Improving quality, minimizing error: Making it happen

Health Affairs

Volumn 20, Issue 3, 2001, Pages 68-81

  Becher, Elise C ^a   Chassin, Mark R ^b  

^a MOUNT SINAI SCHOOL OF MEDICINE   (United States)

^b Department of Health Policy ^*

Author keywords

[No Author keywords available]

Indexed keywords

ARTICLE; CROSS-SECTIONAL STUDY; HEALTH CARE DELIVERY; HEALTH CARE POLICY; HEALTH CARE QUALITY; HEALTH SERVICES RESEARCH; HUMAN; LEADERSHIP; MEDICAL EDUCATION; MEDICAL ERROR; METHODOLOGY; ORGANIZATION; SAFETY; STANDARD; UNITED STATES;

CROSS-SECTIONAL STUDIES; DELIVERY OF HEALTH CARE; EDUCATION, MEDICAL; HEALTH POLICY; HEALTH SERVICES RESEARCH; HUMANS; LEADERSHIP; MEDICAL ERRORS; ORGANIZATIONAL INNOVATION; QUALITY ASSURANCE, HEALTH CARE; SAFETY MANAGEMENT; UNITED STATES;

EID: 0035350644     PISSN: 02782715     EISSN: None     Source Type: Journal    
DOI: 10.1377/hlthaff.20.3.68     Document Type: Article

References (65)

1. Institute of Medicine,To Err Is Human:Building a Safer Health System (Washington: National Academy Press, 1999); R. Weiss, "Medical Errors Blamed for Many Deaths," Washington Post, 30 November 1999, A1; Editorial, "Preventing Fatal Errors," Boston Globe, 23 February 2000, A18; R. Knox and G. Staff, "Patient Safety Center Advances: Groups Divided on Defining Errors," Boston Globe, 10 May 2000, A1; J. Steinhauer, "Legislators Approve Web List Disclosing Missteps by Doctors," New York Times, 24 June 2000, A1; and M. Kaufman, "Clinton Seeks Medical Error Reports," Washington Post, 22 February 2000, A2.
2. Institute of Medicine,To Err Is Human:Building a Safer Health System (Washington: National Academy Press, 1999); R. Weiss, "Medical Errors Blamed for Many Deaths," Washington Post, 30 November 1999, A1; Editorial, "Preventing Fatal Errors," Boston Globe, 23 February 2000, A18; R. Knox and G. Staff, "Patient Safety Center Advances: Groups Divided on Defining Errors," Boston Globe, 10 May 2000, A1; J. Steinhauer, "Legislators Approve Web List Disclosing Missteps by Doctors," New York Times, 24 June 2000, A1; and M. Kaufman, "Clinton Seeks Medical Error Reports," Washington Post, 22 February 2000, A2.
3. Institute of Medicine,To Err Is Human:Building a Safer Health System (Washington: National Academy Press, 1999); R. Weiss, "Medical Errors Blamed for Many Deaths," Washington Post, 30 November 1999, A1; Editorial, "Preventing Fatal Errors," Boston Globe, 23 February 2000, A18; R. Knox and G. Staff, "Patient Safety Center Advances: Groups Divided on Defining Errors," Boston Globe, 10 May 2000, A1; J. Steinhauer, "Legislators Approve Web List Disclosing Missteps by Doctors," New York Times, 24 June 2000, A1; and M. Kaufman, "Clinton Seeks Medical Error Reports," Washington Post, 22 February 2000, A2.
4. Institute of Medicine,To Err Is Human:Building a Safer Health System (Washington: National Academy Press, 1999); R. Weiss, "Medical Errors Blamed for Many Deaths," Washington Post, 30 November 1999, A1; Editorial, "Preventing Fatal Errors," Boston Globe, 23 February 2000, A18; R. Knox and G. Staff, "Patient Safety Center Advances: Groups Divided on Defining Errors," Boston Globe, 10 May 2000, A1; J. Steinhauer, "Legislators Approve Web List Disclosing Missteps by Doctors," New York Times, 24 June 2000, A1; and M. Kaufman, "Clinton Seeks Medical Error Reports," Washington Post, 22 February 2000, A2.
5. Institute of Medicine,To Err Is Human:Building a Safer Health System (Washington: National Academy Press, 1999); R. Weiss, "Medical Errors Blamed for Many Deaths," Washington Post, 30 November 1999, A1; Editorial, "Preventing Fatal Errors," Boston Globe, 23 February 2000, A18; R. Knox and G. Staff, "Patient Safety Center Advances: Groups Divided on Defining Errors," Boston Globe, 10 May 2000, A1; J. Steinhauer, "Legislators Approve Web List Disclosing Missteps by Doctors," New York Times, 24 June 2000, A1; and M. Kaufman, "Clinton Seeks Medical Error Reports," Washington Post, 22 February 2000, A2.
6. Institute of Medicine,To Err Is Human:Building a Safer Health System (Washington: National Academy Press, 1999); R. Weiss, "Medical Errors Blamed for Many Deaths," Washington Post, 30 November 1999, A1; Editorial, "Preventing Fatal Errors," Boston Globe, 23 February 2000, A18; R. Knox and G. Staff, "Patient Safety Center Advances: Groups Divided on Defining Errors," Boston Globe, 10 May 2000, A1; J. Steinhauer, "Legislators Approve Web List Disclosing Missteps by Doctors," New York Times, 24 June 2000, A1; and M. Kaufman, "Clinton Seeks Medical Error Reports," Washington Post, 22 February 2000, A2.
7. L. Altman, "The Doctor's World; Getting to the Core of Mistakes in Medicine," Nav York Times, 29 February 2000, F1.
8. IOM, To Err Is Human; and J. Reason, Human Error (Cambridge: Cambridge University Press, 1990).
9. IOM, To Err Is Human; and J. Reason, Human Error (Cambridge: Cambridge University Press, 1990).
10. Reason, Human Error.
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14. K. Lohr, ed., Medicare: A Strategy for Quality Assurance (Washington: National Academy Press, 1990).
15. M. Chassin, "Quality of Care: Time to Act," Journal of the American Medical Association 266, no. 24 (1991): 3472-3473.
16. L. Leape et al., "Systems Analysis of Adverse Drug Events," Journal of the American Medical Association 274, no. 1 (1995): 35-43.
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19. Advisory Commission on Health Consumer Protection and Quality in the Health Care Industry, Quality First: Better Health Care for All Americans (Washington: U.S. Government Printing Office, 1998); M. Schuster, E. McGlynn, and R. Brook, "How Good Is the Quality of Health Care in the United States?" Milbank Quarterly 76, no. 4 (1998): 517-563; and M. Chassin and R. Galvin, "The Urgent Need to Improve Health Care Quality," Journal of the American Medical Association 280, no. 11 (1998): 1000-1005.
20. Advisory Commission on Health Consumer Protection and Quality in the Health Care Industry, Quality First: Better Health Care for All Americans (Washington: U.S. Government Printing Office, 1998); M. Schuster, E. McGlynn, and R. Brook, "How Good Is the Quality of Health Care in the United States?" Milbank Quarterly 76, no. 4 (1998): 517-563; and M. Chassin and R. Galvin, "The Urgent Need to Improve Health Care Quality," Journal of the American Medical Association 280, no. 11 (1998): 1000-1005.
21. See, for example, R. Gonzales, J. Steiner, and M. Sande, "Antibiotic Prescribing for Adults with Colds, Upper Respiratory Tract Infections, and Bronchitis by Ambulatory Care Physicians," Journal of the American Medical Association 278, no. 11 (1997): 901-904; A.C. Nyquist et al., "Antibiotic Prescribing for Children with Colds, Upper Respiratory Tract Infections, and Bronchitis," Journal of the American Medical Association 279, no. 11 (1998): 875-877; S.J. Bernstein et al., "The Appropriateness of Hysterectomy," Journal of the Amcrican Medical Association 269, no. 18 (1993): 2398-2402; and L.C. Kleinman, et al., "The Medical Appropriateness of Tympanostomy Tubes Proposed for Children Younger than 16 Years in the United States," Journal of the American Medical Association 271, no. 16 (1994): 1250-1255.
22. See, for example, R. Gonzales, J. Steiner, and M. Sande, "Antibiotic Prescribing for Adults with Colds, Upper Respiratory Tract Infections, and Bronchitis by Ambulatory Care Physicians," Journal of the American Medical Association 278, no. 11 (1997): 901-904; A.C. Nyquist et al., "Antibiotic Prescribing for Children with Colds, Upper Respiratory Tract Infections, and Bronchitis," Journal of the American Medical Association 279, no. 11 (1998): 875-877; S.J. Bernstein et al., "The Appropriateness of Hysterectomy," Journal of the Amcrican Medical Association 269, no. 18 (1993): 2398-2402; and L.C. Kleinman, et al., "The Medical Appropriateness of Tympanostomy Tubes Proposed for Children Younger than 16 Years in the United States," Journal of the American Medical Association 271, no. 16 (1994): 1250-1255.
23. See, for example, R. Gonzales, J. Steiner, and M. Sande, "Antibiotic Prescribing for Adults with Colds, Upper Respiratory Tract Infections, and Bronchitis by Ambulatory Care Physicians," Journal of the American Medical Association 278, no. 11 (1997): 901-904; A.C. Nyquist et al., "Antibiotic Prescribing for Children with Colds, Upper Respiratory Tract Infections, and Bronchitis," Journal of the American Medical Association 279, no. 11 (1998): 875-877; S.J. Bernstein et al., "The Appropriateness of Hysterectomy," Journal of the Amcrican Medical Association 269, no. 18 (1993): 2398-2402; and L.C. Kleinman, et al., "The Medical Appropriateness of Tympanostomy Tubes Proposed for Children Younger than 16 Years in the United States," Journal of the American Medical Association 271, no. 16 (1994): 1250-1255.
24. See, for example, R. Gonzales, J. Steiner, and M. Sande, "Antibiotic Prescribing for Adults with Colds, Upper Respiratory Tract Infections, and Bronchitis by Ambulatory Care Physicians," Journal of the American Medical Association 278, no. 11 (1997): 901-904; A.C. Nyquist et al., "Antibiotic Prescribing for Children with Colds, Upper Respiratory Tract Infections, and Bronchitis," Journal of the American Medical Association 279, no. 11 (1998): 875-877; S.J. Bernstein et al., "The Appropriateness of Hysterectomy," Journal of the Amcrican Medical Association 269, no. 18 (1993): 2398-2402; and L.C. Kleinman, et al., "The Medical Appropriateness of Tympanostomy Tubes Proposed for Children Younger than 16 Years in the United States," Journal of the American Medical Association 271, no. 16 (1994): 1250-1255.
25. S.F. Jencks et al., "Quality of Medical Care Delivered to Medicare Beneficiaries: A Profile at State and National Levels," Journal of the American Medical Association 284, no. 13 (2000): 1670-1676.
26. D. Bates et al., "Incidence of Adverse Drug Events and Potential Adverse Drug Events," Journal of the American Medical Association 274, no. 1 (1995): 29-34.
27. J. Steinhauer, "Death in Surgery Reveals Troubled Practice and Lax Hospital," New York Times, 15 November 1998, A37; and J. Steinhauer, "Doctors' Licenses Suspended over Faulty Mammograms," New York Times, 1 June 2000, B1.
28. J. Steinhauer, "Death in Surgery Reveals Troubled Practice and Lax Hospital," New York Times, 15 November 1998, A37; and J. Steinhauer, "Doctors' Licenses Suspended over Faulty Mammograms," New York Times, 1 June 2000, B1.
29. Chassin et al., "The Urgent Need to Improve Health Care Quality"; S. Shortell, C. Bennett, and G. Byck, "Assessing the Impact of Continuous Quality Improvement on Clinical Practice," Milbank Quarterly 76, no. 4 (1998): 593-624; and D. Blumenthal and C. Kilo, "A Report Card on Continuous Quality Improvement," Milbank Quarterly 76, no. 4 (1998): 625-648.
30. Chassin et al., "The Urgent Need to Improve Health Care Quality"; S. Shortell, C. Bennett, and G. Byck, "Assessing the Impact of Continuous Quality Improvement on Clinical Practice," Milbank Quarterly 76, no. 4 (1998): 593-624; and D. Blumenthal and C. Kilo, "A Report Card on Continuous Quality Improvement," Milbank Quarterly 76, no. 4 (1998): 625-648.
31. Chassin et al., "The Urgent Need to Improve Health Care Quality"; S. Shortell, C. Bennett, and G. Byck, "Assessing the Impact of Continuous Quality Improvement on Clinical Practice," Milbank Quarterly 76, no. 4 (1998): 593-624; and D. Blumenthal and C. Kilo, "A Report Card on Continuous Quality Improvement," Milbank Quarterly 76, no. 4 (1998): 625-648.
32. See, for example, F. Orkin, "Patient Monitoring during Anesthesia as an Exercise in Technology Assessment," in Monitoring in Anesthesia, ed. L. Saidman and N. Smith (London: Butterworth-Heineman, 1993); E. Peterson et al., "The Effects of New York's Bypass Surgery Provider Profiling on Access to Care and Patient Outcomes in the Elderly," Journal of the American College of Cardiology 32, no. 4 (1998): 993-999; E. Hannan et al., "Improving the Outcomes of Coronary Artery Bypass Surgery in New York State," Journal of the American Medical Association 271, no. 10 (1994): 761-766; V. Ho, "Evolution of the Volume-Outcome Relation for Hospitals Performing Coronary Angioplasty," Circulation 101, no. 15 (2000): 1806-1811; and R. Gonzales et al., "Decreasing Antibiotic Use in Ambulatory Practice," Journal of the American Medical Association 281, no. 16 (1999): 1512-1519.
33. See, for example, F. Orkin, "Patient Monitoring during Anesthesia as an Exercise in Technology Assessment," in Monitoring in Anesthesia, ed. L. Saidman and N. Smith (London: Butterworth-Heineman, 1993); E. Peterson et al., "The Effects of New York's Bypass Surgery Provider Profiling on Access to Care and Patient Outcomes in the Elderly," Journal of the American College of Cardiology 32, no. 4 (1998): 993-999; E. Hannan et al., "Improving the Outcomes of Coronary Artery Bypass Surgery in New York State," Journal of the American Medical Association 271, no. 10 (1994): 761-766; V. Ho, "Evolution of the Volume-Outcome Relation for Hospitals Performing Coronary Angioplasty," Circulation 101, no. 15 (2000): 1806-1811; and R. Gonzales et al., "Decreasing Antibiotic Use in Ambulatory Practice," Journal of the American Medical Association 281, no. 16 (1999): 1512-1519.
34. See, for example, F. Orkin, "Patient Monitoring during Anesthesia as an Exercise in Technology Assessment," in Monitoring in Anesthesia, ed. L. Saidman and N. Smith (London: Butterworth-Heineman, 1993); E. Peterson et al., "The Effects of New York's Bypass Surgery Provider Profiling on Access to Care and Patient Outcomes in the Elderly," Journal of the American College of Cardiology 32, no. 4 (1998): 993-999; E. Hannan et al., "Improving the Outcomes of Coronary Artery Bypass Surgery in New York State," Journal of the American Medical Association 271, no. 10 (1994): 761-766; V. Ho, "Evolution of the Volume-Outcome Relation for Hospitals Performing Coronary Angioplasty," Circulation 101, no. 15 (2000): 1806-1811; and R. Gonzales et al., "Decreasing Antibiotic Use in Ambulatory Practice," Journal of the American Medical Association 281, no. 16 (1999): 1512-1519.
35. See, for example, F. Orkin, "Patient Monitoring during Anesthesia as an Exercise in Technology Assessment," in Monitoring in Anesthesia, ed. L. Saidman and N. Smith (London: Butterworth-Heineman, 1993); E. Peterson et al., "The Effects of New York's Bypass Surgery Provider Profiling on Access to Care and Patient Outcomes in the Elderly," Journal of the American College of Cardiology 32, no. 4 (1998): 993-999; E. Hannan et al., "Improving the Outcomes of Coronary Artery Bypass Surgery in New York State," Journal of the American Medical Association 271, no. 10 (1994): 761-766; V. Ho, "Evolution of the Volume-Outcome Relation for Hospitals Performing Coronary Angioplasty," Circulation 101, no. 15 (2000): 1806-1811; and R. Gonzales et al., "Decreasing Antibiotic Use in Ambulatory Practice," Journal of the American Medical Association 281, no. 16 (1999): 1512-1519.
36. See, for example, F. Orkin, "Patient Monitoring during Anesthesia as an Exercise in Technology Assessment," in Monitoring in Anesthesia, ed. L. Saidman and N. Smith (London: Butterworth-Heineman, 1993); E. Peterson et al., "The Effects of New York's Bypass Surgery Provider Profiling on Access to Care and Patient Outcomes in the Elderly," Journal of the American College of Cardiology 32, no. 4 (1998): 993-999; E. Hannan et al., "Improving the Outcomes of Coronary Artery Bypass Surgery in New York State," Journal of the American Medical Association 271, no. 10 (1994): 761-766; V. Ho, "Evolution of the Volume-Outcome Relation for Hospitals Performing Coronary Angioplasty," Circulation 101, no. 15 (2000): 1806-1811; and R. Gonzales et al., "Decreasing Antibiotic Use in Ambulatory Practice," Journal of the American Medical Association 281, no. 16 (1999): 1512-1519.
37. S. Pestotnik et al., "Implementing Antibiotic Practice Guidelines through Computer-Assisted Decision Support," Annals of Internal Medicine 124, no. 10 (1996): 884-890; and D. Bates et al., "Effect of Computerized Physician Order Entry and a Team Intervention on Prevention of Serious Medication Errors," Journal of the American Medical Association 280, no. 15 (1998): 1311-1316.
38. S. Pestotnik et al., "Implementing Antibiotic Practice Guidelines through Computer-Assisted Decision Support," Annals of Internal Medicine 124, no. 10 (1996): 884-890; and D. Bates et al., "Effect of Computerized Physician Order Entry and a Team Intervention on Prevention of Serious Medication Errors," Journal of the American Medical Association 280, no. 15 (1998): 1311-1316.
39. M. Chassin, "Is Health Care Ready for Six Sigma Quality?" Milbank Quarterly 76, no. 4 (1998): 565-591.
40. N. Bickell, A. Aufses, and M. Chassin, "The Quality of Early-Stage Breast Cancer Care," Annals of Surgery 232, no. 2 (2000): 220-224.
41. T. Lesar, L. Briceland, and D. Stein, "Factors Related to Errors in Medication Prescribing," Journal of the American Medical Association 277, no. 4 (1997): 312-317; and T. Lesar et al., "Medication Prescribing Errors in a Teaching Hospital," Journal of the American Medical Association 263, no. 17 (1990): 2329-2334.
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43. Chassin, "Is Health Care Ready for Six Sigma Quality?"
44. Leape, "Error in Medicine."
45. J. Hicks, "A Revamping at Alcoa as Pressures Mount," New York Times, 10 August 1991, A33; C. Deutsch, "Six Sigma Enlightenment," New York Times, 7 December 1998, C1; and Chassin, "Is Health Care Ready for Six Sigma Quality?"
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50. M. Chassin, "Assessing Strategies for Quality Improvement," Health Affairs (May/June 1997): 151-161.
51. R. Helmreich, "Managing Human Error in Aviation," Scientific American (May 1997): 62-67.
52. R. Helmreich et al., "Preliminary Results from the Evaluation of Cockpit Resource Management Training," Aviation, Space, and Environmental Medicine 61, no. 6 (1990): 576-579; and R. Helmreich, "On Error Management: Lessons from Aviation," British Medical Journal 320, no. 7237 (2000): 781-785.
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54. Chassin et al., "The Urgent Need to Improve Health Care Quality."
55. J. Hibbard and J. Jewett, "What Type of Quality Information Do Consumers Want in a Health Care Report Card?" Medical Care Research and Review 53, no. 1, (1996): 28-47; J. Hibbard and J. Jewett, "Will Quality Report Cards Help Consumers?" Health Affairs (May/June 1997): 218-228; and S. Robinson and M. Brodie, "Understanding the Quality Challenge for Health Consumers: The Kaiser/AHCPR Survey," Joint Commission Journal of Quality Improvement 23, no. 5 (1997): 239-244.
56. J. Hibbard and J. Jewett, "What Type of Quality Information Do Consumers Want in a Health Care Report Card?" Medical Care Research and Review 53, no. 1, (1996): 28-47; J. Hibbard and J. Jewett, "Will Quality Report Cards Help Consumers?" Health Affairs (May/June 1997): 218-228; and S. Robinson and M. Brodie, "Understanding the Quality Challenge for Health Consumers: The Kaiser/AHCPR Survey," Joint Commission Journal of Quality Improvement 23, no. 5 (1997): 239-244.
57. J. Hibbard and J. Jewett, "What Type of Quality Information Do Consumers Want in a Health Care Report Card?" Medical Care Research and Review 53, no. 1, (1996): 28-47; J. Hibbard and J. Jewett, "Will Quality Report Cards Help Consumers?" Health Affairs (May/June 1997): 218-228; and S. Robinson and M. Brodie, "Understanding the Quality Challenge for Health Consumers: The Kaiser/AHCPR Survey," Joint Commission Journal of Quality Improvement 23, no. 5 (1997): 239-244.
58. A. Milstein et al., "Improving the Safety of Health Care: The Leapfrog Group," Effective Clinical Practice 3, no. 6 (2000): 313-316.
59. M. Chassin, E. Hannan, and B. DeBuono, "Benefits and Hazards of Reporting Medical Outcomes Publicly," New England Journal of Medicine 334, no. 6 (1996): 394-398; J. Hibbard et al., "Choosing a Health Plan: Do Large Employers Use the Data?" Health Affairs (Nov/Dec 1997): 172-180; M. Marshall et al., "The Public Release of Performance Data: What Do We Expect to Gain?" Journal of the American Medical Association 283, no. 14 (2000): 1866-1874; and L. Erickson et al., "The Relationship between Managed Care Insurance and Use of Lower-Mortality Hospitals for CABG Surgery," Journal of the American Medical Association 283, no. 15 (2000): 1976-1982.
60. M. Chassin, E. Hannan, and B. DeBuono, "Benefits and Hazards of Reporting Medical Outcomes Publicly," New England Journal of Medicine 334, no. 6 (1996): 394-398; J. Hibbard et al., "Choosing a Health Plan: Do Large Employers Use the Data?" Health Affairs (Nov/Dec 1997): 172-180; M. Marshall et al., "The Public Release of Performance Data: What Do We Expect to Gain?" Journal of the American Medical Association 283, no. 14 (2000): 1866-1874; and L. Erickson et al., "The Relationship between Managed Care Insurance and Use of Lower-Mortality Hospitals for CABG Surgery," Journal of the American Medical Association 283, no. 15 (2000): 1976-1982.
61. M. Chassin, E. Hannan, and B. DeBuono, "Benefits and Hazards of Reporting Medical Outcomes Publicly," New England Journal of Medicine 334, no. 6 (1996): 394-398; J. Hibbard et al., "Choosing a Health Plan: Do Large Employers Use the Data?" Health Affairs (Nov/Dec 1997): 172-180; M. Marshall et al., "The Public Release of Performance Data: What Do We Expect to Gain?" Journal of the American Medical Association 283, no. 14 (2000): 1866-1874; and L. Erickson et al., "The Relationship between Managed Care Insurance and Use of Lower-Mortality Hospitals for CABG Surgery," Journal of the American Medical Association 283, no. 15 (2000): 1976-1982.
62. M. Chassin, E. Hannan, and B. DeBuono, "Benefits and Hazards of Reporting Medical Outcomes Publicly," New England Journal of Medicine 334, no. 6 (1996): 394-398; J. Hibbard et al., "Choosing a Health Plan: Do Large Employers Use the Data?" Health Affairs (Nov/Dec 1997): 172-180; M. Marshall et al., "The Public Release of Performance Data: What Do We Expect to Gain?" Journal of the American Medical Association 283, no. 14 (2000): 1866-1874; and L. Erickson et al., "The Relationship between Managed Care Insurance and Use of Lower-Mortality Hospitals for CABG Surgery," Journal of the American Medical Association 283, no. 15 (2000): 1976-1982.
63. Hannan et al., "Improving the Outcomes of Coronary Artery Bypass Surgery"; and Chassin et al., "Benefits and Hazards of Reporting Medical Outcomes Publicly."
64. Hannan et al., "Improving the Outcomes of Coronary Artery Bypass Surgery"; and Chassin et al., "Benefits and Hazards of Reporting Medical Outcomes Publicly."
65. Peterson et al., "The Effects of New York's Bypass Surgery Provider Profiling."