Intended for healthcare professionals


Use of process measures to monitor the quality of clinical practice

BMJ 2007; 335 doi: (Published 27 September 2007) Cite this as: BMJ 2007;335:648
  1. Richard J Lilford, professor of clinical epidemiology1,
  2. Celia A Brown, research fellow1,
  3. Jon Nicholl, director MCRU policy research programme2
  1. 1Department of Public Health and Epidemiology, University of Birmingham, Birmingham B15 2TT
  2. 2School of Health and Related Research, University of Sheffield, Sheffield S1 4DA
  1. Correspondence to: R J Lilford r.j.lilford{at}
  • Accepted 25 June 2007

Outcomes of care are a blunt instrument for judging performance and should be replaced, say Richard J Lilford, Celia A Brown, and Jon Nicholl

Healthcare organisations are increasingly scrutinised by external agencies, such as the Health Care Commission in England and Medicare in the Unites States. Such agencies increasingly concern themselves with the quality of care and not just measures of throughput, such as waiting times and the average length of hospital stay. Measures of clinical quality are also likely to be used increasingly to monitor the performance of individual doctors.1 But how should quality be measured? The intuitive response is to measure the outcomes of care—after all, patients use the service to improve their health outcomes. We argue that this beguiling solution has serious disadvantages because of the poor correlation between outcome and quality and that use of outcome as a proxy for quality is a greater problem when the data are used for some purposes than for others.

Purpose of measurement

Data on quality can be used either for internal quality improvement or for external reporting. In the first scenario, data are collected by an organisation or individual for internal audit in the spirit of continuous improvement (quality circles, total quality management, plan do act, Kaizen, etc). In the second scenario, monitoring is imposed externally by health service funders for purposes of accountability (performance management). When results lie above or below some predefined threshold, funders may use the data to prompt further investigation in a completely non-pejorative manner. Alternatively, they may use data as the basis for sanction or reward. For example, hospitals may be given ratings that determine managerial freedoms and financial reward or a doctor may be suspended. We shall refer to use of data for sanction or reward as data for judgment. It is such use that …

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