(Class I; Level of Evidence: C)805 Advising patients on the need for complete smoking cessation. (Class I; Level of Evidence: A)805,820 823 7. Quality and Performance Considerations 7.1. Quality and Performance: Recommendations Class I 1. Every PCI program should operate a quality- improvement program that routinely 1) reviews Presence of established cardiovascular disease plus 1) multiple major risk factors (especially diabetes), 2) severe and poorly controlled risk factors (especially continued cigarette smoking), 3) multiple risk factors of the metabolic syndrome (especially high triglycerides 200 mg/dL plus non high-density lipoprotein cholesterol 130 mg/dL with low high-density lipoprotein cholesterol [ 40 mg/dL]), and 4) acute coronary syndromes. quality and outcomes of the entire program; 2) reviews results of individual operators; 3) includes risk adjustment; 4) provides peer review of difficult or complicated cases; and 5) performs random case reviews. (Level of Evidence: C) 2. Every PCI program should participate in a regional or national PCI registry for the purpose of bench- marking its outcomes against current national norms. (Level of Evidence: C) PCI quality and performance considerations are defined by attributes related to structure, processes, and risk-adjusted outcomes. Structural attributes include elements such as equipment, supplies, staffing, institutional and operator-level volumes, and the availability of electronic medical records. Processes include strategies for the appropriate patient, pro- tocols for pre- and postprocedural care, appropriate proce- dural execution and management of complications, and par- ticipation in databases and registries for benchmarking performance of the program and individual operator. Risk- adjusted outcomes are the end result of these structures and processes of care, and when available are more reliable measures of quality than the institutional and individual operator volumes discussed in Section 7.4. PCI process and outcomes assessments can be used for internal quality-improvement efforts and public reporting. 