The overall objective of this project is to develop a concurrent (real-time) quality appraisal system for an emergency service (ES) which will lead to improvement in the quality of medical care. Our research to date has been directed at: 1) establishment of explicit criteria for evaluating the process and outcome of patient care, 2) identification of cost-valid methods of data acquisition; 3) design of a practical model for evaluating ES provider performance; 4) developement of a methodology for evaluating the interpersonal component of patient care; 5) analysis of ES patient mix as a basis for rational selection of additional tracer conditions, and 6) development of screening devices for cases not expected to be covered by a condition-specific algorithm. The first four issues have been investigated within the context of one specific clinical condition (lacerations). The renewal proposal seeks to expand on work completed by 1) enlarging the number of tracer conditions; 2) implementing a computer-based patient care monitoring system which includes continuous educational feedback to providers to improve compliance with standards; 3) measuring the impact of the feedback system on provider behavior, patient outcome, and cost of medical care, 4) refining and testing a method to measure and improve patient understanding of physician instructions (as an example of how to incorporate the interpersonal component of medical care into a quality assurance system), 5) further developing the concepts of proximate and intermediate outcomes and "healing" curves, and testing assumed relationships between various algorithm-specified care processes and subsequent outcomes, 6) defining the ES operational constraints which impact on patient care quality, and 7) testing the exportability of the case audit system in another ES.