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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 with concerns regarding the accuracy of national hospital performance outcomes due to variation in local practices, such as diagnostic coding.14 As physicians are pushed to expend more energy on performance measures at the expense of broader quality improvement, we fear that providers will increasingly be placed in positions where they will feel pressure to ‘game the system’ instead of focusing exclusively on providing high-quality care.

Realigning quality improvement and patient safety

The concepts of patient safety and quality in medicine are distinct yet rooted in the common principles that care must be safe, equitable and effective. However, there is an increasing chasm between how we approach patient safety and quality in healthcare. Patient safety has clear meaning for patients and providers because safety outcomes are patient-centred. Safety programmes exist within a ‘Just Culture’, in which accountability is balanced with an understanding that human errors are often due to failures of systems.7 A ‘Just Culture’ understands that blaming individuals for errors is counterproductive and that the act of blaming takes away from the opportunity to learn. Quality, when assessed by performance measures, can be punitive and is increasingly being focused on individuals rather than systems. Under the Centers for Medicare and Medicaid Value-Based Payment Modifier, penalties associated with lapses in performance metrics will be tied to individual providers. In contrast with patient safety, performance measures are often not clinically relevant to patients, and providers view them as burdens rather than beacons for high-quality care. To fix how we measure quality, quality improvement advocates must realign how we approach quality and learn from patient safety.

Patient safety is first and foremost patient-centred. Through incident reporting and root-cause analyses, a healthcare system identifies areas for improvement that are meaningful and timely: those causing unexpected patient harms and death. The only outcomes that matter for patient safety are outcomes that are obvious and intuitive to patients and providers. The goal of patient safety is to learn about and improve local, complex systems. As a result, patient safety teams have tremendous flexibility to design solutions that fit within local processes. The importance of institution-specific solutions is central to national patient safety initiatives, such as the central line bundle to reduce central line-associated bloodstream infections (CLABSI).15 Individual institutions developed unique approaches to implementation of the central line bundle based on local needs and processes that resulted in a dramatic decline in national CLABSI rates. Although CLABSI is now included as part of the Centers for Medicare and Medicaid Hospital Value-Based Purchasing Program, a significant portion of the improvement in national CLABSI rates occurred before the institution of financial penalties.16 In this context, processes for implementation were institution specific and were driven by intrinsic motivation of providers to reduce morbidity rather than the fear of financial penalties.6 The real struggle for CLABSI as a performance measure will occur when hospitals have no additional margin for improvement and financial penalties are based on inherent variance in the metric rather than meaningful outcomes.

In contrast, performance measures for healthcare are not often transparent to patients. Many measures are also of questionable significance to providers. Expert-defined performance measures, such as administration of antibiotics for community-acquired pneumonia within 4 h of emergency department arrival, are not intuitive and can have untended and undesirable consequences, such as overuse of antibiotics in patients lacking a clear diagnosis at initial presentation.17 Many performance measures, such as documentation of left ventricular ejection fraction at discharge for patients with heart failure, are related to processes that are easy to measure, but are not clearly linked to outcomes.18 Table 1 provides additional examples of expert-defined performance measures currently in use (left column) and suggestions for performance measures with clearer meaning for patients and providers (right column). Frustratingly, hospitals cannot prioritise which performance measures should be addressed first within their local context, but are forced to follow national mandates regarding process measurement that require significant staff resources to monitor. By allowing each institution to prioritise performance measures and determine how they are implemented locally, regulatory agencies will stand a better chance ensuring that the work hospitals do leads to long-term improvements in quality without jeopardising safety.

Table 1

Examples of expert-defined performance measures and corresponding clinically relevant performance measures

This is not to say that externally developed measures should be abandoned. There remains a need for hospitals to track specific health outcomes that are of great significance to patients and providers, such as mortality and rates of hospital-acquired infections. However, these measures should be limited in number, aimed at institutional improvement and intuitive to patients and providers. To achieve real quality, we must develop performance measures that are clinically relevant and patient-centred, allowing patients the opportunity to help shape how quality is defined, measured and communicated nationally.19 Patients and stewards of quality measurement will need to work together to ensure that patient-proposed outcome measures can be accurately and meaningfully measured prior to implantation. Patient-reported performance metrics, such as patient satisfaction with provider communication, not only have meaning for patients but also have positive associations with desired health outcomes.20 The Hospital Consumer Assessment of Healthcare Providers and Systems Survey is an example of a national performance measure developed with patient input that correlates with hospital performance for readmissions and mortality.21 ,22 The process of including patients in the development of quality measures will result in the abandonment of many current performance measures established by experts and in the development of metrics that have clinical relevance and are intuitive to patients.

Finally, patient safety balances accountability with a systems-focused approach to improvement. Much work has been done in patient safety to establish a ‘Just Culture’ where medical errors become opportunities for learning and improvement. In the current environment, quality is a high-stakes game where the default is to reprimand individual providers for failing to meet performance measures. In a ‘Just Culture’ for quality, failure to meet performance measures would be an opportunity for improvement rather than punishment. Poorly performing hospitals and providers should be identified. If lapses in performance measures are due to inadequate training, resources or processes, punishing frontline staff, essential for correcting problems, is counterproductive. Poorly performing healthcare organisations should be given the latitude to report lapses and transparently describe the steps they will take to improve. This is not to say that accountability is removed from providers or institutions. As in patient safety, those who wilfully manipulate the system should be held accountable. However, we need to change the stakes for performance measures and build a culture where there is support for continuous improvement in addition to accountability.

In a few short years in the USA, we will have a veritable army of physicians trained in patient safety principles and quality improvement methods under the Accreditation Council for Graduate Medical Education Clinical Learning Environment Review programme.23 To capitalise on this opportunity to change healthcare, we must change how we define and use performance measures to support quality improvement. If nothing changes, providers will continue to feel dissatisfied when the performance measures they are held accountable for are inconsistent with their understanding of what it means to provide high-quality care. When the pressure to achieve performance benchmarks leads to professional dissatisfaction, providers may be less able to provide patients with high-quality care and be more likely to game the system. To make performance measures relevant, there needs to be a greater focus on institution-specific measures developed by interprofessional teams of patients and providers. These measures should be instituted with the understanding that physicians are already striving to provide patients with high-quality care and the inability to meet performance measures is an opportunity for growth of the system rather than punishment of providers. To move quality forward, we need to establish a ‘Just Culture’ for performance measures.



  • 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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