To the Editor: The article by Morton1 and the editorial by Van Der Weyden2 raised some important points. Investment in redesigning the health bureaucracy and recruiting more clinicians to work in Queensland is clearly important, but we also need to address more fundamental issues to ensure optimal quality of care. The following two matters require particular attention: lack of measurement and monitoring; and developing clinical governance.

We cannot know how hospitals are performing unless we have well developed and validated markers of quality of care that can be risk-adjusted and benchmarked. Measurement and benchmarking are fundamental components of quality assurance in virtually every industry other than health care, and it is difficult to see how standards can be guaranteed and improved unless they are adopted more widely in health care.

In contrast to Bristol, where data on cardiac surgery were collected but not used effectively,3 we also need systems in place to react to poorly performing individuals, units or hospitals. Effective monitoring is also currently limited by an inability to link data, such as deaths, re-admissions and complications.

Clinical performance has depended too much on personal capabilities — training, experience, memory and vigilance. Although important, the avoidance of human error will necessitate change to a more system-focused approach to patient care.

This will involve greater coordination of care to improve efficiency and to build layers of safety into our daily work practices. Currently, supervision of medical practice is extraordinarily diffuse. The accountability of medical practitioners must be made more explicit, and greater attention paid to ensuring that skills are gained under adequate supervision and maintained over time. Simulation offers great potential for identifying vulnerabilities in a learning environment and in the adoption of new technologies into routine practice.

Doctors have traditionally been reluctant to adopt clinical pathways or decision support tools to supplement memory and record clinical information and results. However, these can help standardise clinical care and reduce human error by ensuring that uniform, evidence-based practices are adopted. These strategies will also provide the basis of effective clinical governance.