on adherence to condition- or procedure-specific standards) or be positive or negative health status outcomes.

The Joint Commission distinguishes sentinel events and comparative indicators. Sentinel events are serious complications or outcomes that should always trigger a more intensified review, such as maternal death or craniotomy more than 24 hours after emergency room admission. Comparative indicators establish rates over time or rates in comparison to other institutions. A particularly high or low rate may trigger further review, for example, the rate of death after coronary artery bypass graft surgery, the rate of wound infections, and the rate of vaginal births after cesarean delivery.

Strengths and Limitations

By and large, the same advantages and drawbacks to generic screening and retrospective review of the process of care apply to clinical indicators. A possible advantage of clinical indicators over standard generic screens is a presumed higher face validity for physicians and other practitioners. A possible drawback is their relative newness.

Patient Reports and Ratings

Patient reports refer broadly to interviews and surveys of patients that are conducted either at the time care is provided or later, by telephone or by mail. Surveys can include potential patients, for example Medicare beneficiaries or HMO members who have not used care. Interviews and surveys may ask patients to report on the process of care (both technical and interpersonal) and its outcome and to rate the quality of the care they received and their satisfaction with it.


Surveys can investigate such aspects of patient experience as access to care, amenities of care, interpersonal and technical aspects of care, health status, understanding of instructions, experience in comparison to expectations (including a judgment of outstanding as well as poor care), and unmet needs. Detailed satisfaction surveys are fielded by many HMOs and, increasingly, by hospitals. In addition to compiling assessments of care received in primary care facilities, some surveys also include questions about care provided by specialists and affiliated hospitals.

Patient assessments are commonly sought internally by organizations (although they are not necessarily fielded by or used by the quality assurance program), and only rarely by external groups. Patient reports can provide information about (1) underuse (such as perceived lack of access,

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