The transformation journey to value in health care.

Every time I review an article on quality measurement--or as we describe it in the 1990s, "outcomes," "guidelines," "TQM," and "value"--I'm struck by the contradiction between how far the science and technology of medicine has advanced compared to our slow and very slight progress in measuring quality and defining its relative relationship to cost and value. In the 1850s, Florence Nightingale admonished the medical profession to consistently measure the results of medical care in order that the public could be better informed and the science of medicine advanced. Sixty years later Boston surgeon Dr. Ernest Codman did just that with the first public report card of surgical results in 1914 and was ignored by both the public and the profession. If one wants to look for a stellar definition of quality today it is hard to beat the 1952 version of pediatrician and public health scientist Dr. Paul Lembcke (1952), who defined quality as follows: "The best measure of quality is not how well or how frequently a medical service is given but how closely the result approaches the fundamental objective of prolonging life, relieving distress, restoring function and preventing disability." I would urge all individuals interested in quality measurement to read the writings of this distinguished scientist, to whom we have paid little attention despite his excellent descriptions of quality measurement, variation in medical practice, data management, medical audit, case-mix adjustment, process evaluation, and small area variation. (Silver 1940). Now in 1995 we are rediscovering these same principles but putting them into the modern lingo of "transformation," "reengineering," and "TQM." Let us hope that authors in 2025 will not be referring to the efforts of this decade as one more historical phase in a long litany of failed opportunities. The article, "The Dilemma of Managing Value," by Austin Ross and L. Frederick Fenster represents a thorough review of the challenges and opportunities that the health system faces in trying to measure, monitor, and motivate the search for value. The traditional view of value has always been value equals quality divided by cost. Ross and Fenster have expanded on the simple quality factor by breaking it in to issues of appropriateness, as well as quality of outcome and quality of service. This type of equation is of value in emphasizing the important relationship between quality and cost, but unfortunately, it is not a simple mathematical equation that can produce a number that defines the relative value of service A versus service B. The lack of numerical correctness has contributed to our poor performance in defining quality over the years. Although quality used to be defined by most physicians as "something I know when I see it, but don't ask me to define it," that excuse is no longer acceptable. Quality is now being defined in more precise terms and in a multitude of ways that includes outcomes. The term "outcomes" also suffers from deficiencies in precision. The most common source of so-called outcomes information today is derived from claims database reviews that do not capture clinical characteristics of patients or document health status change and whose entire focus has always been based on reimbursement data needs rather than quality measurement. A second level of outcomes measures includes so-called key quality indicators or key performance/process indicators. This approach attempts to identify significant tracer conditions and process goals in the areas of health maintenance, disease prevention, disease treatment, and the ability to meet patient expectations. Ross and Fenster correctly urge us to view outcomes in the more comprehensive approach that includes (l)patient-functional health status, (2) patient satisfaction, (3) clinical status and disease-specific measures, and (4) resource consumption/cost. While claims database and key process measure information can be useful in contributing to outcomes information, it is critically important for a health system striving to define quality to have the goal of the more comprehensive outcome measures. …