They are more readily under the control of clinicians than are structural or outcome measures and also are actionable targets for quality improvement. Performance measures of processes are most useful when 1) they are directly linked to improved clinical out- comes through robust evidence, and 2) true gaps in care exist. Expending resources to measure processes that are already con- ducted at uniformly high rates is not justified, particularly when burdensome chart abstraction is required. An acknowledged limitation of process measures is that they might not always indicate how well the process was done. For example, measure 4 (use of embolic protection devices in the treatment of saphe- nous vein bypass graft disease) measures use of the embolic protection device during PCI but does not capture the techni- cal skill with which it was deployed. We considered including measures assessing technical care processes performed in the cardiac catheterization laboratory but did not include any such measures because of the lack of feasible, nonsubjective mea- surement criteria. This should be an area of future investigation. Two areas in which the writing committee tried to advance process measures were in patient selection measures and patient education/shared decision-making measures. Given the novelty of these topics, these are discussed in greater detail in the subsequent sections. 4.1.1. Patient Selection Measures As with many procedures, evaluating patient selection and determining appropriateness is a crucial first step in ensuring high-quality clinical care. Nevertheless, this has not been done previously in performance measures for procedures. 