Glass Houses and the Glory of the Climb

Every day you may make progress. Every step may be fruitful. Yet there will stretch out before you an ever-lengthening, ever-ascending, ever-improving path. You know you will never get to the end of the journey. But this, so far from discouraging, only adds to the joy and glory of the climb.–Winston Churchill

The Institute of Medicine's Committee on Quality in Health Care in America recently concluded that “Health care today harms too frequently and routinely fails to deliver its potential benefits” (1). The potential for harm and failure is perhaps greatest among vulnerable older Americans because they are more likely to have chronic conditions and, as a group, they are the largest consumers of health care. Thus, improving the quality of care for vulnerable older adults is a major challenge for the U.S. health care system. Before one can improve quality, however, it is first necessary to define what “quality” means and then devise a strategy to measure it. The Assessing Care of Vulnerable Elders (ACOVE) project “endeavored to develop a comprehensive set of quality assessment tools for ill older persons” [2]. To accomplish this seemingly straightforward task, the project team had to do three things: 1) develop a definiti of vulnerable elders; 2) identify prevalent and treatable target conditions among older adults that might be amenable to quality improvement efforts; and 3) develop quality-of-care indicators for these conditions that were supported by a reasonable scientific evidence base or at least expert opinion. Developing quality assessment tools for older adults is an important, overdue, and highly complex undertaking.

In their response to the storm on the horizon, the ACOVE investigators have chosen a rain gully as a site on which to build a glass house. Indeed, it is easy to scrutinize this project from the high ground with …