department of Veterans Affairs conducted the National VA Surgical Risk Study between October 1, 1991, and December 31, 1993, in 44 VA medical centers. The study developed and validated models for risk adjustment of 30-day morbidity and 30-day mortality after major surgery in 8 noncardiac surgical specialties. Similar models were developed for cardiac surgery by the VA's Continuous Improvement in Cardiac Surgery Program. Based on the results of the National VA Surgical Risk Study and the Continuous Improvement in Cardiac Surgery Program, the VA established in 1994 a VA National Surgical Quality Improvement Program (NSQIP), in which all the medical centers performing major surgery participated. An NSQIP nurse at each center oversees the prospective collection of data and their electronic transmission for analysis at 1 of 2 data coordinating centers. Feedback to the providers and managers is aimed at achieving continuous quality improvement. It consists of (1) comparative, site-specific, and outcome-based annual reports; (2) periodic assessment of performance; (3) self-assessment tools; (4) structured site visits; and (5) dissemination of best practices. The NSQIP also provides an infrastructure to enable the VA investigators to query the database and produce scientific presentations and publications. Since the inception of the NSQIP data collection process, the 30-day postoperative mortality after major surgery in the VA has decreased by 27%, and the 30-day morbidity by 45%. The future of the NSQIP lies in expanding it to the private sector and in enhancing its capabilities by incorporating additional measures of outcome, structure, process, and cost.