To the Editor: Recent articles drawing attention to the “Bundaberg problem” and its causes1,2 have stressed the need to make hospitals safer. Queensland Health’s approach to improving quality has been the Measured Quality Hospital Reports.3 Unfortunately, this approach puts the cart before the horse.

The quality of all work is a function of the systems in which it is performed.4 Therefore, it is logical to concentrate first on optimising hospital systems. When that is done, the work of the hospital should be consistent and reproducible. It is then logical to use measurement to detect any deterioration or to gauge the effect of any effort to improve a hospital’s systems. This measurement needs to be sequential, and, where random variation occurs, it should take advantage of the excellent statistical process control methods now available.5 In addition, the limitations of risk-adjustment must be applied and understood. Where possible, this is best done at a local level, as at this level risk-adjustment can be made to work better,6 and local ownership promotes efforts to learn how to improve rather than efforts to be seen to comply with a target. Putting measurement first encourages excuses (eg, demographic and classification differences), quick fixes and gaming, not solutions.

Correcting hospital systems requires, for example, a focus on specific processes, use of evidence, employment of multidisciplinary teams, independent audit of surgical outcomes, proper supervision of junior staff and, above all, leadership.4 Central offices are seen to be remote, judgemental, controlling and arbitrary. It is very difficult to foster ownership and trust in such an environment. Without trust, leaders do not emerge and teamwork becomes impossible.

To achieve better systems in hospitals, central offices have to change; they have to become coaches. They must help hospital staff with the difficult task of analysing and changing their systems. They must then institute programs of surveillance to ensure that this process is sustained. Central offices need to ensure that, if a hospital’s measurement system detects a possible change in the quality of its care, a search for a possible cause is undertaken and, if a cause is found, appropriate corrective action is instituted.

Demands on hospitals are potentially infinite and resources are not. Determining what is best requires informed public debate. However, whatever the resources available, safe care is likely to be less costly than unsafe care, as there is much less failed work needing redoing.