The End of the Quality Improvement Movement
Authors: Robert H. Brook
Journal: JAMA (2010)

THE MODERN ACADEMIC QUALITY IMPROVEMENT movement began more than 40 years ago with a series of articles that highlighted substantial deficiencies in the way care was provided. In response, multiple efforts to improve quality were launched. Medical processes that affected patients’ health were identified. Methods of measuring how well the processes were performed in day-to-day practice were developed, and many suggestions were made regarding how the processes could be performed better and care improved. Everyone got into the act. The US government established organizations to review quality of care on an areawide or geographic basis. Hospital accreditation organizations changed their focus from improving the structure of facilities (eg, bricks and mortar, licensure) to what was done to patients, and eventually, to what happened to patients. Organizations were developed to accredit and examine quality of care in the outpatient arena. Hospitals developed quality assurance departments. Organizations such as the Institute for Healthcare Improvement blossomed into leaders in the field of quality improvement, helping institutions provide a better product. Businesses and corporations formed groups to focus the attention of the health care profession on producing a higher-quality product. More than 40 years later it is unclear what the quality movement has accomplished. Very little is known about how many dollars are invested to improve quality of care nationally or who makes that investment, and there is insufficient evidence about whether or how the quality of care has actually improved. However, what is known is that there is a long way to go. There is no yearly clinically detailed comprehensive report on the epidemiology of quality. Quality can be defined with more reliability and validity, but there is little information about which mechanisms for improving quality work better than others. More than a decade ago, as the quality improvement movement seemed to stall, many, including the Institute of Medicine, questioned whether the words or concept “quality of health care” had caught the attention of the US public and whether sufficient resources were being invested in the quality movement to actually improve care. As a result, there was a major effort to relabel and morph the quality improvement movement into the patient safety movement. The difference between quality and safety is not clear. If a surgeon removes the wrong limb, is that a quality problem or a safety problem? Are errors of commission (ie, placing a feeding tube in the lungs as opposed to the stomach) and errors of omission (ie, failing to give a surgical patient anticoagulation) problems of quality or safety? In any event, refocusing quality to safety seemed to have reenergized the quality improvement movement for a period. However, the change did not produce the sustained momentum desired by leaders. So the quality improvement movement began to change again. The focus shifted from improving the outcome of care (ie, health of patients) to establishing a business case for quality. The argument was that in most industries improving the quality of the product saved money (fewer recalls, better and less expensive products), so investing in quality of health care should also save money. Organizations and researchers trying to obtain grant funding were asked to demonstrate the business case for quality. Although there are some examples in the literature to support the concept that better quality of care is less expensive, few studies have produced information that could be generalized across time and institutional settings. Indeed, it is the rare article that actually includes measurement of cost or expenditures in a study that attempts to improve quality. Of course, many chief executive officers in organizations from insurance companies to nursing homes invest in and evaluate projects designed both to improve quality and reduce cost. However, the information derived from such activities is not generally in the public domain.