Intended for healthcare professionals

Analysis Measuring quality through performance

Improving the quality of care with performance indicators

BMJ 2007; 335 doi: (Published 01 November 2007) Cite this as: BMJ 2007;335:916
  1. Azeem Majeed, professor of primary care1,
  2. Helen Lester, professor of primary care2,
  3. Andrew B Bindman, professor of medicine, epidemiology, and biostatistics3
  1. 1Department of Primary Care and Social Medicine, Imperial College Faculty of Medicine, London W6 8RP
  2. 2National Primary Care Research and Development Centre, University of Manchester, Manchester M13 9PL
  3. 3Division of General Internal Medicine, University of California San Francisco, San Francisco General Hospital, San Francisco, CA 94110, USA
  1. Correspondence to: A Majeed a.majeed{at}

    Effective improvements in health care require methods to evaluate professional practice. Azeem Majeed, Helen Lester, and Andrew Bindman examine the assessment of quality

    The quality of services provided by primary care doctors varies widely, and there is often a large gap between optimal primary care services and actual practice.1 This quality gap can have serious health consequences, including deaths from medical errors, increased rates of complications in chronic disease, hospital admissions for adverse drug reactions and interactions, and outbreaks of potentially preventable infectious diseases such as measles. It also has large financial costs for the healthcare system, national governments, and society, as well as affecting patients' quality of life.

    The reasons for the quality gap are not always within the doctors' control. Sometimes the cause can lie with the public—for example, parents who refuse to allow their child to receive the measles, mumps, and rubella vaccine because of concerns about side effects. Even when the doctor and patient agree to follow a healthcare plan that meets the highest standard for quality, structural barriers related to the design or financing of healthcare systems can prevent the timely receipt of that service—for example, screening mammography for an appropriately aged woman. Nevertheless, the focus of this article and others in the series is on measuring the performance of doctors. Causes of the quality gap that lie with the doctor include being unaware of best practice and the latest guidance on managing a condition or being wary about using certain interventions, such as warfarin to reduce the risk of cerebrovascular disease, because of the fear of adverse events.

    What is quality and how do we measure it?

    The Institute of Medicine defines quality as: “The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”2 To …

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