The quality burden.

While the cost of care remains a major focus of attention in pursuing quality patient care, little recognition has been given to the costs of the quality improvement efforts themselves: the time, energy, infrastructure, and emotional stress associated with documenting, monitoring, reporting, implementing, and evaluating quality indicators and initiatives. This article describes an emerging phenomenon, the quality burden, which, though often unmeasured, is significant in size and impact and accompanies ongoing efforts to improve the quality and safety of health care. Recommendations are given to mitigate the impact of the quality burden in delivering care and improving quality and safety.