In reply: The letters in response to my editorial1 reflect concern within the medical community about the continuing saga of safety in our hospitals.

Clarke et al call again for public report cards on individual surgeons. It is difficult to see what positive outcomes such an exercise would have on systemic safety — it is likely to encourage a culture of individual blame and to detract from probing system factors, an outcome not favoured by experts in safety.2,3 Despite this, surgeons in Australia are at the forefront of performance monitoring, as exemplified by the Western Australian Audit of Surgical Mortality.4 Indeed, the Royal Australasian College of Surgeons is introducing a similar program across Australia and New Zealand,5 and its leadership in this matter is to be applauded. Evans and her colleagues and Morton reiterate the dire need for a comprehensive and continuous measurement system for clinical outcomes and the central role of clinical governance. The importance of these requirements is echoed in the use of the words “measurement” or “monitoring” 11 times and “governance” five times in the preceding letters.

Aitken raises the important point that improving safety and quality comes at a cost and requires dedicated time. He also draws attention to the recently introduced protected, non-clinical time for consultants in the United Kingdom, a development that deserves serious consideration by health departments Australia-wide.

That medical manpower shortage is at the root of the Bundaberg Hospital scandal is emphasised by Brooks, but he calls for a debate about the bigger picture: a radical rethink of what we want from our health system and who should be the providers. Such a debate is usually side-stepped by our politicians, but the recent Productivity Commission report on Australia’s health workforce6 may force the issue.

Finally, Barraclough enumerates the achievements of the Australian Council for Safety and Quality in Health Care (ACSQHC). As acknowledged in the recent review of the ACSQHC,7 the Council’s key achievements have been in raising safety issues among clinicians and the public, producing a bevy of quality policies, and focusing on systemic causes rather than individual blame for medical mishaps. The total funding allocation to the Council over its 6-year term was $55 million.7

However, the purpose of my editorial was not to dwell on these achievements, but to draw attention to the lack of a comprehensive system for gathering data on defined clinical outcomes — a necessary tool if we are to achieve meaningful safety and quality improvement. Without these data, we have no way of knowing whether the activities of the ACSQHC have made any difference to safety. As the Royal Australasian College of Physicians noted in its submission to the ACSQHC review: “clinicians do not have ready access to meaningful information about clinical practice”.7

In short, we need to resolve what we want to know and why we want to know it, and then to measure it locally, state-wide and nationally. Measuring progress and demonstrating improvement are potent forces for change. But it all depends on the availability of robust measurements.