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Quantitative and qualitative evaluations of the 10 retained QIs were performed by 84 independent physicians and
by 8 ovarian cancer patients between july 6, 2015 and August 31, 2015 evaluation #3. The list of international
reviewers is available in Appendix 1.2.

3.7 Integration of international reviewers and finalization of the QIs

Responses were pooled and sent to experts who convened during the second one-day meeting September 4,
2015. The international development group discussed all comments evaluation #4. Final decision on definition
of QIs, specifications, targets, and scoring system has been made by the international development group during
the third one-day meeting January 25, 2016.

Each retained QI has a description which specifies what the indicator is measuring. The measurability
specifications are then detailed. The latter highlight how the indicator will actually be measured in practice to
allow audits. In this regard, the timeframe for assessment of criteria is the last calendar year. Further to
measurement of the indicator, a target is indicated. This dictates the level which each unit/center should be
aiming to achieve against each indicator. When appropriate, two or three targets were defined: an optimal target,
expressing the best possible option for patients, a minimal target, expressing the minimal requirement when
practical feasibility factors are taken into account, and intermediate target if necessary. Targets were based on
evidence whenever available, on the personal experience or database of development group members, on expert
consensus, and on feedback from the physicians external reviewers.

Each retained QI is categorized as structural indicators, process indicators, and outcome indicators as defined1
below :

 “Structure” refers to health system characteristics that affect the system’s ability to meet the health care

needs of individual patients or a community. Structural indicators describe the type and amount of resources
used by a health system or organization to deliver programs and services, and they relate to the presence or
number of staff, clients, money, beds, supplies, and buildings. The assessment of structure is a judgment on
whether care is being provided under conditions that are either conductive or inimical to the provision of
good care;

 Process indicators assess what the provider did for the patient and how well it was done. Processes are a

series of inter-related activities undertaken to achieve objectives. Process indicators measure the activities
and tasks in patient episodes of care. Some authors include the patient’s activities in seeking care and
carrying it out in their definition of the health care process. Others limit this term to care that health care
providers are giving. It may be argued that providers are not accountable for the patient’s activities and
these, therefore, do not constitute part of the quality of care, but rather fall into the realm of patient
characteristics and behavior that influence patients’ health outcomes;

 Outcomes are states of health or events that follow care, and that may be affected by health care. An ideal
outcome indicator would capture the effect of care processes on the health and wellbeing of patients and
populations. Outcomes can be expressed as ‘The five Ds’: i death: a bad outcome if untimely; ii) disease:
symptoms, physical signs, and laboratory abnormalities; iii) discomfort: symptoms such as pain, nausea, or
dyspnea; iv disability: impaired ability connected to usual activities at home, work, or in recreation; and
v dissatisfaction: emotional reactio ns to disease and its care, such as sadness and anger. Intermediate
outcome indicators reflect changes in biological status that affect subsequent health outcomes. Some
outcomes can only be assessed after years e.g. 5 -year cancer survival). It is therefore important to assess
intermediate outcome indicators. They should be evidence-based and reflect the final outcome. The final
outcome criterion, such as cancer survival, which can be assessed only long after the completion of surgery,
may have to be replaced by a surrogate outcome that can be assessed in a timely fashion. The surrogate
indicator must be predictive of the final outcome.

1Mainz, J. Defining and classifying clinical indicators for quality improvement. Int J Qual Health Care15, 523-530 2003).

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