Thank you for the opportunity to review this paper. The authors have performed a systematic review aimed at describing approaches utilised in the integrated development of clinical guidelines and quality indicators and to assess the effects of such approaches on common development considerations such as feasibility, time requirements, acceptability, etc. Whilst the authors identified numerous studies which used an integrated guidelines and quality indicator development process, there appears to be paucity in rigorous frameworks to ensure quality in this process itself.

I commend the authors for updating an existing systematic review on an important topic. The efficient and evidence-informed development of quality indicators is critical in modern healthcare. The review provides insight into current literature on this topic and is thought-provoking and informative to readers, especially those involved in performance/quality measurement.

The aim is clearly stated at the end of the abstract background. The abstract methods and results provide a concise synopsis of how the review was performed and its results. The title is informative and relevant. References are generally relevant, recent and in correct format. Key studies seem to have been included. The results are well described and comprehensive. The discussion is concise. I have a few comments on the background and methods section below.

Major points in the article which needs clarification, refinement, reanalysis, rewrites and/or additional information and suggestions for what could be done to improve the article:

The background section does not demonstrate thorough understanding of quality management terminology which, in a paper discussing the systematic review of quality indicator development, would be expected by the reader. For example, the first sentence states that guidelines and quality assurance (QA) schemes both aim to improve health care delivery and health outcomes. Quality assurance, however, is different to quality improvement, i.e. quality assurance aims to assure quality, not improve it. This subtle yet critical differentiation is made even in the reference used to support the sentence. I’m not trying to nit-pick, however, in a filed plagues by a lack of shared understanding of subject-specific vocabulary (such as improvement science) authors should demonstrate knowledge of and command over pertinent terminology.

Whilst undoubtably there are benefits in applying an integrated approach to concurrent guideline and quality indicator development, I think this needs to be examined and argued more carefully in the background section. If guidelines are produced by synthesising best available evidence, it stands to reason that quality indicators should be developed in the same way. If quality indicators are developed from guidelines, their validity is subject to the quality of the guidelines. Furthermore, guidelines are systematically developed statements to assist practitioner and patient decisions prospectively for specific clinical circumstances; in essence the “right thing to do” (Campbell, et al. 2002). It follows that if quality indicators are developed from guidelines, they would be process-type indicators. How are structural and outcome indicators developed? I acknowledge that this is touched on paragraph 3 of the introduction, however, I feel it required a little more in-depth background for the reader.

Minor points like figures/tables not being mentioned in the text, a missing reference, typos, and other inconsistencies:

• There are some in-text references which seem to be in a draft format, i.e. the reference is stated informally and not in proper Vancouver style (e.g. Introduction, fourth paragraph, last sentence) • The methods are generally well described. The exclusion criterion (studies that did not describe the extraction of recommendations from clinical guidelines in detail) would benefit from further description, i.e. how was “in detail” defined and how was consistent application of this between the two reviewers in the study selection process ensured?