BMJ Qual Saf 23:525-527 doi:10.1136/bmjqs-2014-002993
  • Editorial

Quality and the curate's egg

Editor's Choice
  1. Ashish K Jha
  1. Department of Health Policy and Management, Harvard School of Public Health, Boston, Massachusetts, USA
  1. Correspondence to Dr Felix Greaves, Department of Health Policy and Management, Harvard School of Public Health, 677 Huntington Avenue, Boston, MA 02115-6018, USA; fgreaves{at}
  • Received 5 March 2014
  • Accepted 15 March 2014

A famous cartoon in the satirical magazine Punch from the 1890s shows a meek curate assuring his dinner host that his egg is not spoiled. “Parts of it are exceptional”, he suggests. We, the knowing reader, appreciate the humour. An egg cannot be good in parts.

For those who think about quality, the question of whether care can be good in parts is a tricky one. That a hospital might deliver better care for one clinical service—top notch cardiac surgery, say, but below average stroke care—would not surprise anyone. But, the idea that quality itself, even within a given clinical domain, like cardiac surgery or stroke care, might be ‘good in parts’ has been recognised only recently. The US Institute of Medicine lays out six key dimensions of quality: effectiveness, safety, patient-centeredness, efficiency, timeliness and equity.1 In the UK, the National Health Service (NHS) highlights three domains of quality: clinical effectiveness, patient safety and the patient experience.2

As a result of this conceptual division, people have become interested in how these different parts relate to one another. Patient experience—traditionally the poor, subjective cousin in the quality family—sometimes struggles to defend its seat at the table.

Some have argued that measuring patient experience is a distraction. Take the patient dissatisfied by his doctor when he is denied antibiotics for a cold. This is bad for experience, but good clinical practice, and good for society. Many clinicians accept this disconnect between what they regard as appropriate care and what will make patients happy, seeing it as no more significant than a medication that tastes terrible. In acute care settings, hospital emergency rooms, for instance, clinicians may regret that patients often wait on stretchers that are uncomfortable, pillows …