Muir Gray: Bye Bye Quality

Muir GrayThe nasal tones of the Everly Brothers, “Bye Bye Love, Hello Loneliness” are very familiar to people who were young in the fifties and healthcare now faces a similar paradigm shift from quality to value — Bye Bye Quality, Hello Value. The debate is sharpest in the United States because healthcare is the battleground of that republic. There are five pieces of evidence.

The big guns from Boston are booming; firstly Clayton Christensen promotes value for patients as the key criterion in the “Innovator’s Prescription,” and secondly Michael Porter is weighing in from Harvard Business School with the promotion of value as the key issue. His definition, which embraces quality is given below:

“Value in any field must be defined around the customer, not the supplier. Value must also be measured by outputs, not inputs. Hence it is patient health results that matter, not the volume of services delivered. But results are achieved at some cost. Therefore, the proper objective is…patient health outcomes relative to the total cost (inputs). Efficiency, then, is subsumed in the concept of value. ”

Source: Porter ME. (2008) What is Value in Health Care? Harvard Business School

Thirdly, Paul Batalden, one of the most highly respected figures in improvement science, and who published Quality by Design in 2006, does not appear to be publishing a second edition with this title but is publishing a book this year by himself and the same set of authors called “Value By Design.”

Fourthly, the clinical guidelines Committee of the American College of Physicians has published an excellent position paper on “Concepts for Clinicians to Evaluate the Benefits, Harms and Costs of Medical Interventions; High Value Cost-Conscious Health Care.”

Finally, one of the originators of the quality movement, Robert H Brook, wrote a leader in JAMA with the arresting title of “The End of the Quality Improvement Movement” sub-titled “Long Live Improving Value.”

Even if an intervention has been shown to be effective, and is delivered at highest quality it may not be deemed of adequate value when compared with the value that would be derived if the resources were used in another way. High quality will be assumed by commissioners, necessary but not sufficient, Bye Bye Quality, Hello Value.

Muir Gray is visiting professor of knowledge management, Nuffield Department of Surgery, University of Oxford.