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A ‘Just Culture’ for performance measures
  1. Molly J Horstman1,2,
  2. Aanand D Naik1,2
  1. 1Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas, USA
  2. 2Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
  1. Correspondence to Dr Molly J Horstman, Center for Innovations in Quality, Effectiveness, and Safety (152), Michael E. DeBakey VA Medical Center, 2002 Holcombe Blvd, Houston, TX 77030, USA; mhorstma{at}

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Fear of the kind engendered by the disciplinary approach poisons improvement in quality, since it inevitably leads to dissatisfaction, distortion of information, and the loss of the chance to learn.—Donald Berwick1

Quality improvement has a culture problem. In its inception, the quality movement adopted a model of continuous improvement, in which the purpose of performance measurement was to offer providers an opportunity for continual learning.1 Starting in the mid-1990s, healthcare systems explored the role of performance measures in monitoring quality on a national scale and demonstrated significant improvements in the care provided to patients.2 ,3 This initial success has led to an explosion in the number of performance measures.4 ,5 However, as the number of performance measures has increased, the role of performance measures in quality has become increasingly burdensome and punitive for providers and hospitals.4 ,6 To make performance measurement relevant for patients and providers, quality improvement needs to dismiss the current culture of punishment and join patient safety in a ‘Just Culture’ of continual learning and improvement.7

Current state of quality improvement and performance measurement

Providing high-quality care is an important contributor to physician professional satisfaction.8 However, the quality improvement work that is valued by healthcare institutions is often driven by national performance measures rather than local needs identified by providers.9 As performance improves and the margins for further improvement are reduced, clinicians perceive that performance measures result in care that is clinically inappropriate, inconsistent with patient-centredness and less focused on patient concerns.10 ,11 The utility of performance measures as drivers of quality improvement is also unclear. Studies regarding the implementation of public reporting and non-reimbursement policies from the Centers for Medicare and Medicaid have shown little impact on national trends in mortality and healthcare-associated infections.12 ,13 This is coupled …

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  • Funding This material is based upon work supported in part by the Department of Veterans Affairs Center for Innovations in Quality, Effectiveness and Safety (IQuEST) [VA CIN 13-413] and the VA Quality Scholars Program Coordinating Center at the Michael E DeBakey VA Medical Center, Houston, TX. Dr Horstman was previously supported by the VA Office of Academic Affiliations Chief Resident in Quality and Safety program and is currently a VA Advanced Fellow in Health Services Research at IQuESt.

  • Disclaimer The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs, or the US government, or other affiliated institutions.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; internally peer reviewed.

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