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The use of clinical dashboards has expanded significantly in healthcare in recent years in a variety of settings. The ability to analyze data related to quality metrics in one screen is highly desirable for cardiac anesthesiologists, as they have considerable influence on important clinical outcomes. Building a robust quality program within cardiac anesthesia relies on consistent access and review of quality outcome measures, process measures, and operational measures through a clinical dashboard. Signals and trends in these measures may be compared to other cardiac surgical programs to analyze gaps and areas for quality improvement efforts. In this article, the authors describe how they designed a clinical cardiac anesthesia dashboard for quality efforts at their institution.

Context Defining high quality palliative care in seriously ill surgical patients is essential to provide patient-centered surgical care. Quality indicators specifically for seriously ill surgical patients are necessary in order to integrate palliative care into existing surgical quality improvement programs. Objectives To identify existing quality indicators that measure palliative care delivery in seriously ill surgical patients, characterize their development, and assess their methodological quality. Methods A PRISMA-guided systematic review included studies that reported on the development process and characteristics of palliative care quality indicators and guidelines in adult surgical patients. Relevant measures were categorized into the previously defined National Consensus Project domains of palliative care and the Donabedian quality framework, and assessed for methodological quality. Results There were 263 unique measures identified from 26 studies, of which 70% were process measures. Indicators addressing Care of the Patient Near the End of Life (31.5%) and Physical Aspects of Care (20.8%) were the most common. Indicators addressing Spiritual (2.6%) and Cultural Aspects of Care (1.2%) were the least common. Methodological quality varied widely across studies. Although most studies defined a purpose for the indicators and used scientific evidence, many studies lacked input from target populations and few had discussed the practical application of indicators. Conclusion This review was a key step that informed efforts to develop quality indicators for seriously ill surgical patients. Few indicators addressed non-physical aspects of suffering and no indicators were identified addressing palliative surgery. Future attention is needed toward the development and practical application of palliative care quality indicators in surgical patients.

El objetivo de este estudio fue diseñar y evaluar el 1r pilotaje del Programa de Competencia Familiar Universal Auto (PCF-U-Auto), dirigido a promover la autonomía personal de los adultos mayores con síntomas incipientes o sin síntomas de dependencia en diferentes localidades de Mallorca. El estudio contó con un diseño cuasi-experimental y se centró en tres aspectos: a) medidas de proceso; registros de fidelidad, adherencia e implicación por sesión y participante, b) medidas de cambio sobre las variables que miden la dinámica familiar y las destrezas relacionadas con la promoción de autonomía; evaluación pre-test/pos-test sobre la Escala de Recursos Sociales, Cuestionario de Función Familiar, Cuestionario sobre calidad de vida y la Escala de depresión evaluadas sobre los adultos mayores; y (c) medidas de resultado; niveles de satisfacción de los participantes. Los resultados confirman la validez del Programa de Competencia Familiar Universal Auto como herramienta de prevención familiar de las situaciones de dependencia en la edad adulta.

In the "parallel studies" project led by Carl Rogers at the Counseling Center of the University of Chicago over 70 years ago, measures of personality organization and other clinical ratings were applied to 10 recorded and transcribed cases. This paper applied computerized measures of the referential process to the treatment by Rogers of the client known as Miss Vib. The treatment was considered successful and used by Rogers to illustrate his theory of personality, and his view of the therapeutic process. Using the DAAP system, the measures were applied to therapist and client speech at embedded levels of magnification, including measures for the treatment as a whole to be compared to other treatments in the referential process data base; measures for individual sessions to show progression across the trajectory of a treatment for comparison with the clinical ratings; and measures representing word by word variation within a session to enable close examination of the process. The initial prediction concerning the relation of the referential process measures to the clinical measures was not confirmed. Close examination of pivotal sessions provided an account of the results beyond that emphasized in the client-centered approach.

Objective Develop quality indicators that measure access to and the quality of primary PC delivered to seriously ill surgical patients SUMMARY OF BACKGROUND DATA:: PC for seriously ill surgical patients, including aligning treatments with patients' goals and managing symptoms, is associated with improved patient-oriented outcomes and decreased healthcare utilization. However, efforts to integrate PC alongside restorative surgical care are limited by a lack of surgical quality indicators to evaluate primary PC delivery. Methods We developed a set of 27 preliminary indicators that measured palliative processes of care across the surgical episode, including goals of care, decision-making, symptom assessment, and issues related to palliative surgery. Then using the RAND-UCLA Appropriateness method, a 12-member expert advisory panel rated the validity (primary outcome) and feasibility of each indicator twice: (1) remotely and (2) after an in-person moderated discussion RESULTS:: After 2 rounds of rating, 24 indicators were rated as valid, covering the preoperative evaluation (9 indicators), immediate preoperative readiness (2 indicators), intraoperative (1 indicator), postoperative (8 indicators), and end of life (4 indicators) phases of surgical care. Conclusions This set of quality indicators provides a comprehensive set of process measures that possess the potential to measure high quality PC for seriously ill surgical patients throughout the surgical episode.

OBJECTIVE: Differences in the quality of emergency department (ED) care are often attributed to nonclinical factors such as variations in the structure, systems, and processes of care. Few studies have examined these associations among children. We aimed to determine whether process measures of quality of care delivered to patients receiving care in children’s hospital EDs were associated with physician-level or hospital-level factors. METHODS: We included children (

Quality improvement efforts at the federal level have instituted both rewards and penalties as incentives to improve health care quality. However, neither of these methods has shown long-lasting improvements. Furthermore, many programs have focused on decreasing mortality or hospital readmissions, measurements that are not applicable to many surgical fields, including plastic surgery. One model that has been shown to be effective is a collaborative quality initiative that uses a pay-for-participation method whereby participants learn from one another and institute changes to improve patient care. Many of these changes are process measures that are easier to implement and quicker to show improvement than structural or outcome measures. Regional collaborative quality initiatives have been developed in other surgical specialties such as bariatric surgery and urology. Currently, the authors are establishing a new collaborative quality initiative for hand surgery: the Michigan Collaborative Hand Initiative for Quality in Surgery. It is a collaboration of nine sites with the goal of identifying areas that are in need of quality improvement in hand surgery and implementing measures to improve on them. The authors believe that collaborative quality initiatives will promote high-quality care and should be incorporated into the field of plastic surgery.

The purpose of this paper is to present the evidence shared with a citizen consensus panel detailing key issues associated with how nursing CPD can best influence the quality of health and social care experienced by citizens and communities. It presents a summary of contemporary theory, research and evidence of the effectiveness of nursing CPD and outlines four key challenges: (i) how to strengthen the focus on patient experience as the starting point for CPD; (ii) the lack of evidence of CPD effectiveness and accountability in its transfer to practice; (iii) evaluation of CPD effectiveness; and (iv) involving citizens in targeting CPD where it is most needed. It briefly describes the methods used to facilitate public consultation through a citizen consensus panel as part of a collaborative project with the RCN Strategic Research Alliance in 2020 and outlines 7 themes identified as important by the public for future development. The main challenge for nursing is capitalizing on the workplace as a learning resource that can integrate learning with development, improvement, knowledge translation, inquiry and innovation. This requires skilled facilitators, particularly at meso- levels, and systems leaders with the full skillset to develop system-wide cultures of learning that enable everyone to flourish and create good places to work. The paper concludes that the development of CPD process measures would indicate how CPD investment contributes to person-centred, safe and effective care and system transformation and enable commissioners and education providers to optimize CPD’s full potential.

Objective To determine whether utilizing beginner, video-guided tai chi and qigong classes as an adjunct to physical therapy to enhance mobilization among hospitalized patients is feasible and acceptable. Design Single-arm feasibility study over a 15½-week period. Setting Three medical-surgical units at one hospital. Interventions Small-group video-guided beginner-level tai chi and qigong classes supervised by physical therapists occurred three times a week. Main outcome measures The primary outcome was weekly class attendance. Secondary outcomes included patient and staff satisfaction, collected by surveys and semi-structured interviews. Process measures included class duration. Balancing measures included falls. Results One-hundred and fifty-seven patients were referred for recruitment, 45 gave informed consent, and 38 patients attended at least one class. The number of weekly class attendees increased during the study period. Based on first-class experience, 68% (26/38) of patients reported enjoying the class “quite a bit” or “extremely,” 66% (25/38) of patients reported feeling “more mobile” afterward, and 76% (29/38) of patients agreed that the class made them more comfortable going home. Average class duration was 29 minutes. Zero falls occurred during or immediately following class. Conclusions Video-guided tai chi and qigong classes are feasible and well-received at our hospital. Future studies of the impact on preserving mobility and function or reducing length of stay are of interest.

Background: Electronic health records are central to cancer care delivery. Electronic clinical decision support (CDS) systems can potentially improve cancer care quality and safety. However, little is known regarding the use of CDS systems in clinical oncology and their impact on patient outcomes. Methods: A systematic review of peer-reviewed studies was performed to evaluate clinically relevant outcomes related to the use of CDS tools for the diagnosis, treatment, and supportive care of patients with cancer. Peer-reviewed studies published from 1995 through 2016 were included if they assessed clinical outcomes, patient-reported outcomes (PROs), costs, or care delivery process measures. Results: Electronic database searches yielded 2,439 potentially eligible papers, with 24 studies included after final review. Most studies used an uncontrolled, pre-post intervention design. A total of 23 studies reported improvement in key study outcomes with use of oncology CDS systems, and 12 studies assessing the systems for computerized chemotherapy order entry demonstrated reductions in prescribing error rates, medication-related safety events, and workflow interruptions. The remaining studies examined oncology clinical pathways, guideline adherence, systems for collection and communication of PROs, and prescriber alerts. Conclusions: There is a paucity of data evaluating clinically relevant outcomes of CDS system implementation in oncology care. Currently available data suggest that these systems can have a positive impact on the quality of cancer care delivery. However, there is a critical need to rigorously evaluate CDS systems in oncology to better understand how they can be implemented to improve patient outcomes.

Purpose of review Quality improvement and patient safety are relevant to the advancement of clinical care, particularly in the field of minimally invasive gynecologic surgery (MIGS). Although safety and feasibility of MIGS have been established, identification of quality metrics in this field is also necessary. Recent findings Surgical quality improvement has focused on national overarching measures to reduce mortality, surgical site infections (SSIs), and complications. Quality improvement in minimally invasive surgery has additionally led to advancements in postoperative patient recovery and long-term outcomes. Process measures in minimally invasive surgery include use of bundles and enhanced recovery after surgery (ERAS) programs. However, procedure-specific quality metrics for MIGS outcomes are poorly defined at this time. Summary Quality metrics in minimally invasive gynecology are well defined for structural measures and select process measures. Creation of relevant benchmarks for outcome measures in minimally invasive gynecologic surgery are needed.

Objectives: Purposeful SDM posits four modes of shared decision making (SDM). The use of each mode depends on the type of problem of care that is being addressed. We sought to identify how current observer-based SDM measures apply to each mode of Purposeful SDM.Methods: Four coders, working independently, evaluated 192 items pertaining to 12 observer-based SDM process measures. They classified the items into 6 themes that vary across Purposeful SDM modes and then into one of the four modes (weighing, negotiating, problem-solving, developing insight). Disagreements were resolved by consensus.Results: The items were classified as pertaining to the following themes: problem (28), roles/participation (84), options (62), preferences (21), decision (15), and evaluation (6). They were then classified as pertaining particularly to the SDM modes of weighing (54), negotiating (5), problem-solving (0), and developing insight (0) modes, with 191 items applying broadly to all modes of Purposeful SDM.Conclusions: Observer-based SDM measures describe behaviors pertinent to all modes but lack items sensitive to behaviors particular to some modes of SDM. Practice Implications: New or revised observer-based measures of the SDM process could help estimate the extent to which the appropriate SDM mode is being used to address the patient's problem.(c) 2021 Elsevier B.V. All rights reserved.

The purpose of this study was to examine factors that influence a person's choice of cognitive-behavioral therapy (CBT) or yoga, the stability of these preferences, and the impact of preference on engagement and process measures. We conducted a randomized preference trial of CBT and yoga in 500 adults ≥60 years with symptoms of worry. Participants reported their intervention preference, strength of preference, and factors impacting preference. Engagement in the intervention (session completion and dropout rates) was assessed. Process measures included satisfaction with the intervention, therapeutic alliance, and intervention expectancy. Neither intervention preference (48% and 52% chose CBT and yoga, respectively) nor strength of preference differed significantly between the two preference trial groups. Intervention expectancies at baseline among those in the preference trial were approximately 4.5 units (40-point scale) higher for their preferred intervention (p .0001 within each group). A principal component analysis of factors influencing preference identified three constructs. Using logistic regression, components focused on attitudes about CBT or yoga were predictive of ultimate preference (odds ratio = 11.5, 95% C.I.6.3-21.0 per 1SD difference in component 1 for choosing CBT; odds ratio = 7.8, 95% CI4.3-13.9 per 1SD difference in component 2 for choosing yoga). There were no significant differences between the randomized and preference trials on intervention adherence, completion of assessments, intervention satisfaction, or working alliance. Receiving a preferred treatment had no significant effects on intervention outcomes through participant engagement or process measures. When options are limited, providers may have confidence in offering the most readily available non-pharmacological treatments.

Objectives Despite its importance of quality measures used by the Centers for Medicare and Medicaid Services, the underlying cost-effectiveness evidence has not been examined. This study aimed to analyze cost-effectiveness evidence associated with the Centers for Medicare and Medicaid Services quality measures. Methods After classifying 23 quality measures with the Donabedian's structure-process-outcome quality of care model, we identified cost-effectiveness analyses (CEAs) relevant to these measures from the Tufts Medical Center CEA Registry based on the PICOTS (population, intervention, comparator, outcome, time horizon, and setting) framework. We then summarized available incremental cost-effectiveness ratios (ICERs) to determine the cost-effectiveness of the quality measures. Results The 23 quality measures were categorized into 14 process, 7 outcome, and 2 structure measures. Cost-effectiveness evidence was only available for 8 of 14 process measures. Two measures (Tobacco Screening and Hemoglobin bA1c Control) were cost-saving and quality-adjusted life-years (QALYs) improving, and 5 (Depression Screening, Influenza Immunization, Colon Cancer Screening, Breast Cancer Screening, and Statin Therapy) were highly cost-effective (median ICER ≤ $50 000/QALY). The remaining measure (Fall Screening) had a median ICER of $120 000/QALY. No CEAs were available for 15 measures: 10 defined by subjective patient ratings and 5 employed outcome measures without specifying an intervention or process. Conclusions When relevant CEAs were available, cost-effectiveness evidence was consistent with quality measures (measures were cost-effective). Nevertheless, most quality measures were based on subjective ratings or outcome measures, posing a challenge in identifying supporting economic evidence. Refining and aligning quality measures with cost-effectiveness evidence can help further improve healthcare efficiency by demonstrating that they are good indicators of both quality and cost-effectiveness of care.

Background The accreditation of medical educational programs is thought to be important in supporting program improvement, ensuring the quality of the education, and promoting diversity, equity, and population health. It has long been recognized that accreditation systems will need to shift their focus from processes to outcomes, particularly those related to the end goals of medical education: the creation of broadly competent, confident professionals and the improvement of health for individuals and populations. An international group of experts in accreditation convened in 2013 to discuss this shift. Main text Participants unequivocally supported the inclusion of more outcomes-based criteria in medical education accreditation, specifically those related to the societal accountability of the institutions in which the education occurs. Meaningful and feasible outcome metrics, however, are hard to identify. They are regionally variable, often temporally remote from the educational program, difficult to measure, and susceptible to confounding factors. The group identified the importance of health outcomes of the clinical milieu in which education takes place in influencing outcomes of its graduates. The ability to link clinical data with individual practice over time is becoming feasible with large repositories of assessment data linked to patient outcomes. This was seen as a key opportunity to provide more continuous oversight and monitoring of program impact. The discussants identified several risks that might arise should outcomes measures completely replace process issues. Some outcomes can be measured only by proxy process elements, and some learner experience issues may best be measured by such process elements: in brief, the “how” still matters. Conclusions Accrediting bodies are beginning to view the use of practice outcome measures as an important step toward better continuous educational quality improvement. The use of outcomes will present challenges in data collection, aggregation, and interpretation. Large datasets that capture clinical outcomes, experience of care, and health system performance may enable the assessment of multiple dimensions of program quality, assure the public that the social contract is being upheld, and allow identification of exemplary programs such that all may improve. There remains a need to retain some focus on process, particularly those related to the learner experience.

The aim of this study was to predict self-report data for self-regulated learning with sensor data. In a longitudinal study multichannel data were collected: self-report data with questionnaires and embedded experience samples as well as sensor data like electrodermal activity (EDA) and electroencephalography (EEG). 100 students from a private university in Germany performed a learning experiment followed by final measures of intrinsic motivation, self-efficacy and gained knowledge. During the learning experiment psychophysiological data like EEG were combined with embedded experience sampling measuring motivational states like affect and interest every 270 s. Results of machine learning models show that consumer grade wearables for EEG and EDA failed to predict embedded experience sampling. EDA failed to predict outcome measures as well. This gap can be explained by some major technical difficulties, especially by lower quality of the electrodes. Nevertheless, an average activation of all EEG bands at T7 (left-hemispheric, lateral) can predict lower intrinsic motivation as outcome measure. This is in line with the personality system interactions (PSI) theory of Julius Kuhl. With more advanced sensor measures it might be possible to track affective learning in an unobtrusive way and support micro-adaptation in a digital learning environment.

Appropriate metrics are needed to measure the quality, clinical, and financial impacts of antimicrobial stewardship programs. Metrics are typically categorized into antibiotic use measures, process measures, quality measures, costs, and clinical outcome measures. Traditionally, antimicrobial stewardship metrics have focused on antibiotic use, antibiotic costs, and process measures. With health care reform, practice should shift to focusing on clinical impact of stewardship programs over financial impact. This article reviews the various antimicrobial stewardship metrics that have been described in the literature, evidence to support these metrics, controversies surrounding metrics, and areas in which future research is necessary.

Purpose The enactment of the Patient Protection and Affordable Care Act in 2010 placed an emphasis on measuring the quality of care. However, the issue of how best to measure quality remains in question. Although some surgical specialties frequently rely on quality measures such as the mortality rate, measuring quality in hand surgery necessitates the use of metrics beyond this traditional scope. A review was performed of the potential quality metrics used in the hand surgery literature published after the Affordable Care Act was enacted, to identify current trends in quality measurement and guide efforts to improve the quality of care in hand surgery. Methods We searched the PubMed and EMBASE databases to identify original research articles within hand surgery to assess how care is being measured. Data extracted from the articles included study characteristics, quality metrics, and the domain(s) of quality. Results A total of 7,308 articles were identified, and 63 prospective and retrospective articles were included in the analysis. The most common quality measure reported in the hand surgery literature was an outcome measure (100%) and the least common was a structure measure (30.2%). The most common metrics were pain (44.4%) and patient-reported measures (41.3%). Effectiveness (42.9%) was the most frequently assessed domain of quality, whereas efficiency (3.2%) was the least studied. Conclusions We identified quality measures used in contemporary hand surgery literature and found a substantial variation in the representation of quality metrics. Structure and process measures can be leveraged to provide a more holistic assessment of the quality of care in hand surgery. Clinical relevance Although outcome measurements are critical to understanding effectiveness, structure and process measures should be considered and reported as necessary, because these metrics may influence treatment outcomes and the development of quality measures.

Evaluation and payment for health plans and providers have been increasingly tied to their performance on quality metrics, which can be influenced by patient- and community-level sociodemographic factors. The aim of this study was to examine whether performance on Healthcare Effectiveness Data and Information Set (HEDIS) measures varied as a function of community sociodemographic characteristics at the primary care clinic level. Twenty-two primary care sites of a large multispecialty group practice were studied during the period of April 2013 to June 2016. Significant associations were found between sites' performance on selected HEDIS measures and their neighborhood sociodemographic characteristics. Outcome measures had stronger associations with sociodemographic factors than did process measures, with a range of significant correlation coefficients (absolute value, regardless of sign) from 0.44 to 0.72. Sociodemographic factors accounted for as much as 25% to 50% of the observed variance in measures such as HbA1c or blood pressure control.

Quality Improvement (QI) science focuses on how healthcare is delivered (process measures) and the results (outcome measures). Although instruction in QI methodology is recognized as an important part of a resident's education, maintaining resident engagement is a challenge. A Resident Quality Council (RQC) was established to (1) create and maintain a resident-generated and relevant quality dashboard, (2) enhance resident awareness of in-hospital QI initiatives, and (3) increase QI scholarly activity among residents. A RQC was established in 2017 consisting of five resident champions and three chief residents, mentored by program leadership, a Chief Quality Officer, and QI staff. To increase resident engagement a continuously updated resident-inspired dashboard, which highlighted both quality and operational standards, was created. Metrics were chosen based on resident feedback. Over 18 months, a lecture series was introduced into the residency curriculum which highlighted various QI initiatives with a special focus on process and outcome measures related to the dashboard. At the start of the 2019-2020 academic year, the RQC surveyed residents in regards to their level of QI engagement and the utility of the dashboard as part of the residency curriculum. The most relevant metrics, as reported, included asthma guidelines, length of stay, and number of safety events. There was a reported increase in understanding of a dashboard's utility from 15.8% to 78.3% (N = 23). 78% reported continued interest in the maintenance of a dashboard with resident-pertinent metrics and acknowledged that the dashboard contributed to their understanding of the significance of QI science. Lastly, 87% felt the knowledge presented to them through the dashboard directly resulted in their increased interest in in-hospital QI initiatives and their desire to partake in QI scholarly work. Establishment of an RQC has proven beneficial in promoting QI interest amongst residents. Resident-pertinent dashboard metrics have kept housestaff engaged and interested in expanding their QI fund of knowledge through QI-driven scholarly projects.

Classic studies on judge-juror agreement have converged on the finding that judges and jurors agree on the outcomes in most cases (71-75%). This study extends these findings by comparing trial process evaluations of judges, jurors and litigants in actual civil trials. The results suggest that judges and juries largely overlap in their perceptions of trial process measures (e.g. case complexity). However, judicial and jury perceptions often differ from litigants' perceptions. The way in which different perspectives of the trial process predict satisfaction with the outcome is also explored. Litigant, but not judicial or jury, perceptions of the trial process were found to predict satisfaction. These results support past research concerning judge-juror agreement, but suggest there is less agreement between objective (i.e. judges and jurors) and subjective (i.e. litigants) perspectives of the trial process.

Improving patient safety is an ongoing journey that benefits from periodic assessment to recognize, reward, and redirect efforts. As an independent, nonregulatory state agency, the Patient Safety Authority (PSA) is uniquely positioned to both conduct comprehensive safety assessments and support improvement efforts. A process measures survey of acute care facilities was conducted in November and December 2018. The purpose was to inform the PSA’s strategic direction, provide benchmarking data to facilities, and understand the current patient safety landscape. The survey consisted of 48 questions divided into 10 domains: Behavioral Health, Falls, Health Information Technology, Improving Diagnosis, Infection Prevention and Control, Leadership, Medication Safety, Obstetrics, Safe Surgery, and Transition of Care. Each question asked respondents to report the degree to which a specific safety practice has been implemented at their facility. In all, 153 unique facility responses with at least 30% of the survey questions completed were received and analyzed. According to respondents, the domains Safe Surgery, Infection Prevention and Control, and Obstetrics had the highest percentages of full implementation, while Behavioral Health, Medication Safety, and Improving Diagnosis had the lowest. Looking across domains, two new themes emerged: first, a high percentage of full implementation of safety practices to support communication about patient safety with frontline staff and second, a low percentage of full implementation of safety practices that promote patient engagement in organizational efforts to support safe patient care. These results will inform the PSA’s focus over the next several years. In a couple of places the phrase is used “Improving patient safety is an endless journey….”. I worry that the use of “endless journey” may imply progress can never be made in patient safety and be self-defeating. I suggest changing it to something like, “In the ongoing journey to improve patient safety….”

[Excerpt] Aboriginal and/or Torres Strait Islander Australians have a life expectancy 8 years less than other Australians.(1) Access to equitable high-quality surgical care may be a contributing factor to this dis-parity. Aboriginal and Torres Strait Islander patients have a higher emergency to elective surgery ratio,(2,3) a global indicator of access to surgical care.(4) When Aboriginal and/or Torres Strait Islander Australians do access surgical care, they may experience higher rates of post-operative morbidity and mortality.(5–11) The focus must now shift from simply reporting disparities in surgical outcomes for Aboriginal and/or Torres Strait Islander Australians to identifying,measuring and addressing the process measures involved in these poor surgical outcomes.

Aim In colorectal cancer care, many indicators for assessment and improvement of quality of care are being used. These quality indicators serve as national and international benchmarks to compare health care on hospital and patient level. However, the scientific basis of these indicators is often unclear. Therefore, the aim of this systematic review is to examine reported quality indicators used in multidisciplinary colorectal cancer care and categorise these indicators based on scientific evidence. Methods We searched PubMed from 2005 to 2015 for original articles reporting on development, evaluation or validation of quality indicators in colorectal cancer care. Included articles were categorised in consensus-based, evidence-based and validation cohort studies. Extracted quality indicators were divided into structure, process and outcome indicators and grouped per discipline(s) involved. Results From 1163 studies, 41 articles were included: 12 (29%) consensus-based, 7 (17%) evidence-based and 22 (54%) validation cohort studies. In total, we identified 389 reported quality indicators: consensus-based (n = 349), evidence-based (n = 7) and validation (n = 33), respectively. Of all reported indicators, 45% (n = 186) concerned surgical items. The vast majority were process indicators (n = 315; 81%) and the remaining outcome (n = 57; 15%) or structure measurements (n = 17; 4%). Only 5 indicators were reported in the majority (≥7/12 articles) of consensus-based papers and 7 indicators were successfully validated. Conclusions There is an abundance of reported colorectal cancer quality indicators, of which the majority are surgical, consensus-based process measures, which have not been validated in cohort studies. There is a need for international consensus on a limited evidence-based data set of validated quality indicators, with a focus on outcome indicators.

There are guidelines for the medical management of cirrhosis and associated quality indicators (QIs), but QIs focusing on standards for palliative aspects of care are needed. We convened a 9-member, multidisciplinary expert panel and used RAND/UCLA modified Delphi methods to develop palliative care quality indicators for patients with cirrhosis. Experts were provided with a report based on a systematic review of the literature that contained evidence concerning the proposed candidate QIs. Panelists rated QIs prior to a planned meeting using a standard 9-point RAND appropriateness scale. These ratings guided discussion during a day-long phone conference meeting, and final ratings were then provided by panel members. Final QI scores were computed and QIs with a final median score of greater than or equal to 7, and no disagreement was included in the final set. Among 28 candidate QIs, the panel rated 19 as valid measures of quality care. These 19 quality indicators cover care related to information and care planning (13) and supportive care (6). These QIs are evidence-based process measures of care that may be useful to improve the quality of palliative care. Research is needed to better understand the quality of palliative care provided to patients with cirrhosis.

The study objective was to develop quality measures for adult cochlear implant centers. A modified Delphi design beginning with focus groups of surgeons and audiologists was used, as adapted from the American College of Cardiology / American Heart Association method for creating quality measures. Two academic cochlear implant programs and 1 private program participated. Qualitative focus group analysis yielded 58 candidate measures. An additional 5 candidate measures were added from a systematic review of the literature. After exclusion of pediatric measures, structure measures, and process measures and discussion of details and implications of each measure, 8 measures remained as the preliminary Adult Cochlear Implant Outcome (CI-OUTCOME) Measure Set. This study provides a preliminary set of measures for evaluating the quality of adult cochlear implant centers, based on input from implant surgeons and audiologists. The next step will be to gather feedback from implant patients.

BACKGROUNDMeasuring processes of care performance rates is an invaluable tool for quality improvement; however, collecting daily process measure data is time-consuming and burdensome.OBJECTIVETo evaluate the accuracy of sampling strategies to estimate monthly compliance rates with ventilator-associated pneumonia prevention measures.SETTING AND PARTICIPANTSA total of 37 intensive care units affiliated with 29 hospitals participating in a 2-state 35-month ventilator-associated pneumonia prevention collaborative. Analysis was limited to 325 unit-months with complete data entry rates.METHODSWe calculated unit-month level actual and sample monthly compliance rates for 6 ventilator-associated pneumonia prevention measures, using 4 sampling strategies: sample 1 day per month, sample 1 day per week, sample 7 consecutive days per month, and sample 7 consecutive days per month plus additional consecutive days as necessary to obtain at least 30 ventilator-days for that month whenever possible. We compared sample versus actual rates using paired t test and χ2 test.RESULTSMean sampling accuracy ranged 84%–97% for 1 day per month, 91%–98% for 1 day per week, 92%–98% for 7 consecutive days per month, and 96%–99% for 7 consecutive days with at least 30 days per month if possible. The most accurate sampling strategy was to sample 7 consecutive days with at least 30 ventilator-days per month if possible. With this strategy, sample rates were within 10% of actual rates in 88%–99% of unit-months and within 5% of actual rates in 74%–97% of unit-months.CONCLUSIONSampling process measures intermittently rather than continually can yield accurate estimates of process measure performance rates.Infect Control Hosp Epidemiol 2016;37:1037–1043

Process measures of healthcare quality are usually formulated as the number of patients who receive evidence-based treatment (numerator) divided by the number of patients in the target population (denominator). When the systems being evaluated can influence which patients are included in the denominator, it is reasonable to wonder if improvements in measured quality are driven by expanding numerators or contracting denominators. In 2003, the US Department of Veteran Affairs (VA) based executive compensation in part on performance on a substance use disorder (SUD) continuity-of-care quality measure. The first goal of this study was to evaluate if implementing the measure in this way resulted in expected improvements in measured performance. The second goal was to examine if the proportion of patients with SUD who qualified for the denominator contracted after the quality measure was implemented, and to describe the facility-level variation in and correlates of denominator contraction or expansion. Using 40 quarters of data straddling the implementation of the performance measure, an interrupted time series design was used to evaluate changes in two outcomes. All veterans with an SUD diagnosis in all VA facilities from fiscal year 2000 to 2009. The two outcomes were 1) measured performance—patients retained/patients qualified and 2) denominator prevalence—patients qualified/patients with SUD program contact. Measured performance improved over time (P

221 Background: ASCO’s Quality Oncology Practice Initiative (QOPI) includes process measures on oral chemotherapy education. Whether achievement of these measures has an impact on clinical outcomes and if an intervention to improve these measures can improve outcomes is not yet known. Methods: A retrospective analysis was conducted of patients initiated on oral chemotherapy in an academic medical center site and a community oncology practice between January 2016 and October 2019. The primary aim was to compare the time to emergency department (ED) within 90 days from initiation of oral chemotherapy of patients who met the QOPI process measure through an intervention of pharmacist-driven education with a comparison group of patients who had not received formal education. A secondary aim was to assess for a difference in oral chemotherapy medication persistence. Data were also analyzed by demographics, concurrent parenteral therapy, intent of therapy, and disease group. Results: 285 patients in the education group and 284 patients in the non-education group were analyzed. The education group had a higher proportion of patients with gastrointestinal and gynecologic cancers, and a lower proportion of patients with hematologic malignancies, compared to the non-education group. The education group also had a higher proportion of patients treated at the community practice compared to the non-education group. There was no statistical difference in median time-to-ED, with 49 days (IQR 37-74) in the education group and 59 days (IQR 41-60) in the non-education group (p=0.15). Conclusions: In patients receiving oral chemotherapy, pharmacist-driven education with improvement in QOPI process measures did not result in an improvement in time to ED. One factor contributing to this result may be that only 20% of patients required ED-level care within 90 days of starting oral We continue to collect data regarding medication persistence, which may be a more sensitive outcome measure. At this point, further work is needed to determine if achievement or modification of the QOPI oral chemotherapy process measures results in a clinically significant change in outcome. [Table: see text]

Background A robust infection prevention and control (IPC) program is critical for a safe nursing home (NH) resident environment. Data sharing, auditing with feedback on performance, and implementation of evidence-based practices are cornerstones of an effective IPC program. The purpose of this study was to identify outcome and process measures data that are collected and shared in NHs, and specific IPC strategies used to prevent both non-catheter and catheter-associated urinary tract infections (UTIs and CAUTIs). Methods Over a two-year period, 50 NHs participated in a 12-month program to reduce healthcare-associated infections by enhancing relationships between NHs and hospitals. A 36-question survey on IPC facility characteristics was distributed; 11 surveys were administered between January-March 2018 and another 39 administered January-February 2019. Missing responses for individual questions were omitted from analyses. Surveys were completed by infection preventionists, directors of nursing, or NH administrators. Results All 50 NHs (100%) completed the survey. 92% of responding NHs were aware of their facility's UTI/CAUTI rates. When asked about process measures, 48% knew their facility's hand hygiene rates and 44% their glove/gown use rates. While all 100% indicated they share infection data with NH leadership, only 72% share infection data with bedside nursing staff and 32% with residents and families. UTI/CAUTI prevention strategies implemented by NHs included hydration practices (83%); nurse-initiated indwelling urinary catheter (IUC) discontinuation (65%); stop orders for IUCs (46%); multidisciplinary rounds examining indwelling devices (33%); and electronic alerts/reminders of IUC need (25%). Despite evidence to the contrary, 56% reported cranberry juice/tablet use to prevent UTI/CAUTI. Two NHs (0.04%) reported having no UTI/CAUTI prevention strategies. Conclusions While awareness of UTI and CAUTI rates is high, process measures like facility hand hygiene rates are not evaluated consistently. Additionally, data are not routinely shared with stakeholders. NHs have made significant progress operationalizing many evidence-based infection prevention practices but gaps exist.

Quality metrics are the methods by which hospitals and insurers measure the quality of care at a particular institution or practice. Examples of quality metrics include structural measures, process measures, objectively assessed outcome measures, registries, patient-reported outcome measures, and patient-reported satisfaction through the hospital consumer assessment of healthcare providers and systems. Each metric provides unique insight about the care a particular institution can provide. These metrics are particularly relevant in spine care with spinal issues being such a common reason for patients to seek medical attention and mixed surgical outcomes for different surgical indications. The results are useful to patients choosing the institution at which they receive treatment, to hospitals in guiding efforts to improve their quality of care, and to insurers to rate hospitals and providers to direct policies and reimbursements. These metrics are continually evolving in order to adapt to constantly changing healthcare systems. No single metric is perfect, while each have their own unique benefits and insights about an institution; they also come with some potential downsides that must be balanced by using a varied set of measures.

Great strides have been achieved in the development of quality-of-care measures and standards for inflammatory bowel disease (IBD) over the last decade. The central structural component of care in IBD revolves around the multidisciplinary team, which should be equipped with the necessary resources to operate and implement decisions. Process measures have been defined by interest groups and can be adapted into process tools for the delivery of care for various patient subgroups and clinical scenarios. The emerging treat-to-target approach to IBD management may be used to achieve optimal long-term and holistic patient-centred outcomes, such as survival, control of inflammation and disease progression, symptomatic remission, quality of life and complications. Other important quality-of-care outcome measures for IBD include disutility of care, healthcare utilization and other patient-reported outcomes such as nutritional status and impact of fistulae. The current challenge for healthcare providers and health systems is the integration of quality-of-care structures and processes into clinical practice, and the consistent delivery of updated evidence-based quality IBD care to various patient populations by individual health care providers. Finally, the awareness and appreciation for quality of care in IBD is increasing in Asia, and Asian healthcare institutions should be encouraged to take the lead in improving the quality of care in IBD.

The modified Value Chain Model (VCM) of curricula related to a particular problem is formally described and it's process measures are proposed. The major components of the domain knowledge (modified VCM) are management functions and information flows related by a control loop to the processes in the problem domain. The formal description of the information transformations of a particular management function is defined as an Elementary Management Cycle (EMC). The modified VCM-based framework for the refinement of curricula content is developed and discussed.

Acute pancreatitis (AP) is a common and expensive condition. Improving quality of care in AP is vital to minimizing cost and improving patient outcomes. However, there has been little work accomplished toward developing and validating explicit quality indicators (QIs) in AP. To define quality of care in patients with AP by developing explicit QIs using standardized techniques. We used the UCLA/RAND Delphi panel approach to combine a comprehensive literature review with the collective judgment of experts to identify a defined set of process measures for AP. We produced 164 candidate QIs after a comprehensive literature review. After Delphi review, 75 had a median rating ≥ 7. We excluded 11 QIs where the disagreement index exceeded 1.0 and combined indicators overlapping in content to produce a final list of 22 QIs. Overall, 8 QIs related to diagnosis, prevention, or determination of etiology, 2 QIs focused on determination of severity, 3 QIs captured fluid resuscitation, 2 QIs measured nutrition, 1 QI use of antibiotics, and 6 QIs captured endoscopic or surgical management. We have developed 22 QIs spanning the spectrum of AP management including diagnosis, risk stratification, and pharmacological and endoscopic therapy. These QIs will facilitate future quality improvement by practitioners and organizations who treat patients with AP and further identify areas that are amenable to improvement to enhance patient care. We anticipate that this QI set will represent the first step in determining a framework for demonstrating value in the care of patients with AP.

Recent debate has focused on which quality measures are appropriate for surgical oncology and how they should be implemented and incentivized. Current quality measures focus primarily on process measures (use of adjuvant therapy, pathology reporting) and patient-centered outcomes (health-related quality of life). Pay for performance programs impacting surgical oncology patients focus primarily on preventing postoperative complications, but are not specific to cancer surgery. Future pay for performance programs in surgical oncology will likely focus on incentivizing high-quality, low-cost cancer care by evaluating process measures, patient-centered measures, and costs of care specific to cancer surgery.

The ESRD program provides medical care to a diverse and medically complex patient population. The care for the ESRD patient population has become increasingly benchmarked with process of care measures. These measures include dialysis adequacy, anemia, nutrition, and vascular access outcomes. These process-related dialysis measures may not improve the care of the individual patient as care relates to the individual's goals and values. There is also evidence that these process measures may not be causally related to quality of life, hospitalization, and survival. The adoption of patient-reported outcomes may shift the balance toward more patient-centered care. However, the extent to which mandated measures of health-related quality of life and patient satisfaction result in improved outcomes remains unclear.

Purpose – This paper aims to propose a model for building performance, based on control of fabric and services, and the influence of occupant behaviour. This work also demonstrates where significant change has been achieved through the processes of testing, measurement and monitoring. Modern Man’s impact on the Ecosystem, sustainability and the built environment’s contribution to global emissions are highlighted. The review provides a specific focus on the thermal performance of buildings and work undertaken to recognise and reduce wasted heat energy. Drawing on current research, data on buildings achieving enhanced levels of energy efficiency are presented and underperformance are discussed. While it is clear that domestic properties can perform, the pressure from legislation has been limited and significant gaps in thermal building performance continue. Design/methodology/approach – Drawing on a number of current research projects, this paper identifies the emergent methods for testing buildings and assessing fabric energy efficiency. Findings – The research identifies methods suitable for understanding and assessing building fabric performance. Using established methods, the performance metrics identify a significant difference between those achieving the energy efficiency standards and those failing to meet their designed performance. Originality/value – Highlighting the issue of sustainability is commonplace, but few have identified practical process measures that differentiate innovation that can lead to significant improvements in the building stock and identify those failing to achieve target performance.

This review examined the extent to which existing behavioral health quality measures address the priority areas of the National Behavioral Health Quality Framework (NBHQF) as well as the extent to which the measures have received National Quality Forum endorsement and are used in major reporting programs.This review identified behavioral health quality measures in widely used measure inventories, including the National Quality Measures Clearinghouse, National Quality Forum, and the Center for Quality Assessment in Mental Health. Additional measures were identified through outreach to federal agencies. Measures were categorized by type, condition, target population, data source, reporting unit, endorsement status, and use in reporting programs.The review identified 510 measures. Nearly one-third of these measures address broad mental health or substance use conditions rather than a specific condition or diagnosis. Seventy-two percent are process measures. The most common data source for measures is administrative claims, and very few measures rely on electronic health records or surveys. Fifty-three (10%) measures have received National Quality Forum (NQF) endorsement, and 28 (5%) unique measures are used in major quality reporting programs. Several subdomains of the NBHQF, such as treatment intensification, financial barriers to care, and continuity of care, lack measures that are NQF endorsed.Despite the wide array of behavioral health quality measures, relatively few have received endorsement or are used in reporting programs. Future efforts should seek to fill gaps in measurement and to identify the most salient and strongest measures in each priority area.

Background: Clinical reasoning is essential for the practice of medicine. Dual process theory conceptualizes reasoning as falling into two general categories: nonanalytic reasoning (pattern recognition) and analytic reasoning (active comparing and contrasting of alternatives). The debate continues regarding how expert performance develops and how individuals make the best use of analytic and nonanalytic processes. Several investigators have identified the unexpected finding that intermediates tend to perform better on licensing examination items than experts, which has been termed the “intermediate effect.” Purpose: We explored differences between faculty and residents on multiple-choice questions (MCQs) using dual process measures (both reading and answering times) to inform this ongoing debate. Method: Faculty (board-certified internists; experts) and residents (internal medicine interns; intermediates) answered live licensing examination MCQs (U.S. Medical Licensing Examination Step 2 Clinical Knowledge and American Board of Internal Medicine Certifying Examination) while being timed. We conducted repeated analysis of variance to compare the 2 groups on average reading time, answering time, and accuracy on various types of items. Results: Faculty and residents did not differ significantly in reading time [F (1, 35) = 0.01, p = 0.93], answering time [F (1, 35) = 0.60, p = 0.44], or accuracy [F (1, 35) = 0.24, p = 0.63] regardless of easy or hard items. Discussion: Dual process theory was not evidenced in this study. However, this lack of difference between faculty and residents may have been affected by the small sample size of participants and MCQs may not reflect how physicians made decisions in actual practice setting.

Over the past decade, there has been significant growth in the prevalence and ramifications of health care provider report cards. These provider performance evaluations are believed to increase transparency for patients and caregivers, enable evaluation of best practices, enhance quality assurance, and improve quality of care if report cards motivate patients to choose high-performing providers or cause providers to improve performance to compete on quality (Berwick, James, and Coye 2003; Galvin and McGlynn 2003; Romano and Zhou 2004; Hibbard, Stockard, and Tusler 2005; Fung et al. 2008; Bundorf et al. 2009; Werner et al. 2009; Werner, Stuart, and Polsky 2010). However, there are also concerns that patients may be adversely affected by increased use of report cards, especially when report cards are used to determine compensation or choice of providers. Report cards can be misleading to patients and payers because of inadequate risk adjustment, limited relationship between easily observed process measures and patient outcomes, the potential for providers to artificially improve outcome measures by “teaching to the test,” skimping on important areas of care that are not measured, or selecting healthier patients or those perceived as less of a threat to measured performance (Dranove, Shanley, and Simon 1992; Iezzoni 1997; Mullen, Frank, and Rosenthal 2010; Nicholas and Dimick 2011; Nicholas, Dimick, and Iwashyna 2011; Werner et al. 2011).

Aligning maintenance of certification with quality reporting may ease reporting burden, but the impact on quality is uncertain. This study compared changes in quality measures from American Board of Family Medicine Performance in Practice Modules (PPMs), Physician Quality Reporting System (PQRS), and a combined PQRS/PPM for diabetes between 2008 and 2012. Physicians completed 7264 diabetes PPMs, 297 only reported PQRS measures 2 or more times, and 675 completed a combination project, representing more than 200 000 patients. After adjustment, PQRS and PQRS/PPM projects were associated with greater blood pressure and cholesterol control improvement than PPM only (P.05). PPM-only projects had greater improvement than PQRS-only projects on 4 of 6 process measures and greater hemoglobin A1c improvement (P.05) but were only better on 2 process measures and on hemoglobin A1c control than PQRS/PPM projects. These findings identify differences between quality reporting and quality improvement, suggesting reason to align the 2 programs.

The US healthcare system is shifting towards reimbursement for quality over quantity of care. Quality measures are tied to financial incentives in these healthcare models. It is important that surgeons become familiar with quality measures addressing ventral hernia repair and understand candidate measures that may drive future quality measure development. We performed a systematic review of society websites, quality measure databases, and the literature (Pubmed, Embase/Scopus, and Google Scholar) for quality measures addressing ventral hernia surgery. Clinical practice guidelines were included as candidate quality measures. All measures were categorized as structure, process or outcome according to Donabedian domains, as well as within the six National Quality Strategy (NQS) domains. Thirty quality measures and candidate measures were identified. Eight candidate measures from the American Hernia Society addressed ventral hernia repair, and 22 quality measures in general surgery were also relevant to ventral hernia repair. Of the candidate measures, 6 (75%) were outcome and 2 (25%) were process measures. Of existing general surgery quality measures, 9 (41%) were outcome and 13 (59%) were process measures. No structural measures were identified. Overall, the majority of measures addressed NQS priorities of effective clinical care (33%) and patient safety (27%), while few addressed other domains. Both the Donabedian domains of quality and NQS priorities were unequally represented in the current measures addressing ventral hernia repair. Recognizing and addressing the under-represented areas will provide a more balanced framework for developing quality measures and ensure that ventral hernia surgery is appropriately evaluated in value-based payment models.

Objective Defining quality healthcare is an important topic, particularly within the context of emerging payment reforms. Reviews of adult quality metrics have demonstrated an overabundance of process measures intended to address underuse of services. It has been suggested that the preponderance of such measures skews our definition of quality care and may contribute to unnecessary utilization in an already financially burdened healthcare system. Our specific aim was to systematically review and characterize available …

This editorial refers to ‘The Contribution of the Composite of Clinical Process Indicators as a Measure of Hospital Performance in the Management of Acute Coronary Syndromes-insights from the CONCORDANCE Registry ’, by B. Aliprandi-Costa et al ., on page 37. Evidence for between and within country variation in mortality from cardiovascular disease has made the measurement and reporting of quality of cardiac care and its outcomes increasingly relevant to clinical practice. The European Society of Cardiology has recognized the importance of this through a number of ventures including the EurObservational Research Programme and the European Atlas of Cardiology, each collecting information from member countries about processes and outcomes relating to cardiovascular disease and its treatment. In 1910, Dr Ernest Codman suggested that surgeons track and publish their patient’s outcomes.1 Nowadays, outcomes reporting has become central to the evaluation of clinical care across a number of healthcare systems. For example, the National Health Service of England and Wales transparently reports operator-level standardized mortality rates for percutaneous coronary intervention, which includes all publically funded procedures performed by all operators. Yet, many argue that we should concentrate on the measurement of adherence to guideline-indicated care, ‘the process’ rather than mortality, ‘the outcome’.2 There … [↵][1]* Corresponding author. Tel: +44(0) 113 3438905, Fax: 44(0) 113 343 4877, Email: c.p.gale{at}leeds.ac.uk [1]: #xref-corresp-1-1

AimTo study (a) the covariation between patient reported experience measures (PREMs) and registered process measures of access and continuity when ranking providers in a primary care setting, and (b) whether registered process measures or PREMs provided more or less information about potential linkages between levels of access and continuity and explaining variables.BackgroundAccess and continuity are important objectives in primary care. They can be measured through registered process measures or PREMs. These measures do not necessarily converge in terms of outcomes. Patient views are affected by factors not necessarily reflecting quality of services. Results from surveys are often uncertain due to low response rates, particularly in vulnerable groups. The quality of process measures, on the other hand, may be influenced by registration practices and are often more easy to manipulate. With increased transparency and use of quality measures for management and governance purposes, knowledge about the pros and cons of using different measures to assess the performance across providers are important.MethodsFour regression models were developed with registered process measures and PREMs of access and continuity as dependent variables. Independent variables were characteristics of providers as well as geographical location and degree of competition facing providers. Data were taken from two large Swedish county councils.FindingsAlthough ranking of providers is sensitive to the measure used, the results suggest that providers performing well with respect to one measure also tended to perform well with respect to the other. As process measures are easier and quicker to collect they may be looked upon as the preferred option. PREMs were better than process measures when exploring factors that contributed to variation in performance across providers in our study; however, if the purpose of comparison is continuous learning and development of services, a combination of PREMs and registered measures may be the preferred option. Above all, our findings points towards the importance of a pre-analysis of the measures in use; to explore the pros and cons if measures are used for different purposes before they are put into practice.

* Abbreviation: EHR — : electronic health record In this issue of Pediatrics , the article by House et al1 provides a summary of pediatric quality measures currently available in national databases as well as an assessment of how comprehensively these measures represent common pediatric issues. The authors found a preponderance of process measures that have not been outcome-validated. They also found a dearth of measures for some of the most common and/or costly conditions, and relatively few health outcome measures. These findings are not unexpected and are unlikely to change without a paradigm shift in how quality measures are developed and implemented in health care systems across the United States. The first step in quality measure development is to review the evidence and/or clinical practice guidelines related to the topic under consideration.2 Guidelines represent “state-of-the-art” thinking about how conditions should be diagnosed, treated, and, for chronic conditions, managed over time. Thus, when they exist for a given condition, clinical practice guidelines are usually the main source used to develop quality measures. When guideline recommendations are based on low-quality … Address correspondence to Rita Mangione-Smith, MD, MPH, Seattle Children’s Research Institute, Center for Child Health, Behavior, and Development, 2001 Eighth Avenue, Suite 400, Seattle, WA 98121. E-mail: rita.mangione-smith{at}seattlechildrens.org

Variation in the quality of breast care affects outcomes. Objective measurement tools are central to this effort. Most quality measures are process measures. Application of these improves quality. Many national organizations are promoting them for purposes ranging from feedback to providers to public reporting and directing payment. Surgeons should evaluate their own practices and should be involved in local, regional and national efforts to assess and improve breast care.

Approximately 500,000 hysterectomies are performed each year in the United States despite the existence of numerous nondefinitive alternatives. Gaining an understanding of the relationship between quality, safety, and cost is critical to gynecologists performing this procedure. Analysis of quality measures includes important process measures such as time-out procedures, the Surgical Care Improvement Project, Peer Review, and Credentialing. Databases, such as the National Surgical Quality Improvement Program, are also available for review of quality. Safety is evaluated by analyzing outcomes including complications, route of procedure, and patient satisfaction. The cost of hysterectomy is impacted by continuous quality and safety improvements.

The Coordinating Council on the Clinical Laboratory Workforce (CCCLW) initiated a task force charged with describing the value of clinical laboratory medicine toward the overarching needs of achieving quality patient care and improving patient outcomes. In part, a survey was conducted to discover what clinical laboratories do or should do to achieve these goals. A total of 469 respondents representing various sized and types of facilities, as well as various clinical positions participated. It confirmed that the topic was impacting about two-thirds of respondents who reported pressure from senior leadership to actively show the value of the laboratory. Interestingly, a slightly higher number (69%) indicated they felt constant pressure to cut costs. Open-ended questions were utilized to determine approaches to demonstrating value and responses fell in six categories. Questions also sought approaches to measuring value with responses largely falling within five categories primarily composed of structural and process measures.