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Keywords: Quality, EMR.
Citation: deBronkart D. Who gets to define quality? J Participat Med. 2011 Mar 14; 3:e13.
Published: March 14, 2011.
Competing Interests: The author has declared that no competing interests exist.

The Problem

After three years of looking at US health care, trying to figure out why it refuses to improve, I have a humble but impatient suggestion: When we talk about quality, we should only include measures that patients agree define quality. Talk about other metrics, but don’t call them quality, and don’t think that adjusting them is improving quality.

Why? Because we have a big, intractable safety problem in American health care — thousands of accidental killings a month — so improving quality is urgent; and because other industries have shown that successful process improvement starts with defining quality as “what the customer finds valuable.” In health care we don’t do that — we think customers (patients) don’t know enough. And I suspect that’s a root cause of why quality doesn’t improve.

The Urgency

Most readers will know that in November two disturbing, depressing studies were released, showing little or no progress in the more than 10 years of effort since the publication of “To Err Is Human”:[1]

  • The New England Journal of Medicine reported on North Carolina’s four years of trying to improve safety, and “found that harms remain common, with little evidence of widespread improvement.[2]”
  • The HHS Inspector General looked at a month of Medicare data and projected that we have 15,000 accidental deaths per month (500/day) and 134,000 cases of non-trivial harm (over 4000/day). And that’s only among Medicare patients — people over 65.[3]

Is It Sane to Let Customers Define Quality in a Complex Profession?

It was true in the auto industry and it’s true in medicine: When highly trained, technically skilled people are told something new is more important than their opinions, egos can get in the way; who wants to give up being the most valuable opinion? Years ago Detroit’s best experts told Congress it wasn’t possible to build a safer, more efficient car: “We know what we’re talking about; this is our industry!” But Japan listened to consumers and did it anyway.

Changing the “quality compass” in no way diminishes the value of those skilled services. Our voyage can’t succeed without those skills – but they’re the ship’s engine, not its compass.

Mark Graban, author of Lean Hospitals, cites this example from Wisconsin health system ThedaCare, which implemented “lean thinking”: “When working on lean in the birthing suites, the staff and leaders thought it was about efficiency for staff. The mothers on the team said ‘hey, when you’re running in and out of the room constantly, it’s not a calm peaceful environment.’ So there was a far softer edge to the need to make sure the rooms were properly stocked and supplied. It wasn’t just about ‘avoid walking back and forth’ it became more about ‘create the right environment for the mother and baby.'”[4]

That is customer centered/patient centered care … it’s not just the biological outcome but whether we feel well taken care of.

Let Us Scrutinize Every Definition of Quality

January’s Archives of Internal Medicine included a retrospective analysis of EMR data and found “no consistent association between EHRs and [clinical decision support systems] and better quality. These results raise concerns about the ability of health information technology to fundamentally alter outpatient care quality.[5]” This article brought quality definitions to a head in a new way, which we discussed on

What do they mean by care quality? To me, as a patient, it’s how well they took care of me and how well I “got better”. But this study only examined whether the doctors prescribed the right thing. I assert that as long as medicine defines quality as “not prescribing the wrong thing,” all our discussions about how to improve quality will be far from improving what patients want.

Yet reporters echoed the conclusions, from health IT vehicles such as FierceEMR (“EHRs and the Quality Conundrum”[6]) to the mass media, such as CNN’s Sanjay Gupta’s “Electronic Health Records No Cure-All.”[7] All gave the impression that if the goal of the stimulus bill was to improve the care people get, EMRs won’t do it.

(As a side note, other observers more knowledgeable than I have detailed numerous design problems with the study — not the least of which is a commentary appearing in the issue expressing suspicion that the EMRs in the study were not fully functioning, nor even covering the guidelines that the study targeted! Those posts are summarized in the post. How can an article with such major concerns get through peer review and be approved by editors, especially with that commentary alongside?)

Let us all, patients, clinicians, policy makers, and insurance companies look carefully when anyone cites quality statistics, and find out what they measured. And henceforth, let’s start by asking customers. Because if we don’t, I don’t see any reason to expect that safety and care in hospitals will be any better when your time comes to be treated.


When originally published, this article incorrectly stated that “The HHS Inspector General looked at a month of Medicare data and projected…400,000 cases of non-trivial harm (1300/day).” The actual figures from the cited report are 134,000 cases of non-trivial harm (over 4000/day). The correct figures now appear in the body of the article.


  1. To Err is Human: Building A Safer Health System. Institute of Medicine of the National Academies; 1999. Available at: Accessed March 4, 2011.
  2. Landrigan CP, Parry GJ, Bones CB, Hackbarth AD, Goldmann DA, Sharek., PJ. Temporal trends in rates of patient harm resulting from medical care. N Engl J Med 2010; 363:2124-2134. Available at: Accessed March 4, 2011.
  3. Adverse events in hospitals: National incidence among medicare beneficiaries. United States Department of Health and Human Services Office of Inspector General; 2010. Available at: Accessed March 4, 2011.
  4. Graban M. Lean Hospitals: Improving Quality, Patient Safety, and Employee Satisfaction. New York: Productivity Press; 2008.
  5. McDonald C, Abhyankar S. Electronic health records and clinical decision support systems: impact on national ambulatory care quality . Arch Intern Med. 2011 Jan 24 [Epub ahead of print]. Available at: Accessed March 4, 2011.
  6. EHRs and the quality conundrum. FierceEMR; 2011. Available at: Accessed March 4, 2011.
  7. Electronic health records no cure-all. CNN Health; 2011. Available at: Accessed March 4, 2011.

Copyright: © 2011 Dave deBronkart. Published here under license by The Journal of Participatory Medicine. Copyright for this article is retained by the author(s), with first publication rights granted to the Journal of Participatory Medicine. All journal content, except where otherwise noted, is licensed under a Creative Commons Attribution 3.0 License. By virtue of their appearance in this open-access journal, articles are free to use, with proper attribution, in educational and other non-commercial settings.