TY - JOUR T1 - To improve quality, keep your eyes on the road JF - BMJ Quality & Safety JO - BMJ Qual Saf DO - 10.1136/bmjqs-2020-011102 SP - bmjqs-2020-011102 AU - Marc Philip T Pimentel AU - John Matthew Austin AU - Allen Kachalia Y1 - 2020/05/11 UR - http://qualitysafety.bmj.com/content/early/2020/05/11/bmjqs-2020-011102.abstract N2 - In healthcare quality improvement, we are trained to believe that, “every system is perfectly designed to get the results it gets”.1 By focusing relentlessly on getting the process right, we will know we can arrive at better outcomes.2 Over the past decade, however, publicly reported metrics for hospitals have moved away from process metrics, further emphasising outcome metrics. The Centers for Medicare and Medicaid Services (CMS) has major pay-for-performance programmes for hospitals aimed squarely at improving outcomes, such as hospital-acquired infections and 30-day readmission rates. US News and World Report’s and Leapfrog’s hospital rankings heavily weight outcomes, such as 30-day mortality rates and postoperative complications. In this viewpoint, we propose that although process measures have had limitations that led to the shift towards outcome measures, new developments in electronic health records, data collection, and quality measurement have the potential to overcome these limitations and vastly improve the utility of process measures.The rationale for shifting towards outcome measures is more than reasonable, as process measures have had their challenges. If performance on a process measure improves (eg, increased haemoglobin A1c testing for diabetes management) but is not accompanied by sufficient resulting improvements in outcomes (eg, haemoglobin A1c results meeting desired levels), it may not make sense to continue optimising performance on that process measure.3 4Also, seeking improvement in process measures, if not carefully constructed, may not always lead to meaningful changes in the clinical process. One notable example is smoking cessation counselling at discharge. A hospital could meet the smoking cessation counselling measure by simply adding to every discharge summary an instruction that says, “If you smoke, we advise you to stop”. As a result of the lack of meaningful change in clinical practice, that tobacco cessation measure was subsequently dropped. A more stringent measure was … ER -