Accountability Through Measurement: A Global Healthcare Imperative, by Vahe A. Kazandjian. Milwaukee, WI. ASQ Quality Press. 2002. 353 pages, hardcover, $45.00.
Although this is a small book in terms of physical dimensions, it is a big work in terms of its scope and the ramifications of the author's study of the relationship between health care provider and patient or client. Kazandjian raises some challenging questions about our customary approaches to evaluating and improving patient care. There is a lot here to get your arms around.
Kazandjian summarizes the thesis of this book in the following terms:1
* A contract exists between the provider and the recipient of health care services, implying accountability on the part of the provider.
* Accountability requires measurement and evaluation.
* Evaluation efforts are influenced inevitably by tradition and precedent.
* Providers of health care services not only deliver services, but also shape the expectations of the recipients of services.
A useful concept called "the accountability contract" is introduced as an effective way to look at and evaluate the performance of health care organizations and professionals. Kazandjian holds that a contract exists between the health care provider and the client or patient because the relationship involves an agreement that, if performance fails to meet expectations, the client or patient has the right to terminate or modify the contract. He goes on to say that accountability cannot be achieved unless there is full disclosure of the performance measures to the recipient of the services in question. This concept and its implications are neatly illustrated in a figure, "The Functional Dimensions of the Accountability Paradigm."1
The author devotes most of Chapter 1 to a discussion of the historical and behavioral components of this relationship. With his examination of the final three components, dealing respectively with the tools for reporting performance, the method of evaluating performance, and the mandate to amend or revoke the contract, the analysis turns to the bread-and butter, everyday issues in quality management. Here Kazandjian takes up the broad issues involved in reporting (such as selecting what to report) and evaluating performance in a thoughtful, reflective fashion not usually characteristic of discussions about data collection and interpretation.
Reflecting on Donabedian's structure-process-outcome model, the author challenges the primacy we currently give to outcomes per se, by introducing the issues of "goodness" and the appropriateness of the provider's decision making. He makes a strong case for addressing the relationships among structure, process, and outcomes in evaluating care rather than focusing exclusively on outcomes. Kazandjian's wide-ranging examination of accountability includes a look at Weber's "ideal type" model of the professional (in this context, the physician) as the repository and guardian of the knowledge and values that support performance measurement and improvement.
Kazandjian calls for an introspective analysis of health care practice and the assessment of efficacy and effectiveness of care as the first step in the comprehensive evaluation process. He suggests that greater understanding of the challenges in producing services and a more evidence-driven justification of the types and nature of those services may cause both providers and recipients to adjust their expectations to more realistic levels.
In an excellent chapter on measurement strategies, the author discusses epidemiological review methods and the differences between what he terms the "visual" and the "auditory" cultures or approaches to data collection and interpretation. His visual culture is represented by statisticians and all those who comfortably rely on graphic and tabular displays of data, and are accustomed to making decisions on the basis of such displays. In describing the auditory culture and its role in evaluation, he points to the need to capture those aspects, often subjective and behavioral, of the care process that cannot be reported and displayed in a quantitative way. This is an interesting and thought-provoking discussion. The chapters addressing report cards and the role of root cause analysis in evaluation are well done.
Chapter 8 consists of eight reports "from the field," addressing studies, observations, and new directions in health care performance evaluation research. Reporting in are experts from Austria, the Czech Republic, Denmark, Flanders, Hungary, Singapore, and the United States.
Vahe A. Kazandjian, MPH, PhD, is president of The Center for Performance Sciences, Inc., senior vice president of the Maryland Hospital Association, and adjunct associate professor at the Bloomberg School of Public Health and Johns Hopkins University in Baltimore. The compelling subject matter, the breadth of the author's interests (going back to Max Weber and Sociology 401), and his insights and originality make up for the fact that the writing could have been tighter. No matterthis is a volume well worth spending some time with.
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