All or none measurement: why we know so little about the comprehensiveness of care

Abstract

In a recent article published in JAMA, ‘All or None Measurement Raises the Bar on Performance’, Nolan and Berwick describe the methods used by the Institute for Healthcare Improvement (IHI), the US National Healthcare Reports, the Joint Commission on Accreditation of Healthcare Organizations, the National Committee for Quality Assurance, and other organizations to examine care across a set of measures [1]. This approach, to state it simply, looks at data at the patient level to examine whether a ‘bundle’ or set of evidence-based interventions that are supposed to be done for the patient are actually done for the patient. The all or none approach, as Berwick and Nolan point out, has the tremendous advantage of offering a more complete picture of care across a range of aspects of quality for specific conditions. However, there are a number of practical limitations to this method which have been inadequately explored in the literature. Based on experience at the Agency for Healthcare Research and Quality (AHRQ) in the US National Reports, this approach has tremendous potential. However, until further research is done on the impact on outcomes of receiving ‘all’ recommended interventions and until consensus is achieved on the interventions that ‘all’ patients with a given condition should receive, the potential of this method will remain unrealized. When AHRQ applied this approach for work on the US National Healthcare Reports, first in the area of diabetes and then in the area of respiratory disease and cardiac care, the explicit goal was to try and move the discussion of health care quality away from the indicator-specific debates that too often dominate the health care debate in scientific circles in America. In devising the first US National Healthcare Reports, the AHRQ team received nominations for over 700 potential measures to be used in …