The holy grail of surgical quality improvement: Process measures or risk-adjusted outcomes?

Quality of care in surgery has garnered increased attention. Focus on the structure, processes of care, and use of risk-adjusted outcomes has offered different possible solutions. Volume-outcome studies have consistently demonstrated relationships between higher surgeon and hospital volume and favorable outcomes. The policy implications for quality improvement remain unclear. Recent efforts have focused on the use of risk-adjusted outcomes, such as the American College of Surgeons National Surgical Quality Improvement Program, to drive quality improvement. Conversely, large efforts, mandated by the Center for Medicare and Medicaid Services, have focused on process measures, such as perioperative complication prevention. For the future of surgical quality improvement, the combination of process measures and risk-adjusted outcomes are essential. It is only through the combined use of improved understanding of the relationship of processes of care and outcomes that we will make surgical care safer and improve quality.