INPATIENT SAFETY II The purpose of monitoring clinical performance, the focus of the second article in this Lancet series, 1 is to learn and improve. If providers regularly review performance, design interventions to improve, and create a team to implement the intervention, it will facilitate improvement. 2 Quality is a characteristic of the system in which care is delivered. To improve, we need to reorganise work. As an analogy, last spring Ethan, my (PJP) 6-year-old son, and I were weeding our garden. He pulled the green leaves off the top of the weed. I pulled the weeds up from the roots. A month later, Ethan had a garden full of weeds and I had a garden full of flowers. If I did not like his performance, I could punish him or put him in a time out. Nonetheless, he would continue to have a garden of weeds unless we changed the way he worked. The same applies to quality and safety. If we want a nice garden, we need to change the way the individual gardener works and we can start by counting the weeds and flowers. In medicine the measurements are not that simple. The growing demand for improved safety in health care from patients, providers, insurers, regulators, accreditors, and purchasers is warranted; evidence suggests that safety and quality of care in hospitals can be improved. 3–7 Indeed, patients can count on receiving only half the treatments they ought to. 8 This result is predictable. Hitherto, research funding and activities have focused on understanding disease mechanisms and identifying effective therapies, whereas few researchers have looked into methods of delivering those treatments safely, effectively, and efficiently (figure 1). As a result, one of the Lancet 2004; 363: 1061–67 Departments of Anesthesiology/Critical Care Medicine (P J Pronovost MD); Surgery (P J Pronovost); Biostatistics (S Zeger PhD); Pediatrics (P J Pronovost, M Miller MD); Medicine (M Miller, H Rubin MD); Health Policy and Management (P J Pronovost); and Institute for Healthcare Improvement (T Nolan PhD), Johns Hopkins University School of Medicine and Bloomberg School of Public Health, Baltimore, MD, USA Correspondence to: Dr Peter J Pronovost, Department of Anesthesiology/Critical Care Medicine, Johns Hopkins University, Meyer 297A, Baltimore, MD 21287, USA (e-mail: ppronovo@jhmi.edu) greatest opportunities to improve patient outcomes will probably come not from discovering new treatments but from more effective delivery of existing therapies, including lifestyle interventions such as exercise and smoking cessation. 9 We might realise these improvements with a balanced research portfolio in which the end, health services research, is valued 4,6,12 as highly as the beginning of the translation superhighway. 10,11 The same imbalance between discovery and delivery of health services exists in healthcare institutions. To improve, caregivers need to know what to do, how they are doing, and be able to improve the processes of care. 2,13–15 Although the ability to monitor performance is fundamental to improvement of any system, 2 health care providers have little ability to monitor performance in their daily work, due in part to an absence of both information systems and agreement on how to measure quality of care. 6 As a result, we often fail to learn from the daily practice of medicine and restrict learning to formal clinical studies that enrol few patients who receive health care. Nonetheless, it is possible to obtain feedback and learn from routine practice. For example, improvements in surgical morbidity and mortality derive in part from frequent feedback, generally as case series, regarding what works and what does not. 16–21 Methods of continuous feedback from industrial engineering could provide an opportunity to learn from routine practice and improve quality of care. 22 In this paper, we will explore the possibilities of obtaining frequent feedback in health care. Toward that end, we will discuss what quality of care is, how the reporting of incidents could improve quality, development How can clinicians measure safety and quality in acute care? Peter J Pronovost, Thomas Nolan, Scott Zeger, Marlene Miller, Haya Rubin Inpatient safety II THE LANCET • Vol 363 • March 27, 2004 • www.thelancet.com 1061 The demand for high quality care is increasing and warranted. Evidence suggests that the quality of care in hospitals can be improved. The greatest opportunity to improve outcomes for patients over the next quarter century will probably come not from discovering new treatments but from learning how to deliver existing effective therapies. To improve, caregivers need to know what to do, how they are doing, and be able to improve the processes of care. The ability to monitor performance, though challenging in healthcare, is essential to improving quality of care. We present a practical method to assess and learn from routine practice. Methods to evaluate performance from industrial engineering can be broadly applied to efforts to improve the quality of healthcare. One method that may help to provide caregivers frequent feedback is time series data—ie, results are graphically correlated with time. Broad use of these tools might lead to the necessary improvements in quality of care. Search strategy and selection criteria We searched MEDLINE from 1995 to 2003 using the following medical subject headings (safety, quality of healthcare). We also used the following text words: patient safety, errors, acute care, intensive care, hospital staff organization. We searched EMBASE, Healthstar (Health Services, Technology, and Research) and HSRPOJ (Health Services Research Projects in Progress) via the Internet Grateful Med. For personal use. Only reproduce with permission from The Lancet.