Clinical and nonclinical indicators of performance in thoracic surgery.

One of the most important steps in the entire process of monitoring and improving quality of care is to identify the proper quality measures. This may be challenging from the outset since no single indicator can fully comprehend the entire concept of quality of care, which is multidimensional by nature. Ideally, multiple indicators should be used at the same time to obtain a more precise assessment of the quality of care. The quality of care can be measured by observing its structure, its processes, and its outcomes. Each indicator may reflect different aspects of quality and may be of particular interest to different audiences (providers, consumers, regulators, purchasers). The selection of one or the other may depend on the objectives of the analysis and the target audience. Although outcomes represent the ultimate product of health care, if the focus is on identifying and remedying apparent variations in performance, it is often preferable to measure not only outcomes but also the desirable processes of care. From a performance management perspective, the key issue is that a desirable process should be unambiguously associated with improved patient health outcomes. Monitoring the process can then be a substitute for measuring the outcome. Unlike outcome indicators, process measures have the potential to identify for clinicians exactly which processes they followed or did not follow that had the potential to affect patient outcomes. Process indicators provide information that is actionable. Finally, thoracic surgeons should take the lead in the managerial approach to the evaluation of performance, preventing administrative personnel unfamiliar with our multifaceted clinical world from judging our practice through imprecise instruments. We, as physicians, must absolutely improve our skill and confidence in risk analysis, outcome-evaluation methods, and process-based assessment of our practice.