Objectives To determine whether high rates of compliance with perioperative processes of care used for public reporting and pay-for-performance are associated with lower rates of risk-adjusted mortality and high-risk surgical complications. Design Retrospective analysis of Medicare inpatient claims data (from January 1, 2005, through December 31, 2006). Hierarchical logistic regression models assessed the relationship between adverse outcomes and hospital compliance with the surgical processes of care reported on the Hospital Compare Web site. Setting Two thousand US hospitals. Participants Beneficiaries who underwent 1 of 6 high-risk operations in 2005 and 2006. Main Outcome Measures Thirty-day postoperative mortality rate, venous thromboembolism, and surgical site infection. Results Process compliance ranged from 53.7% in low compliance hospitals to 91.4% in high compliance hospitals. Risk-adjusted outcomes did not vary at high compliance hospitals relative to medium compliance hospitals for mortality rate (odds ratio, 0.98; 95% confidence interval, 0.92-1.05), surgical site infection (1.01; 0.90-1.13), or venous thromboembolism (1.04; 0.89-1.20). Outcomes also did not vary at low compliance hospitals. Stratified analyses by operation type confirm these trends for the 6 procedures individually. Conclusions Currently available information on the Hospital Compare Web site will not help patients identify hospitals with better outcomes for high-risk surgery. The Centers for Medicare and Medicaid Services needs to identify higher leverage process measures and devote greater attention to profiling hospitals based on outcomes to improve public reporting and pay-for-performance efforts.