929 S. Berkowitz (ed.), Cleft Lip and Palate, DOI 10.1007/978-3-642-30770-6_47, © Springer-Verlag Berlin Heidelberg 2013 47 47.1 Monitoring and Improving Outcomes Through Multicenter Collaboration 47.1.1 Obligations It goes without saying that professionals involved in health care have a continuing obligation to review the quality of care they provide. As stated in a WHO report (2002): Professionals entrusted with the provision of health care have an obligation to review the success of their practices and, where shortcomings are revealed, to take remedial action. Such efforts should constitute a continuous cycle, sometimes known as a ‘clinical audit’…… (which) is divided into evaluating the process of care (the way in which care is delivered) and the outcomes of care (what is achieved) …… Audit of the treatment of clefts is a considerable challenge, because of the lengthy follow-up required, the complexity, sub- tlety and number of relevant outcomes and, above all, the relatively small number of cases. Inter- center collaboration still offers significant advan- tages, by providing insight into the processes and outcomes of treatment of comparable services elsewhere, the establishment of future goals and the exchange of clearly successful practices. … Perhaps the greatest benefit of inter-center com- parisons is the cooperative spirit that they foster and a gradual diminution of rivalry. Planned recall of patients and collection of standardized clinical records at prescribed points in time, not only provide the data for internal audit of outcomes, but if done identically by a group of centers, will allow comparisons to be undertaken. 47.1.2 Measuring Outcome The ultimate goal of cleft care is restoration of the patient as far as possible to a life, unhindered by handicap or disability. However, the measure- ment of well-being is a highly complex proposi- tion, and there is certainly no index at present that would allow sufficiently sensitive comparison between alternative treatment protocols. Whether in internal audit, intercenter comparisons, or clin- ical trials, emphasis will typically be on “proxi- mate” outcomes. These will mainly represent different aspects of form and function in the parts affected by the cleft, often reflecting the particu- lar interest of individual provider groups. In essence, most measures will be an indication of the deficits that persist despite (or as a result of) treatment, such as variations in appearance, speech, hearing, and dentofacial development. For outcome measures to be deemed meaning- ful, they should reflect the needs and aspirations of patients and their families. They should be Eurocleft and Americleft Studies: Experiments in Intercenter and International Collaboration Ross E. Long Jr., William C. Shaw, and Gunvor Semb R.E. Long Jr., DMD, M.S., Ph.D. (*) Lancaster Cleft Palate Clinic, 223 N Lime Street, Lancaster, PA 17602, USA e-mail: rlong@supernet.com W.C. Shaw, BDS, Ph.D. • G. Semb, DDS, Ph.D. Department of Orthodontics, University of Manchester, School of Dentistry, Room G.009, Coupland III Building, Coupland Street, Manchester M13 9PL, UK e-mail: bill.shaw@manchester.ac.uk; gunvor.semb@manchester.ac.uk