OBJECTIVE: To improve pacing mode selection and to reduce complications of pacing using continuous quality improvement. DESIGN: Criterion standard study. Comparison of implantations from 1992-94 with preset standards. Implementation of corrections in 1994 and re-evaluation in 1995, with one year follow up of all patients. SETTING: Tertiary hospital. PATIENTS: Consecutive patients implanted with a pacemaker from January 1992 to October 1993, 361 patients; October 1993 to June 1994, 115 patients; and January 1995 to October 1995, 140 patients. MAIN OUTCOME MEASURES: Reasons for not choosing physiological pacing and complications of pacemaker implantation. RESULTS: Most frequent reasons for not selecting physiological pacing for patients in sinus node disease were age (12.8%, 5 of 39) and technical problems (12.8%, 5 of 39); and for patients in atrioventricular block, age (31.4%, 16 of 51), and disability due to other diseases (13.7%, 7 of 51). To improve the standards, age as a sole reason for not selecting physiological pacing was disregarded and VDD pacing was introduced. Follow up showed fulfillment of standards. Cost analysis indicated minimally increased expenses of pacing hardware and no additional costs of procedures. A high rate of complications (16.2%, 77 of 476) was found related to atrial lead displacement (10.2%, 19 of 186), and to subclavian puncture from January 92-June 94. To reduce complications use of atrial screw-in leads and cephalic cut down were encouraged. Follow up showed significant reduction of complications from January 92-June 94 (77 of 476) compared with January 95-October 95 (12 of 140) (P = 0.03). CONCLUSIONS: Better compliance with international pacing guidelines was obtained by registration of reasons for deviations followed by corrections of procedures. By using screw-in leads and by using cephalic cut down the set standards were met.