Quality-based Procedures Research Articles

The impact of the Ontario quality-based procedures funding model on radical prostatectomy outcomes.

In 2015, radical prostatectomy (RP) in Ontario transitioned to the quality-based procedures (QBP) funding model, which assigns disbursement from surgical quality indicator (QI) outcome performance. The objective of this study was to assess the QBP QI outcomes before and after implementation of the QBP funding model for RP, and to determine whether changes seen were attributable to the QBP model. We conducted a population-based, retrospective cohort study including all men who underwent RP for prostate cancer in Ontario from 2010-2019. We used administrative data from Ontario's health databases to gather surgical and QI outcome data. Our primary outcomes were the five measurable QBP QIs outlined by the province. We performed a pre- and post-intervention comparison, in addition to an interrupted-time series (ITS) analysis. Two of the five QIs improved after implementation of the QBP model (complication rate: 11.89% vs. 9.96%, p<0.001; proportion meeting length of stay target: 78.11% vs. 86.84%, p<0.001). ITS analysis revealed that there was no difference in trend in either outcome between pre- and post-implementation periods (p=0.913 and p=0.249, respectively). Two QIs were worse in the post-implementation period (unplanned visit rate: 23.45% vs. 25%, p=0.015; proportion meeting Wait 2 target: 94.39% vs. 92.88%, p<0.001). ITS revealed no significant trend changes post-implementation (p=0.260 and p=0.272, respectively). There was no difference in re-operation rate (2.84% vs. 2.45%, p=0.107). The QBP model for RP corresponds with mixed QI changes, but further analysis suggests that these changes were pre-existing trends and not attributable to the model.

A quasi-experimental evaluation of the association between implementation of Quality-Based Procedures funding for hip fractures and improvements in processes and outcomes for hip fracture patients in Ontario: an interrupted time series analysis.

In 2013, Ontario introduced a patient-based funding model for hip fracture care (Quality-Based Procedures [QBP]). The association of QBP implementation with changes in processes and outcomes has not been evaluated. We conducted a quasi-experimental study using linked health data for adult hip fractures as an interrupted time series. The pre-QBP period was from 2008 to 2012 and the post-QBP period was from 2014 to 2018; 2013 was excluded as a wash-in period. We used segmented regression analyses to estimate the association of QBP implementation with changes in processes (surgery in less than two days from admission, use of echocardiography, use of nerve blocks, and provision of geriatric care) and clinical outcomes (90-day mortality, 90-day readmissions, length of stay, and days alive at home). We estimated the immediate (level) change, trend (slope) postimplementation, and total counterfactual differences. Sensitivity analyses included case-mix adjustment and stratification by hospital type and procedure. We identified 45,500 patients in the pre-QBP period and 41,256 patients in the post-QBP period. There was a significant total counterfactual increase in the use of nerve blocks (11.1%; 95% confidence interval [CI], 6.2 to 16.0) and a decrease in the use of echocardiography (-2.5%; 95% CI, -3.7 to -1.3) after QBP implementation. The implementation of QBP was not associated with a clinically or statistically meaningful change in 90-day mortality, 90-day readmission, length of stay, or number of days alive at home. Evaluation of the QBP program is crucial to inform ongoing and future changes to policy and funding for hip fracture care. The introduction of the QBP Hip Fracture program, supported by evidence-based recommendations, was associated with improved application of some evidence-based processes of care but no changes in clinical outcomes. There is a need for ongoing development and evaluation of funding models to identify optimal strategies to improve the value and outcomes of hip fracture care. Open Science Framework ( https://osf.io/2938h/ ); first posted 13 June 2022.

A Clinical Consensus Approach to Developing a New Funding Model for Radiation Services in Ontario.

In 2021, Ontario Health (Cancer Care Ontario) introduced a quality-based procedure model for the funding of radiation treatment (RT) in Ontario. This model ties reimbursement to patient care activities, ensuring equity and transparency in funding. Over 200 RT interprofessionals (oncologists, therapists and physicists) participated on 22 expert panels to establish or identify 288 evidence-based RT protocols and 672 quality expectations (QEs) to optimally deliver RT, which eventually led to the micro-costing of all protocols. Iterative review is required to ensure updated techniques and identify evolving standards of care, thereby providing the highest quality of RT care to Ontarians.

Developing Radiation Treatment Protocols to Support the Transition to a Quality Based Procedure

Purpose: Ontario Health is introducing a quality-based procedures (QBP) model for the funding of radiation treatment (RT) in Ontario. This model ties funding to specific patient care activities ensuring equity and transparency in allocations. A key initial requirement was to develop, catalogue and review all RT protocols for the QBP model. This necessary first step allowed for micro-costing of each protocol but has also lead to a discussion regarding “how should RT be optimally delivered across Ontario?”

189: Putting the “Quality’ in ‘Quality-Based Procedures”: Driving Quality of Care for Patients Through the Development of a Provincial Radiation Treatment Funding Model

189: Putting the “Quality’ in ‘Quality-Based Procedures”: Driving Quality of Care for Patients Through the Development of a Provincial Radiation Treatment Funding Model

Effect of a health system payment and quality improvement programme for tonsillectomy in Ontario, Canada: an interrupted time series analysis

BackgroundTonsillectomy is among the most common and cumulatively expensive surgical procedures in children, with known variations in quality of care. However, evidence on health system interventions to improve quality of...

Radiation oncologist consultations prior to prostatectomy in Ontario, Canada: Disparities and opportunities.

e17052 Background: Men with localized prostate cancer have many options for initial definitive treatment. In 2015, Cancer Care Ontario Quality Based Procedures (QBP) recommended that men undergoing radical prostatectomy (RP) in Ontario be seen by a radiation oncologist (RO) or discussed at a multidisciplinary case conference (MCC) prior to surgery. An a-priori target rate of 76% was set by QBP, but to our knowledge, has not been reported upon to date. Our objective was to use population-based data to explore factors associated with not receiving RO consult/MCC prior to RP. Methods: Men with localized prostate cancer diagnosed and treated in Ontario, Canada with RP between 2007 and 2017 were identified using administrative data from the Institute for Clinical Evaluative Sciences. Physician billing data was utilized to identify patients who received RO consult/MCC prior to RP. Trends were evaluated using the Cochran-Armitage test. Multivariable logistic regression was used to identify patient and provider factors predictive of RO/MCC prior to RP. Results: 31,467 men with localized prostate cancer underwent RP between 2007 and 2017. Prior to RP, 29.3% of men were seen by RO, 1.0% underwent MCC, and 1.6% had both. RO consult/MCC prior to RP increased from 18.0% in 2007 to 47.8% in 2017 ( p&lt;0.001). On multivariable analysis, the Odds Ratio (OR) of RO consult/MCC prior to RP between the lowest and highest geographic regions (LHINs) was 8.79 (95% CI 6.83–11.32, p&lt;0.001). RO consult/MCC was less likely to occur for patients living further from the nearest cancer center (OR 0.74 per 50km, 95% CI 0.70–0.77, p&lt;0.001) and more likely to occur for men residing in the highest versus lowest income quintile regions (OR 1.42, 95% CI 1.30–1.55, p&lt;0.001). Men with NCCN Low (OR 1.31, 95% CI 1.16–1.47, p&lt;0.001), High (OR 1.20, 95% CI 1.09–1.31, p&lt;0.001) or Very High (OR 1.24, 95% CI 1.11–1.30, p&lt;0.001) risk disease were more likely to receive RO consult/MCC compared to those with favourable-intermediate risk disease. Of the 128 urologists who performed at least 10 RP between 2016 and 2017, RO referral/MCC rate ranged from 0% to 100%, with 31 urologists (24.2%) having ≥76% of their patients seen prior to RP. To meet QBP targets in 2017, an additional 701 men would have needed RO consult/MCC. If all were seen by RO, approximately 2.4 additional full time equivalent RO positions would be needed. Conclusions: Despite increasing rates of utilization, a large proportion of men are not seen by RO or MCC prior to RP in Ontario, Canada. While the largest factors predicting RO consult/MCC discussion appear to be geographic and which urologist performs the RP, these factors are closely intertwined. In addition, these factors may be related to RO availability and radiation system capacity, which would need to be addressed to meet patient demand should QBP consultation rates be mandated to reduce disparities in pre-RP consultation practices.

Divergent notions of “quality” in healthcare policy implementation: a framing perspective

PurposeThis paper examines how “quality” was framed in the design and implementation of a policy to reform hospital funding and associated care delivery. The aims of the study were: (1) To describe how government policy-makers who designed the policy and managers and clinicians who implemented the policy framed the concept of “quality” and (2) To explore how frames of quality and the framing process may have influenced policy implementation.Design/methodology/approachThe authors conducted a secondary analysis of data from a qualitative case study involving semi-structured interviews with 45 purposefully selected key informants involved in the design and implementation of the quality-based procedures policy in Ontario, Canada. The authors used framing theory to inform coding and analysis.FindingsThe authors found that policy designers perpetuated a broader frame of quality than implementers who held more narrow frames of quality. Frame divergence was further characterized by how informants framed the relationship between clinical and financial domains of quality. Several environmental and organizational factors influenced how quality was framed by implementers.Originality/valueAs health systems around the world increasingly implement new models of governance and financing to strengthen quality of care, there is a need to consider how “quality” is framed in the context of these policies and with what effect. This is the first framing analysis of “quality” in health policy.

189: Putting The “Quality’ in ‘Quality-Based Procedures”: Driving Quality of Care for Patients Through The Development of a Provincial Radiation Treatment Funding Model

189: Putting The “Quality’ in ‘Quality-Based Procedures”: Driving Quality of Care for Patients Through The Development of a Provincial Radiation Treatment Funding Model

Effects of quality-based procedure hospital funding reform in Ontario, Canada: An interrupted time series study

The Government of Ontario, Canada, announced hospital funding reforms in 2011, including Quality-based Procedures (QBPs) involving pre-set funds for managing patients with specific diagnoses/procedures. A key goal was to improve quality of care across the jurisdiction. Interrupted time series evaluated the policy change, focusing on four QBPs (congestive heart failure, hip fracture surgery, pneumonia, prostate cancer surgery), on patients hospitalized 2010-2017. Outcomes included return to hospital or death within 30 days, acute length of stay (LOS), volume of admissions, and patient characteristics. At 2 years post-QBPs, the percentage of hip fracture patients who returned to hospital or died was 3.13% higher in absolute terms (95% CI: 0.37% to 5.89%) than if QBPs had not been introduced. There were no other statistically significant changes for return to hospital or death. For LOS, the only statistically significant change was an increase for prostate cancer surgery of 0.33 days (95% CI: 0.07 to 0.59). Volume increased for congestive heart failure admissions by 80 patients (95% CI: 2 to 159) and decreased for hip fracture surgery by 138 patients (95% CI: -183 to -93) but did not change for pneumonia or prostate cancer surgery. The percentage of patients who lived in the lowest neighborhood income quintile increased slightly for those diagnosed with congestive heart failure (1.89%; 95% CI: 0.51% to 3.27%) and decreased for those who underwent prostate cancer surgery (-2.08%; 95% CI: -3.74% to -0.43%). This policy initiative involving a change to hospital funding for certain conditions was not associated with substantial, jurisdictional-level changes in access or quality.

Hysterectomy in Ontario: A Population-Based Study of Outcomes and Complications in Minimally Invasive Compared with Abdominal Approaches.

As quality-based procedures (QBPs) are being established across the province of Ontario, it is important to identify reliable quality indicators (QIs) to ensure that compensation coincides with quality. Hysterectomy is the most commonly performed gynaecologic procedure and as such is a care process for which a QBP is being developed. The aim of this study was to evaluate the technicity index (TI) as a QI for hysterectomy by defining it in the context of specific surgical outcomes and complications. This population-based, retrospective cohort study included all women who underwent hysterectomy from April 2003 to October 2014 in the province of Ontario. Unadjusted and adjusted generalized linear models were created to assess the effect of a minimally invasive hysterectomy (MIH) approach on the primary outcome measure: all hysterectomy-associated complications (Canadian Task Force Classification II-2). Of the procedures meeting the study's inclusion criteria, 56.8% were performed using an abdominal hysterectomy approach, whereas 43.2% were performed using an MIH approach. Over the study period, TI improved significantly from 33.23% in 2003 to 58.47% in 2014. During this time span, the overall incidence of all hysterectomy-associated complications was 13.1%. The composite risk of all hysterectomy-associated complications was reduced by 46% with an MIH approach. The uptake of MIH improved significantly in Ontario from 2003 to 2014 and is adequately assessed by the TI. The TI is an appropriate QI for hysterectomy that can be used to track patients' outcomes and direct hysterectomy funding.

Standardising costs or standardising care? Qualitative evaluation of the implementation and impact of a hospital funding reform in Ontario, Canada

BackgroundSince 2011, the Government of Ontario, Canada, has phased in hospital funding reforms hoping to encourage standardised, evidence-based clinical care processes to both improve patient outcomes and reduce system costs. One aspect of the reform – quality-based procedures (QBPs) – replaced some of each hospital’s global budget with a pre-set price per episode of care for patients with specific diagnoses or procedures. The QBP initiative included publication and dissemination of a handbook for each of these diagnoses or procedures, developed by an expert technical group. Each handbook was intended to guide hospitals in reducing inappropriate variation in patient care and cost by specifying an evidence-based episode of care pathway. We explored whether, how and why hospitals implemented these episode of care pathways in response to this initiative.MethodsWe interviewed key informants at three levels in the healthcare system, namely individuals who conceived and designed the QBP policy, individuals and organisations supporting QBP adoption, and leaders in five case-study hospitals responsible for QBP implementation. Analysis involved an inductive approach, incorporating framework analysis to generate descriptive and explanatory themes from data.ResultsThe 46 key informants described variable implementation of best practice episode of care pathways across QBPs and across hospitals. Handbooks outlining evidence-based clinical pathways did not address specific barriers to change for different QBPs nor differences in hospitals’ capacity to manage change. Hospitals sometimes found it easier to focus on containing and standardising costs of care than on implementing standardised care processes that adhered to best clinical practices.ConclusionImplementation of QBPs in Ontario’s hospitals depended on the interplay between three factors, namely complexity of changes required, internal capacity for organisational change, and availability and appropriateness of targeted external facilitators and supports to manage change. Variation in these factors across QBPs and hospitals suggests the need for more tailored and flexible implementation supports designed to fit all elements of the policy, rather than one-size-fits-all handbooks alone. Without such supports, hospitals may enact quick fixes aimed mainly at preserving budgets, rather than pursue evidence- and value-based changes in care management. Overestimating hospitals’ change management capacity increases the risk of implementation failure.

Supporting the implementation of stroke quality-based procedures (QBPs): a mixed methods evaluation to identify knowledge translation activities, knowledge translation interventions, and determinants of implementation across Ontario

BackgroundIn 2013, Health Quality Ontario introduced stroke quality-based procedures (QBPs) to promote use of evidence-based practices for patients with stroke in Ontario hospitals. The study purpose was to: (a) describe the knowledge translation (KT) interventions used to support stroke QBP implementation, (b) assess differences in the planned and reported KT interventions by region, and (c) explore determinants perceived to have affected outcomes.MethodsA mixed methods approach was used to evaluate: activities, KT interventions, and determinants of stroke QBP implementation. In Phase 1, a document review of regional stroke network work plans was conducted to capture the types of KT activities planned at a regional level; these were mapped to the knowledge to action framework. In Phase 2, we surveyed Ontario hospital staff to identify the KT interventions used to support QBP implementation at an organizational level. Phase 3 involved qualitative interviews with staff to elucidate deeper understanding of survey findings.ResultsOf the 446 activities identified in the document review, the most common were ‘dissemination’ (24.2%; n = 108), ‘implementation’ (22.6%; n = 101), ‘implementation planning’ (15.0%; n = 67), and ‘knowledge tools’ (10.5%; n = 47). Based on survey data (n = 489), commonly reported KT interventions included: staff educational meetings (43.1%; n = 154), champions (41.5%; n = 148), and staff educational materials (40.6%; n = 145). Survey participants perceived stroke QBP implementation to be successful (median = 5/7; interquartile range = 4–6; range = 1–7; n = 335). Forty-four people (e.g., managers, senior leaders, regional stroke network representatives, and frontline staff) participated in interviews/focus groups. Perceived facilitators to QBP implementation included networks and collaborations with external organizations, leadership engagement, and hospital prioritization of stroke QBP. Perceived barriers included lack of funding, size of the hospital (i.e., too small), lack of resources (i.e., staff and time), and simultaneous implementation of other QBPs.ConclusionsInformation on the types of activities and KT interventions used to support stroke QBP implementation and the key determinants influencing uptake of stroke QBPs can be used to inform future activities including the development and evaluation of interventions to address barriers and leverage facilitators.

Correction: Qualitative analysis of the dynamics of policy design and implementation in hospital funding reform.

[This corrects the article DOI: 10.1371/journal.pone.0191996.].

Qualitative analysis of the dynamics of policy design and implementation in hospital funding reform.

BackgroundAs in many health care systems, some Canadian jurisdictions have begun shifting away from global hospital budgets. Payment for episodes of care has begun to be implemented. Starting in 2012, the Province of Ontario implemented hospital funding reforms comprising three elements: Global Budgets; Health Based Allocation Method (HBAM); and Quality-Based Procedures (QBP). This evaluation focuses on implementation of QBPs, a procedure/diagnosis-specific funding approach involving a pre-set price per episode of care coupled with best practice clinical pathways. We examined whether or not there was consensus in understanding of the program theory underpinning QBPs and how this may have influenced full and effective implementation of this innovative funding model.MethodsWe undertook a formative evaluation of QBP implementation. We used an embedded case study method and in-depth, one-on-one, semi-structured, telephone interviews with key informants at three levels of the health care system: Designers (those who designed the QBP policy); Adoption Supporters (organizations and individuals supporting adoption of QBPs); and Hospital Implementers (those responsible for QBP implementation in hospitals). Thematic analysis involved an inductive approach, incorporating Framework analysis to generate descriptive and explanatory themes that emerged from the data.ResultsFive main findings emerged from our research: (1) Unbeknownst to most key informants, there was neither consistency nor clarity over time among QBP designers in their understanding of the original goal(s) for hospital funding reform; (2) Prior to implementation, the intended hospital funding mechanism transitioned from ABF to QBPs, but most key informants were either unaware of the transition or believe it was intentional; (3) Perception of the primary goal(s) of the policy reform continues to vary within and across all levels of key informants; (4) Four years into implementation, the QBP funding mechanism remains misunderstood; and (5) Ongoing differences in understanding of QBP goals and funding mechanism have created challenges with implementation and difficulties in measuring success.ConclusionsPolicy drift and policy layering affected both the goal and the mechanism of action of hospital funding reform. Lack of early specification in both policy goals and hospital funding mechanism exposed the reform to reactive changes that did not reflect initial intentions. Several challenges further exacerbated implementation of complex hospital funding reforms, including a prolonged implementation schedule, turnover of key staff, and inconsistent messaging over time. These factors altered the trajectory of the hospital funding reforms and created confusion amongst those responsible for implementation. Enacting changes to hospital funding policy through a process that is transparent, collaborative, and intentional may increase the likelihood of achieving intended effects.

Coding Accuracy for Outpatient Ophthalmic Surgery: St. Joseph's Healthcare Hamilton.

Coding accuracy is an important factor in ensuring hospitals receive adequate reimbursement from the government for healthcare services rendered. A retrospective review of 100 charts, the purpose of this study was to determine the degree of coding accuracy from the surgeon perspective, for outpatient procedures performed for ophthalmic services at St. Joseph's Healthcare Hamilton from July to December 2016. Using ICD-10-CA, Canadian Classification of Health Interventions, Quality-Based Procedures criteria where applicable, and the 3M Coding and Reimbursement system, this paper reveals three primary sources of coding errors and presents recommendations to increase accuracy of reimbursement for the benefit of both the Ministry of Health and hospital organizations.

Value agenda for heart failure in Ontario: Application of the Porter model.

Value in healthcare is a challenge that is faced all over the world; costs continue to rise despite efforts to increase quality and efficient healthcare delivery. Heart failure is a progressive chronic condition that has been demonstrated to benefit from close monitoring with positive effects on mortality and morbidity when well managed. This article will review the Porter model for value in healthcare by comparing the current state of heart failure management in Ontario, Canada, with the six key concepts of the value agenda. The Ontario quality-based procedure model has been implemented for heart failure management and will be applied against the Porter model to provide an increased understanding of how managers can think differently about patient outcomes. An examination as to how the quality and value of the treatment of this condition can be improved will be conducted using the principles of the value agenda.

Clinical and psychosocial predictors of exceeding target length of stay during inpatient stroke rehabilitation

Background: In Ontario, Canada, patients admitted to inpatient rehabilitation hospitals post-stroke are classified into rehabilitation patient groups based on age and functional level. Clinical practice guidelines, called quality-based procedures, recommend a target length of stay (LOS) for each group.Objectives: The study objective was to evaluate the extent to which patients post-stroke at an inpatient rehabilitation hospital are meeting LOS targets and to identify patient characteristics that predict exceeding target LOS.Methods: A quantitative, longitudinal study from an inpatient rehabilitation hospital was conducted. Participants included adult patients (≥18 years) with stroke, admitted to an inpatient rehabilitation hospital between 2014 and 2015. The percentage of patients exceeding the recommended target LOS was determined. Logistic regression was performed to identify clinical and psychosocial patient characteristics associated with exceeding target LOS after adjusting for stroke severity.Results: Of 165 patients, 38.8% exceeded their target LOS. Presence of ataxia, recurrent stroke, living alone, absence of a caregiver at admission, and acquiring a caregiver during hospital LOS was each associated with significantly higher odds of exceeding target LOS in comparison to patients without these characteristics after adjusting for stroke severity (p < 0.05).Conclusions: Findings suggest that social and stroke-specific factors may be helpful to adjust LOS expectations and promote efficient resource allocation. This exploratory study was limited to findings from one inpatient rehabilitation hospital. Cross-validation of results using data-sets from multiple rehabilitation hospitals across Ontario is recommended.

Quality-Based Procedures for Knee Replacement, Hip Replacement, and Hip Fracture: Physiotherapists' Perceptions of Adherence, Barriers, and Facilitators.

Purpose: This mixed-methods study examined the perceived barriers to and facilitators of implementing best-practice guidelines (BPGs) and adhering to provincial Quality-Based Procedures (QBPs) by Ontario physiotherapists working with patients after total knee replacement (TKR), total hip replacement (THR), and hip fracture (HF). Method: Using snowball sampling, 93 hospital and home care physiotherapists working with patients after TKR, THR, or HF completed a Web-based survey. A subset of these participated in follow-up semi-structured telephone interviews. Results: The perception of QBP adherence varied, with self-reported adherence rates across identified practice standards for TKR, THR, and HF reported as 62%, 69%, and 60%, respectively. Physiotherapists generally believed that BPGs improved outcomes; however, they identified clinical experience as their primary guide to practice. Only 66% perceived that their institutions met provincial standards. Barriers to BPG implementation and QBP adherence included insufficient time, lack of access to QBPs, and limited awareness of current BPGs. Qualitative themes included awareness and knowledge, flexibility and funding, communication, and availability of and equitable access to outpatient and community-based physiotherapy services. Conclusions: Physiotherapists reported that they primarily used clinical experience to inform care after TKR, THR, and HF, but they were also supportive of BPGs and QBPs. The results suggest that increased access to and education about QBPs, as well as supportive resources, could increase their integration into clinical practice.

STANDARDIZATION AND MEASUREMENT OF CARDIAC SERVICES PERFORMANCE THROUGH THE DEVELOPMENT OF QUALITY-BASED PROCEDURES (QBPS)

s S51 vs. 67%, p1⁄40.02), and more CARDS than RES agreed that cost was an important factor in deciding whether to use an intervention (74% vs. 44%, p1⁄40.01). Both CARDS and RES agreed that physicians were primarily responsible for decreasing inappropriate services (93% vs. 89%, p1⁄40.6) and believed that patients would benefit from the implementation of the recommendations (89%, vs. 84%, p1⁄40.6). More RES than CARDS believed medical malpractice was a major barrier to reducing inappropriate testing (48% vs. 23%, p1⁄40.01). There was no difference between CARDS and RES in the belief that payment policies (43% vs. 39%, p1⁄40.3), referring physician expectations (62% vs. 47%, p1⁄40.2) or patient requests (43% vs. 40%, p1⁄40.9) were major barriers to reducing inappropriate tests. Both CARDS and RES believed it was their responsibility to promote cost conscious care in their patients (83% vs. 78%, p1⁄40.9). CONCLUSION: Despite a relative lack of awareness of the CWC recommendations, both CARDS and RES agreed that physicians are ultimately responsible for cost conscious care and that implementing the CWC recommendations would improve care in their patients. While both groups believe that cost is an important deciding factor on using interventions, CARDS were more aware of the actual costs of care than RES. 103 STANDARDIZATION AND MEASUREMENT OF CARDIAC SERVICES PERFORMANCE THROUGH THE DEVELOPMENT OF QUALITY-BASED PROCEDURES (QBPS) V Braga, L Li, A Pardhan, D Lian, A Leeksma, B Petersen, EA Cohen, HC Wijeysundera, A Forsey, KJ Kingsbury