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EDITORIALS: John Wright and Kaveh G Shojania Measuring the quality of hospital care BMJ 2009; 338: b569 [Full text]

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SMR irrationality

David Brookman   (25 March 2009)

Multi-Dimensional Quality

Rupert J Suckling   (11 April 2009)

SMR irrationality 25 March 2009
David Brookman, Remote Rural GP/VMO Lightning Ridge Send response to journal: Re: SMR irrationality	When DRG based reimbursement was introduced in the USA within a few years 'DRG creep' was found to be a problem as administrators influenced the diagnosis and severity, and complications of reasons for admission. This did not stop other countries, including Australia, from blindly following. The problem with assessing hospitals is always the biases introduced by management response to the alteration to their 'performance' criteria, this will occur if SMR's are used as 'quality measures'. SMR's are useful if and only if they are used in relation to a fixed geographhical catchment area - they can be validly used to assess health services that have responsibility for health outcomes in a defined geographical area. This particularly useful as the catchment population morbidity associated measures such as unemployment, education, disposable income are also available for analysis on a geographical basis - so the variability of input (patient risk measures) can also be used when assessing outcomes. We are left with process measures as the only reliable measure for the quality of service provided by a single service entity, but many of these remain to be validated and those being applied are more often selected by their cost and simplicity. AS usual more research is needed. Competing interests: None declared
Multi-Dimensional Quality 11 April 2009
Rupert J Suckling, Deputy Director Public Health NHS Doncaster DN4 5DJ Send response to journal: Re: Multi-Dimensional Quality	Measuring quality is a thorny issue, one that is complicated by the apparent desire to have a single measure of quality. The Institute of Medicine lays out six characteristics of high- quality care, which have been widely adopted in healthcare these include care must be safe, effective and reliable, patient-centered, timely, efficient and equitable. All of these dimensions are important in delivering public value. The key challenge is to balance these potentially conflicting characteristics. The use of a 'dilemmas approach' (Hampden-Turner) or a 'Balanced Scorecard Approach' (Kaplan & Norton) may be more beneficial than the reliance on a single measure. Competing interests: None declared