Although operator proficiency is important in the catheterization laboratory (cath lab), regular monitoring and assessment of other indicators are important to ensure quality health care delivery. Hany Eteiba, MD, Glasgow Royal Infirmary, Glasgow, Scotland, outlined 5 types of quality indicators encompassing the measurement and improvement of quality in terms of delivery of health care, specifically for interventional cardiologic care: data collection and benchmarking, appropriate use indicators, process of care indicators, clinical privilege indicators, and clinical outcomes indicators.

For data collection and benchmarking, a patient-specific data collection system should be used that enables consistent data collection from all patients. From this, parameters such as number of specific procedures, number of complications, or time elapsed can be tracked, graphed, and reviewed against a comparison population. Outlier values can be opportunities to learn, because they can represent a particularly complex case, or they may represent areas in which improvement is needed to move the outlier value closer to the median.

The appropriate use of a procedure was guided by experience and intuition about 30 years ago, and in turn it became guided by professional society guidelines about 20 years ago [Stone GW, Moses JW. Nat Rev Cardiol. 2011]. Today, Prof Eteiba indicated that appropriate use criteria should be used. For example, the appropriate use criteria for coronary revascularization support the use of clinical judgment and experience, and allow for the assessment of use patterns for procedures (eg, that which was defined in data collection and benchmarking), yet do not eliminate the challenge of decision making. Appropriateness is typically classified within 3 ranges: 1 to 3 represents inappropriate use, because the procedure is unlikely to improve health outcomes or survival; 4 to 6 represents uncertain use, because it is not clear if the procedure would improve outcomes or survival; and 7 to 9 represents appropriate use, because the procedure would likely improve outcomes or survival [Patel MR et al. J Am Coll Cardiol. 2009].

For process of care indicators, it is important to look at the entire process leading up to, during, and after the procedure. For example, protective measures such as renal and radiation protection are important to track. In addition, process efficiency and transport times are particularly important in revascularization, because door-to-balloon time is critical. Prof Eteiba demonstrated the use of data tracking, in which the times of symptom onset, call for help, paramedical contact, first electrocardiograph, arrival, and procedure start can be documented, tracked, and assessed.

Clinical privilege indicators include staff credentialing and proficiency. Formal training requirements and competency should be reviewed, and the role of noninvasive specialties should be recognized as well. Proficiency can be maintained through various mechanisms, such as assessment of annual caseload of a specific procedure per year, institutional measures of proficiency, attending morbidity and mortality conferences, and peer review of random cases.

Clinical outcomes indicators, such as major adverse cardiac and cerebrovascular events and percutaneous coronary intervention success rate, should be monitored on a regular basis. The data, as well as catheterization laboratory statistics, should be shared and reported in both compiled and physician-specific formats, with a focus on quality improvement.

In conclusion, Prof Eteiba stated that quality improvement begins with fostering an environment of quality and clinical governance, which requires a commitment from the entire health care system. Operator and staff proficiency are crucial in assuring quality; however, other aspects such as process, data collection and benchmarking, and outcome indicators are important to continue to provide quality health care and to enable improvement in quality.