To the Editor: Nisselle’s recent editorial on managing medical indemnity raises important issues.1 I would like to comment on some points. The quality movement, in the form of a system of hospital accreditation, actually began via the New South Wales Branch of the Australian Medical Association in the late 1960s. However, credentialling and the delineation of clinical privileges for medical staff are far from the norm that Nisselle claims. In fact, although some hospitals claim to be credentialling medical staff, in most instances this is little more than an exercise in tokenism and is quite incapable of contributing either to quality or to minimising risk.

Nisselle also refers to the “safety movement”. While recognising current common usage, to talk of safety as separate from quality in healthcare is tautological. It is not credible to visualise a hospital that claims to provide quality care but tolerates unsafe practices of any description. Similarly, unsafe practices in a facility mean that quality care is not being achieved.

In attempting to untangle the semantic problems occasioned by the term “risk management”, Nisselle merely compounds the problem that bedevils this subject. Of course, he is far from alone, and the medical literature further aggravates this confusion.

I suggest the following definitions in the hope of introducing some clarity:

Quality management: The management of all these issues, as Nisselle points out, is a big task. While the term “clinical governance” is currently in vogue, it means little, I believe, to most doctors. Managing quality is a complex task (as illustrated by Nisselle’s appropriate elephant analogy). So why not call it what it is? Managing quality is largely about avoiding patient harm.

Risk management: The same definition should be used whether we are talking about an insurance company or a medical service. It is the minimisation of financial loss. In the case of healthcare, the risk is malpractice litigation directed at both doctors and hospitals. The techniques of risk management are very similar to those of quality management, and risk management is an intrinsic component of quality management.2 Risk management in healthcare is not simply about reducing error, any more than is quality management. It is this focus that leads to so much confusion.

Quality assurance: This is the deliberate activity of ensuring that what was done and achieved is what should have been done and should have been achieved. It is another facet of the broader activity of quality management.

The management of quality and avoidance of the risk of litigation is difficult enough. It would help if we did not all use the terminology to mean whatever we want it to mean.

In reply: Wilson highlights the confusing taxonomy of quality/risk in healthcare. My editorial distinguished prudential risk management (ensuring insurer solvency) from clinical risk management (reducing medical error).1 The term “clinical governance” combines quality improvement (ie, getting it right more often) and risk management (ie, getting it wrong less often). Wilson writes that “Managing quality is largely about avoiding patient harm”. But quality management is as much about finding more effective ways of doing things as it is about finding safer ones. Quality and safety are separate, albeit overlapping, concepts.

Similarly, risk management is more than just “minimisation of financial loss”. Reducing the rate of head injuries by using seat belts has a human benefit, not just a financial one. One trade-off for the “Abbott reforms” to medical indemnity is a demand by government for a real commitment by both medical indemnity insurers and those insured to clinical risk management.

Although we may disagree on the language, Wilson and I are in heated agreement on the need for a concerted, systemic approach to quality management. The medical indemnity insurers have a role to play that goes beyond just remaining solvent and keeping indemnity costs down!