Some thoughts on health and healthcare

Abstract Healthcare quality measurement routinely relies on structure (resources), process (actions), and outcome (results) indicators, often combined into broader “quality indicator” systems. While foundational, each indicator type is vulnerable to confounding, weak causal interpretability, data artifacts, and behavioral distortion when linked to accountability or incentives. Building on Donabedian’s framework for evaluating quality and modern guidance on measure evaluation and lifecycle management, this essay proposes a practical governance approach: (1) mixed-method evaluation that triangulates quantitative signals with theory-driven and qualitative inquiry; (2) anti-gaming measure design that anticipates Goodhart/Campbell effects and reduces manipulability; and (3) periodic reassessment that treats measures as adaptive social instruments requiring continuous validation, recalibration, and retirement. The central thesis is that credible quality assessment is not achieved by “bet...

 The idea of 'value-based healthcare' (VBHC) isn't entirely new. The concept of evidence-based quality improvement goes back to the 1850s with Florence Nightingale and her collaboration with the medical statistician William Farr (E.C. Kudzma, 2006). In medicine, a result- or outcome driven approach goes back to the 'End Result System' of Ernest A. Codman and his article on ' A Study in Hospital Efficiency: As Demonstrated by the Case Report of the First Five Years of a Private Hospital ' (1914), in which he stated: "Every hospital should follow every patient it treated to determine whether the treatment has been succesfull for this patient, and should inquire - if not - why not - with the view to prevent similar failure in the future" (E.A. Codman, 2013). Codman put forward three core principles of quality assurance (QA): Examining quality measures to determine if problems are patient-, system-, or clinician-related Assessing the frequency and p...