For years, the debate raged over which focus was the best...structure, process or outcome. Structure always presented the least challenge in measurement. Its inherent objective nature made it the easiest to quantify and assess, and eliminated so many of the issues around which we debate. Structure variables are present or they are not, making them nicely discrete.

Process was a focus of choice, particularly in health care's early attention to continuous quality improvement. During the late 80's to the mid 90's, process improvement became the clear winner. Though one could never "assure" quality, it was always possible to improve the process. This period set the stage for intensive measurement of how one worked. Strong commitment to process improvement often diminished attention to structure and outcome. Experts discussed (and still discuss) which process was the most critical, but for a period of time, there was no question that process was the most important of the three.

The mid to late 90's was the time for an outcome focus to be most strongly sought. Outcomes management and outcomes improvement were touted as the way to truly assure impact and quality. Even though we carry out a "perfect process," we said, it is always necessary to know that the end result met the desired goal. Structure, process and outcome debates had impact beyond or intellectual curiosity, as they set the stage for the nature of improvement work carried out in many health care organizations. This debate drove models, measures and roles. It captured attention and generated substantial amounts of literature. Yet for all the debate of the past, effective improvement efforts of today suggest that the debate was moot, and in fact each component is critical to understanding and improving quality. Essential structure elements, process elements, and outcome elements work together to reflect "quality" performance. No single element can convey the necessary whole.

So with the resolution of this three-way debate we enter the world of population-specific improvement. Significant improvements in care, service, and clinical impact have been achieved in sites all over the world through the focus on a clinical population. Honing in on one targeted group has allowed interdisciplinary teams to clarify the state of the art research, define essential care processes, and project necessary clinical outcomes to be achieved across the continuum of care. A proactive and continuous model for disease management has emerged. Using this approach, the 'center of the universe,' so to speak, becomes the population and meeting its need of maintaining health. The debate about the value of process versus outcomes is dead. This shift in primary focus of improvement efforts is a good thing, encouraging a more comprehensive understanding of the nature and impact of health care. The shift also encourages care givers to support intervention to maintain health, rather than only doing a good job in treating illness. Today's attention to population-specific improvement models, no matter how effective, does not suggest this will be the one true way to improve health care. Instead, I believe, it reminds us that there are new ways we can frame improvement efforts, many of which we have yet to identify. New models, new tools, and new approaches to improving quality are limited only by our intelligence and creativity in inventing them. Population-specific models for improvement have demonstrated very positive impact. While we should learn from those who have success stories in the use of this approach, it should be pique our intellectual curiosity in identifying other new models for making care more effective.

Patricia Schroeder RN, MSN, MBA

Editor