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The End of the Quality Improvement Movement: Long

Live Improving Value

Robert H. Brook
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current as of November 2, 2010. JAMA. 2010;304(16):1831-1832 (doi:10.1001/jama.2010.1555)

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The End of the Quality Improvement Movement

Long Live Improving Value
Robert H. Brook, MD, ScD “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.

HE MODERN ACADEMIC QUALITY IMPROVEMENT As a result, there was a major effort to relabel and morph
movement began more than 40 years ago with a the quality improvement movement into the patient safety
series of articles that highlighted substantial defi- movement.8
ciencies in the way care was provided.1 In response, The difference between quality and safety is not clear. If
multiple efforts to improve quality were launched. Medical a surgeon removes the wrong limb, is that a quality prob-
processes that affected patients’ health were identified. lem or a safety problem? Are errors of commission (ie, plac-
Methods of measuring how well the processes were per- ing a feeding tube in the lungs as opposed to the stomach)
formed in day-to-day practice were developed, and many and errors of omission (ie, failing to give a surgical patient
suggestions were made regarding how the processes could anticoagulation) problems of quality or safety? In any event,
be performed better and care improved. refocusing quality to safety seemed to have reenergized the
Everyone got into the act. The US government estab- quality improvement movement for a period.
lished organizations to review quality of care on an area- However, the change did not produce the sustained
wide or geographic basis.2 Hospital accreditation organiza- momentum desired by leaders. So the quality improve-
tions changed their focus from improving the structure of ment movement began to change again. The focus shifted
facilities (eg, bricks and mortar, licensure) to what was from improving the outcome of care (ie, health of patients)
done to patients, and eventually, to what happened to to establishing a business case for quality. The argument
patients.3 Organizations were developed to accredit and was that in most industries improving the quality of the
examine quality of care in the outpatient arena.4 Hospitals product saved money (fewer recalls, better and less expen-
developed quality assurance departments. Organizations sive products), so investing in quality of health care should
such as the Institute for Healthcare Improvement blos- also save money. Organizations and researchers trying to
somed into leaders in the field of quality improvement, obtain grant funding were asked to demonstrate the busi-
helping institutions provide a better product.5 Businesses ness case for quality. Although there are some examples in
and corporations formed groups to focus the attention of the literature to support the concept that better quality of
the health care profession on producing a higher-quality care is less expensive, few studies have produced informa-
product.6 tion that could be generalized across time and institutional
More than 40 years later it is unclear what the quality settings. Indeed, it is the rare article that actually includes
movement has accomplished. Very little is known about how measurement of cost or expenditures in a study that
many dollars are invested to improve quality of care nation- attempts to improve quality.9 Of course, many chief execu-
ally or who makes that investment, and there is insuffi- tive officers in organizations from insurance companies to
cient evidence about whether or how the quality of care has nursing homes invest in and evaluate projects designed
actually improved. However, what is known is that there is both to improve quality and reduce cost. However, the
a long way to go.7 There is no yearly clinically detailed com- information derived from such activities is not generally in
prehensive report on the epidemiology of quality. Quality the public domain.
can be defined with more reliability and validity, but there
is little information about which mechanisms for improv-
ing quality work better than others. Author Affiliation: RAND Corporation, Santa Monica, California; and David Gef-
More than a decade ago, as the quality improvement fen School of Medicine, and School of Public Health, University of California, Los
movement seemed to stall, many, including the Institute Corresponding Author: Robert H. Brook, MD, ScD, RAND Health, 1776 Main St,
of Medicine, questioned whether the words or concept PO Box 2138, Santa Monica, CA 90407 (

©2010 American Medical Association. All rights reserved. (Reprinted) JAMA, October 27, 2010—Vol 304, No. 16 1831

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So more than 40 years after the birth of the quality im- swered. If an individual has a myocardial infarction in Lon-
provement movement, there is still not much known about don, New York, Los Angeles, or Athens, what is the quality
what has been accomplished. There is little information about of care he or she will receive, what is the likelihood he or
whether quality is better in one state or country than an- she will survive, and what is the cost in each city for pro-
other; what the relationship is between the amount a coun- ducing that level of quality and that health outcome? Per-
try spends on health care and the quality of care provided haps this exercise would help leaders of hospitals and health
in its health care system; whether a business case for qual- systems to make a business case for investing in improving
ity actually exists in an individual institution or physi- quality.
cian’s office; and whether the amount of money spent on Facilitating such an agenda will require changing the
improving quality is too little or too much. names of organizations. Organizations with names such as
In addition, there is little debate about how to allocate the International Society for Quality in Health Care might
health care dollars between developing new technologies change to the International Society for Value in Health
or improving the quality of care of existing systems. For Care. Perhaps quality researchers and other individuals
example, a company develops a new drug that for $30 000 who lead quality improvement activities should no longer
provides one person one good year of life. Such a drug meet just with their own community, which is mostly con-
would meet the criteria set by the National Institute for cerned with health, but also with managers, economists,
Clinical Excellence (NICE) and would be included in the and financial experts.
formulary in the UK’s National Health Service (NHS).10 It may be possible to answer questions about what has
Would individuals in the NHS have been better off if the happened to quality of care in the world in the last 40 years,
funding needed to provide this drug were spent on and at the same time, answer the more difficult question of
improving the quality of care given to diabetic children— what investments in quality improvement are worthwhile.
care that, in turn, could prevent or delay complications? Establishing the business case for quality would be a win-
For that matter, there are no publicly available data to win proposition for everyone. Maybe it will lead to more
answer the question of whether spending $30 000 on qual- time and money being spent on improving the current sys-
ity improvement activities could produce 0, 1, or 100 addi- tem rather than paying for some new products and tech-
tional good years of life. nologies that are costly and produce only marginal improve-
In considering the next 50 years of quality assurance ac- ments in health.
tivities, perhaps academics and industry leaders should em-
Financial Disclosures: None reported.
brace the business case for quality and focus on the nexus
of quality and cost. What is needed is a health care system
at the intersection of higher quality and lower cost. In or- REFERENCES

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1832 JAMA, October 27, 2010—Vol 304, No. 16 (Reprinted) ©2010 American Medical Association. All rights reserved.

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