What have we learned from measuring “quality” that we can apply to measuring “value” in healthcare?


With all of the focus and attention in healthcare turning towards the concept of “value” I am surprised at how few resources exist to help healthcare professionals figure out how to assess and measure it. As an industry, we seem to be proceeding as if everyone has the same level of understanding of value, and as if there is no need to converse and come to a shared understanding. Value to whom? Value as measured by what? We continue to roll-out “value-based” programs and initiatives, but every time I talk to a physician or other healthcare professional, they have a different take on what value is or what it should be.

One of the most interesting aspects of this is that we’ve been here before. The term “quality” is just as general and just as ubiquitous as “value;” we’ve learned over decades of measuring quality that we can’t assume that it means the same thing to everyone or in every situation. We know from experience that our ability to affect quality is directly related to our ability to get specific about it.

Consider the questions you’ve learned to ask any time you’re trying to measure quality or developing an initiative. Some of them likely include some form of the following:

  • How will we define quality in this situation?
  • How will we measure quality, and what data will we use?
  • What do those data allow us to do? What don’t they allow us to do?
  • How will we compare quality fairly (e.g., risk-adjust) and know when there’s a meaningful difference or change?
  • How will we determine what thresholds represent “good” or “acceptable” levels of quality?

We know that as a concept, “quality” is complex and nuanced, and that the answers to the above questions (and others) will change depending on the situation, the perspective, the objective, and even the available data. Often, the answers to these questions ARE what drive quality. That is, within the sphere of all of the possible aspects of care we could potentially improve upon, there is a subset of activities where quality can be measured and therefore where improvement can be demonstrated.

To assess, measure, and eventually affect value, we need to get just as specific. We need to understand that the same questions we ask of quality need to be asked of value. In order to design a quality improvement project and measure value, we need to ask ourselves:

  • How will we define value in this situation? Are we interested in only the direct monetary impacts (i.e., costs and revenues), or are we also interested in indirect benefits (e.g., impacts on value-based reimbursements, availability of beds, changes in staff time)?
  • How will we measure value? What metrics will we use? What time frame will we look at (during the intervention vs some time into the future, etc.)? If we’re interested in less tangible benefits (patient/staff satisfaction, quality of life) how do we plan to measure and quantify them?
  • To what will we compare the results? What is a meaningful threshold or benchmark for value, and how will we make comparisons fairly?

These are just a few of the questions we could ask. But, we can already see how the answers to these questions could have a direct impact on how value is calculated and what it represents.

Also keep in mind that the answers to these questions will evolve as we better understand our systems, our data, and the value that we want to capture. Note that even after all of the years of assessing quality, we still have conversations and debates about the best way to measure and compare quality. It would be naive of us not to assume that we face a similar journey in the exploration of value.

Sometimes I wonder if we’re not having these conversations because we assume that we’re supposed to already know the answers. We don’t. We need to approach issues related to value with the same reverence and diligence that we approach those related to quality.

Let’s keep the conversation going. Let’s pursue the ideal of expending at least a proportional level of time, effort, and study to the concept of value that we do to the concept of quality. There is an opportunity to lead in this area, to blaze the trail and set an example of how to think about and study value in healthcare. But first we need to be honest with ourselves regarding where we currently stand.