Since joining the NQF in 2006 to the publication of this manuscript, the ACCP reviewed 130 NQF PMs and 107 NQF best-practice recommendations. The QIC struggled with the most effective way of providing feedback to the NQF when measures were not at a standard the QIC felt was appropriate. If a PM did not meet the ACCP evaluation criteria, the QIC was uncertain if it was more effective to disapprove the PM or approve the measure with comments. Despite commenting on 90% of the PMs that were reviewed, QIC input from 2005 to 2009 resulted in perceptible changes on two occasions: (1) 032 Ventilator Bundle, for which the ACCP suggested the inclusion of definitions for “sedation vacations” and “readiness to wean,” and changes were made in the PM, and (2) VTE best practices, which provided a framework for the later-endorsed VTE measure set. Early in 2006, the QIC reviewed, commented on, and voted on the NQF VTE Preferred Practices set. Despite significant concerns expressed by the QIC and others about several of the recommended practices, especially the endorsement of individualized risk assessment for VTE prophylaxis, the set was approved at the NQF Board of Directors meeting. The following month, the QIC filed a formal appeal to the CSAC. In that appeal, the QIC noted that the seventh edition of the ACCP Guidelines (arguably the most definitive guidelines on the topic in the world) specifically recommended against the use of individualized risk assessment9 and expressed concern that the required risk assessment might have the unintended consequences of either deterring prophylaxis or contributing to variability in prophylaxis administration patterns. Noting that most patients who are hospitalized meet the criteria for prophylaxis, the QIC argued instead for a measure requiring universal prophylaxis (or documentation of why prophylaxis was not given). While the NQF initially denied the appeal, the ACCP was invited in spring 2007 to debate the issue of risk assessment at the NQF meeting. Although the QIC was not included in conversations subsequent to that meeting, when the measures were put forward for comment and vote, the standards for VTE prophylaxis were consistent with the modification suggested by the QIC.