Intended for healthcare professionals

Analysis Measuring quality through performance

Respecting the subjective: quality measurement from the patient's perspective

BMJ 2007; 335 doi: (Published 15 November 2007) Cite this as: BMJ 2007;335:1021
  1. Glyn Elwyn, professor1,
  2. Stephen Buetow, director of research2,
  3. Judith Hibbard, professor3,
  4. Michel Wensing, senior researcher4
  1. 1Department of Primary Care and Public Health, Cardiff University, Cardiff CF14 4YS
  2. 2Department of General Practice and Primary Health Care, University of Auckland, Auckland, New Zealand
  3. 3Department of Planning, Public Policy, and Management, University of Oregon, Eugene, Oregon, USA
  4. 4Centre for Quality of Care Research, Radboud University Nijmegen Medical Centre, Nijmegen, Netherlands
  1. Correspondence to: G Elwyn elwyng{at}

    An unhappy patient suggests poor quality care, but Glyn Elwyn and colleagues point out that using measures of satisfaction to assess health providers is not without problems

    Modern health care is recognising, albeit with difficulty, that it is a service industry and has to pay more attention to those who use it. It may have unique features—in that it deals with high stake issues—but in common with other knowledge intensive services, it has to balance the expert skills with the expectations and experiential expertise of users. Service industries have learnt that sustained profitability stems from meaningful customer focus, collaboratively designed products and services, and positive interpersonal exchanges that management science calls “moments of truth.”1 Healthcare organisations are now keen to take patients' perspectives seriously, but it's not as simple as it may sound.

    What do patients want?

    Reviews of patient priorities are consistent.2 Summarised, they state that patients assume technical competence at both professional and organisational levels. Patients admit difficulty in judging whether these assumptions are met, although they further assume that systems are in place to ensure that basic standards are maintained and that all aspects of care are safe. They expect, however, to have good access to care and be respected. Patients also report high expectations about the experience of receiving and, often co-producing, health care—that it should be timely and that their views and preferences will be considered at least equally important as those of health professionals. Patient perceptions of what constitutes high quality care are likely to be fluid and will change as they understand that performance is not uniformly high. Providing patients with a framework to help them understand a broader array of performance and quality measures would help.3

    Is what patients say they want the same as good quality care?

    Patients' preferences do not exactly overlap with good quality care; meeting their priorities is necessary but …

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