Quality and the curate's egg.

To cite: Greaves F, Jha AK. BMJ Qual Saf 2014;23: 525–527. A famous cartoon in the satirical magazine Punch from the 1890s shows a meek curate assuring his dinner host that his egg is not spoiled. “Parts of it are exceptional”, he suggests. We, the knowing reader, appreciate the humour. An egg cannot be good in parts. For those who think about quality, the question of whether care can be good in parts is a tricky one. That a hospital might deliver better care for one clinical service—top notch cardiac surgery, say, but below average stroke care—would not surprise anyone. But, the idea that quality itself, even within a given clinical domain, like cardiac surgery or stroke care, might be ‘good in parts’ has been recognised only recently. The US Institute of Medicine lays out six key dimensions of quality: effectiveness, safety, patientcenteredness, efficiency, timeliness and equity. In the UK, the National Health Service (NHS) highlights three domains of quality: clinical effectiveness, patient safety and the patient experience. As a result of this conceptual division, people have become interested in how these different parts relate to one another. Patient experience—traditionally the poor, subjective cousin in the quality family—sometimes struggles to defend its seat at the table. Some have argued that measuring patient experience is a distraction. Take the patient dissatisfied by his doctor when he is denied antibiotics for a cold. This is bad for experience, but good clinical practice, and good for society. Many clinicians accept this disconnect between what they regard as appropriate care and what will make patients happy, seeing it as no more significant than a medication that tastes terrible. In acute care settings, hospital emergency rooms, for instance, clinicians may regret that patients often wait on stretchers that are uncomfortable, pillows are hard to find, and so on. But, when lives are being saved, comfort comes second. Policymakers have not necessarily seen it this way and have pushed organisations to pay more attention to patient experience by using public reporting and pay-for-performance schemes that reward higher levels of patient satisfaction. In response, hospitals increasingly spend their hard-pressed money on cosmetic aspects of facilities and care, installing fountains in lobbies and having concert pianists serenade the guests. It is increasingly difficult to tell hospitals from the plush hotels they appear so keen to emulate 4 and critics wonder whether sky-high patient experience is just a marker of pandering to superficial expectations and inappropriate use of limited resources? The push by policymakers has also led to the development of subjective patientcentred outcomes measures (PROMS), which some suggest may represent a new way to understand the effectiveness of care. In England, mandatory reporting of PROMS for a range of surgical procedures provides an opportunity not just to capture a patient’s experience at the point of care, but also to measure their health experiences over a prolonged period. A paper in this issue of the journal explores the relationship between experience and subjective measures of outcomes. Black et al examine the link between surgical patients’ experience of care and their eventual outcomes in terms of safety and effectiveness. They find that patients who experience good care for hip replacements, knee replacements and groin hernia repairs tend to have better outcomes—in terms of subjective well-being—further down the line. The strength of the association is not terribly strong (with a correlation coefficient between 0.1 and 0.2), but it certainly seems to be there. They also found that those with better experience (1 SD above the average) were 30% less likely to have reported a complication. This study adds to a body of literature that examines this relationship between patient experience and measures of both effectiveness and safety. A recent Editor’s choice Scan to access more free content EDITORIAL