The language of health care has had dramatic change – we now commonly use terms like patient centred care, quality outcomes, accountability, and so on in our description of a current or desired state for health care systems and the delivery of care.
One discussion I do not hear frequently enough is a discussion of values in health care. I’m not talking about values of individual patients or values of practitioners or values of funders, but a discussion of the values of the health care system itself. The values that determine how we conduct ourselves as a system, how we make difficult decisions, and how we approach the increasing number of dilemmas our system faces.
Our system doesn’t really have clear values. The Canada Health Act lays out five conditions for federal funding of health care (public administration, comprehensiveness, universality, portability and accessibility), but these aren’t values, they’re legal conditions for the transfer of dollars. They don’t provide us with very much guidance when it comes to making hard decisions about something like appropriate allocation of resources or transfer of care from one environment to another.
I’m also not talking about value for money, nor the need to work within fixed funding envelopes or adhere to budgets; these are not values, they are constraints within which our values must operate. Instead, values help us determine whether we want a hospital-based health care system. Of course we already have a large, expensive, hospital based system and those practices, as much as the hospitals themselves, are solid, difficult to repurpose or change, and have been created at great expense. Clear shared values can help us with the enormously difficult task of changing course, if that’s what we decide needs to happen.
I think we need a thoughtful discussion of values, where we clearly articulate shared values that we can rely on to inform decision making, can assist us to cut through the morass of conflict when encounter difficult of troubling decisions, and can use to backstop our decisions when we have made them.
In an era where the practice of medicine is more complicated than ever and we are having to do more with less (despite ever more expensive tests and treatments), we need values to guide the health care system. This discussion won’t be an easy one. It transcends individual preferences, political demands, provider wants – all of them.
My worry is that if we do not start defining the values of the health care system, that the courts will make the decisions. We have seen the courts intervene in a number of circumstances and those decisions, independent of the reasons for their original filing, and independent of the benefit to the patient, may or may not be helpful or healthy for the health care system.
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excellent blog and much respect to all here! As a patient I find it curious to note that one of the pillars of health care that I was taught since health class in grade school was proper nutrition but no mention and not just here every where. I am not talking about nutritionists I am referring to “food” there is one other “person” who provides me care in the hospital “the cook” and if you ask me or any other patient I am sure they will say ” when I am hurt/sick and trying to regain my health and wellness food is VERY important! good quality food when I am in a bad way and trying to leave a hospital bed and go home or just survive is what I know is good for me and when I am fed food ” I think is not good food I lose faith in the values of getting me healthy and back home!
My whole point is FOOD is definitely a pillar of health care for patients and should be treated as such by the system but it is not because of the aforementioned ” constraints to our values system! please all of you health care providers embrace the food cooks they are doing just as much for me as every one else caring for me! and I can connect with food way better than medicine.
I challenge anyone any where to walk into a bakery and not feel BETTER and then remember how I feel in my bed when the food comes to me? my mental state of mind can easily be boosted or depressed by food acting on that info is health care to me
Hi Jeff. I agree that food is very important. We did run a story on hospital food a while ago –
http://healthydebate.ca/2012/05/topic/cost-of-care/hospital-food
I think the most important point that Dr. Macleod makes is that there is a mismatch between what we would all like our health care system to be and the resources/funds to deliver them. To talk about improving the system by more transparency does not address this fundamental problem. We can try to make things better by inspecting and improving them but the reality is that we do not have the resources to provide the totality of state-of-the-art care.
We have to exit this pipe dream. We have to make difficult and bitter decisions on where and how we change and go forward with our health care system. We need to have these discussions soon or as Mark has said the squeaky wheels will have the advantage.
Congratulations for Mark writing his article and for everyone, including Mark’s continued discussion.
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May 6, 2013 at 1:17 AM
I think the most important point that Dr. Macleod makes is that there is a mismatch between what we would all like our health care system to be and the resources/funds to deliver them. To talk about improving the system by more transparency does not address this fundamental problem. We can try to make things better by inspecting and improving them but the reality is that we do not have the resources to provide the totality of state-of-the-art care.We have to exit this pipe dream. We have to make difficult and bitter decisions on where and how we change and go forward with our health care system. We need to have these discussions soon or as Mark has said the squeaky wheels will have the advantage.
Congratulations for Mark writing his article and for everyone, including Mark’s continued discussion.
I would be so interested in feedback from those who are participating in this discussion regarding resource allocation.
We can, and must, identify and articulate system values, as Mark has discussed.
We can, and must, operationalize those values into specific behaviours, which are monitored and evaluated.
We can adhere to those values and behaviours within the context of a publicly-funded and equitably applied health care system.
Do we have any structural control or recourse regarding those who “jump the queue” within the system, through personal connection and/or wealth or influence?
Gerry wrote: “We have to exit this pipe dream. We have to make difficult and bitter decisions on where and how we change and go forward with our health care system. We need to have these discussions soon or as Mark has said the squeaky wheels will have the advantage. ”
I totally agree and I would add that I believe that these decisions are presently being made covertly according the values of the physician, cultural values of a given department or in some other manner. I would say that we need to have these TRANSPARENT discussions now, before there is a significant erosion of public trust.
Barb…
I agree the emphasis has to be transparency. In that context, we need input from
the supply side and the demand side.
As an indicator , for my self on the demand side I attended the CMA forums on two occasions. In the first I logged 100,000 words and the range of input from users of the system dominated and were wide-based.
In the current one I am up to 13, 000 words and the supply side is mostly shadowing the comments that declare: patient’s are given limited service, little concern for delays, dramatic stories involving life and death, poor connections to any referral.
In real life I know patients in the top 5% treated like royalty with meticulous treatment regimes ( e.g. diabetes)
This scenario could lead to even physicians and hospital removed from the legislated protection of the Canada Health Act( versus broader inclusion of regulated professionals ).
The only thing that can result in the “preferred status” of the supply side is the biggest apology on the planet!
In the US that led to the book ” To Err is Human”. In Canada perhaps we could add to that with ” To Forgive is Divine””
From a doctor’s perspective, the value is to do the best thing for the patient at all times. But as we all know, there aren’t many doctors in the system. The rules are made by businessmen and politicians, and their values are in drastic conflict to our own.
I think in order of medicine to establish a clear set of values, it needs to have a clear set of leaders.
But I ask what is the best thing for the patient? I’m no longer sure what that thing is or how to know – and we should have a pretty good idea of what that thing is before we have to encounter the specific patient .
There are two sets of rules in the system – the policy rules which might be clearly articulated but then another set of rules that are unwritten – and those are the rules made by providers of all sorts. I think we need strong leadership in health care and I am increasingly of the opinion that doctors are GENERALLY woefully ill-equipped to provide that leadership . . . . we need to choose and train physicians differently . . . but that is a topic for another day.
People have been saying that we need to choose physicians differently. I don’t know if things have really changed that much since I graduated in 1976 but even ophthalmologists need to look at the whole patient. I believe that I personally try to know what is in the best interests of my patients. I have told children that “ideal” care would involve dragging a mildly demented parent for tests and other opinions. I have taken the burden on myself to tell the children that I believe the chances of helping the patient are real but unlikely. I suggest that on balance I suggest not doing the “ideal”. Some might say that I am “playing God” but I feel that I am just accepting my responsibility as a physician.
I may have strong opinions at times but I don’t believe that I am an arrogant person. With my medical and life experiences I feel than I am doing what is best for my patients by sometimes taking burdens off them when I can and when it is reasonable. I would like to believe that my colleagues do the same.
As for the choosing of physicians, we still have not mastered that, and we never will.
The training, however, is something we should, and could, change. Perhaps a new specialty – Administrative medicine – could be started. It would serve a far greater purpose than half of the things listed currently: who even goes into things like general pathology (lab techs) or nuclear medicine(to be replaced by radiology). Redistribute funds to help train physician leaders and administrators!
This is indeed a worthy series of questions.
Universally we bring our values to the work. So they vary between people, they change within ourselves over time, and those values coincide with the patients, or the publics, by some miracle of social homeostasis, or doesn’t.
And its difficult to attach values to our train of thoughts…when the train is travelling at full speed.
For example, we now struggle with the issues of assisted dying, long after we developed the techniques to save those lives.
“we now struggle with the issues of assisted dying, long after we developed the techniques to save those lives.”
Very well said, Peter. I am going to steal these words and put them on Twitter.
The chronic and perpetual shortage of physicians plagues healthcare. strawman ama!
Thanks Mark for starting this discussion.
I thought I’d note that the Romanow Commission examined this issue and commissioned a citizens’ dialogue and report on values. That report can be found here:
http://publications.gc.ca/collections/Collection/CP32-77-2002E.pdf
The citizens that were consulted said they wanted to see greater transparency, earmarked taxes, an auditor general for health care, more intergovernmental co-operation, and a national ombudsman.
The values that citizens’ said should underpin the system were: universality, solidarity, equity, quality, fairness, wellness, efficiency and accountability.
One might quibble about whether each of these is really a “value” or not, but I think the work still stands as the most in-depth and rigorous ascertainment of Canadian values as they relate to health care.
Hi Irfan – thanks for this. This was important work and I suspect that the findings would largely be the same if it were repeated now. I think the values that were articulated in the report are a good reflection of thoughtful societal values – when people are not in the system as patients. I think that once the population members switch and become patients, and the patients of providers, many distortions can occur as the perception/needs/wants hijack the apersonel thoughtfulness of society . . . .
It’s interesting that I had a conversation around the end of my life with Bill last week – not because of any imminent demise (just to be really clear) and it was stunning to me that I didn’t say to Bill “don’t let me suffer” but that I said to him, “please don’t allow them to make me suffer”. Perhaps that says far more about me and my perspective on health care than I should say.
I am and have been a patient in our healthcare system for 30 years living with serious rheumatoid arthritis. I know you, as an orthopedic surgeon see patients like me on a daily basis. I actively participated in the Romanow dialogue and can say without reservation that the values of universality, solidarity, equity, quality, fairness, wellness, efficiency and accountability are extremely important to me. If these values were truly reflected in our healthcare system it would serve Canadians very well.
I agree with you, Irfan, about the values that SHOULD underpin our health care system. I believe that a major point Mark makes is that our resources are finite and this fact must be accepted and addressed. Even if we were to get tremendous value for our health care dollars, the resources are still limited. The fact that resources (manpower and money) are limited and that medical science’s achievements and future achievements will continue to make the gap between our wishes and our ability to pay for them even wider means that we have choices to make. Unfortunately, I believe none of our choices will be ideal nor will they be pleasant.
The first start in determination and application of values stems all the way back to the formation of Public Health and Hospitals ( a reactive “ad hoc” collection of services in response to a tainted meat scare )
Reports using “ values” as leverage stem all the way back to that community concept of caring and responding …..travelling all the way past good, better and best practices…and presently settling on “ good” ( civil ).purpose and “ right” person ( versus best).
Physicians are inside the world of evidence-based “ harm reduction” versus prevent /treat /rehab and you are looking at an ethical base that analyzes, compares and assigns on the basis of:
• Utility ( do benefits exceed costs)?
• Rights ( are human rights respected ?) Check how narrow the tribunal list is.
• Justice? Are benefits and costs fairly( equitable) distributed?
We have morphed from equality ( ?balance) to equity ( ?fairness ) that opens more than one door for those who still wish to bankroll equality for their own situation.
Companioned to this ?progression / declension is the culling of anything not devoted to “ equity”.
How does this effect the system ?
There is no “ healthcare” system ( just multiple reports defining how it should develop a standard of practice).
There IS a payment system supported by a legislated standard ,the Canada Health Act, where only physicians and hospitals are specifically named as the health providers . However this could be broadened or eliminated .
At present this gives great power to both to actually design a “ system” ( now there’s a thought )
%featured%One value of the health care system that I think is exceptionally important, much talked about, but often ignored (I note today’s media reports about five years of no public reporting by the Ontario Drug Benefit Program) is “transparency”. %featured%The quality of heath care is so important to all of us that a fundamental value should be that we publicly report on all aspects of our health care system. The onus should be on people to justify why they should not publicly report, rather than the other way around.
I suspect one reason that people are reluctant to publicly report is the culture of shame and blame frequently seen in the media, among politicians and others. There are clearly instances of care and management that is so poor that shame and blame is appropriate. However, in most instances we will only get better by approaching instances of suboptimal performance in a spirit of quality improvement – we measure how we are doing; if we are not doing as well as we should we work together to figure out why and how to improve things; and then we re-measure again. Perhaps another value should be “quality improvement before shame-and-blame” (yes – I agree – we need to find a more succinct and articulate way of stating that).
Andreas …..
I don’t think the thrust for ” transparency and accountability” should be confused with ” transparency and answerability” ( *D..A.D.S.)
This is an arena of sanctions.
Alternatives selected on answerability focus on public and political preference
Alternatives selected on accountability focus on governance choice
We are now organized horizontally transferring responsibility and answerability inside the program level and sanctions must work back to back with incentives.
Big debates have focused too long on alternatives and equivalents and now we need innovation.
Demanding innovation doesn’t work ( makes healthcare planners hide )
Seeking innovation starts with application of interprofessional P3 dialogue ( = synergy) and new working models should emerge making the dialogue the incentive and the outcome becomes “preferred choice”
To accomplish this every member of the value chain has to have a voice and a use **
*Regina Herzlinger ( Harvard)…supply side perspective
http://www.centerpointforleaders.org/articles_0303/systems.html
** Julio Frenk ( Harvard).. demand side perspective
http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1000089
(excerpt)
Part of the problem with the health systems debate is that too often it has adopted a reductionist perspective that ignores important aspects. Developing a more comprehensive view requires that we expand our thinking in four main directions.
First, we should think of the health system not only in terms of its component elements (like human resources, financing, hospitals, clinics, technologies, etc.) but most importantly in terms of their interrelations.
Second, we should include not only the institutional or supply side of the health system, but also the population. In a dynamic view, the population is not an external beneficiary of the system; it is an essential part of it.
A third expansion of our understanding of systems refers to their goals. …. improving health. ;distribution; responsiveness; legitimate expectations of the population ;fair financing….
Finally, we should expand our view with respect to the functions that a health system must perform.
( end of excerpt)
Keith- I can understand that there are many times where a physician can accomplish providing appropriate care for his/her patient while being mindful of the wise use of limited resources. Yet, I believe there are times, for some patients, where there might be a conflict and where the personal values of the physician might result in the provision of care that some might deem to be unethical.
I understand Mark’s comments to relate to these situations.
At this point I have two primary concerns:
The first is of providers to use the system to do what they want, when they want, how they want – without necessarily having to justify those decisions or to provide evidence that there is value in the service provided.
The second is what I call for lack of other terms, patient and population expectations and how do those expectations match or not match the ability of the system to provide . . . . if the system can’t meet the expectations of the population, are the expectations wrong or the ability of the system to provide/meet expectations wrong, or both.
In what seems to be a perpetual mismatch, what are the values that the system uses to decide how and who receives care?
%featured%Thanks everyone for your thoughtful comments. I realize that I have looked under the lid of a big black box . . . %featured%I didn’t write to give answers but to ask some questions.
I’ve heard someone say (my memory escapes me who) that value leadership required intelligence, integrity, innovation capacity, and interpersonal skills. It may be a stretch to apply these principles to a leading health care system – but perhaps not. Such a system would be informed by good quality data, would have integrity about decision making, would be at it’s core innovative to provide better quality, better value care, and would treat people well. These are perhaps qualities that inform HOW a health care system works but perhaps again, not why or to what end it exists.
I worry about the interplay of what we understand as human rights and charter rights with the capacity of the system to deliver. Is the health care system to provide whatever users or providers want to have/do? Is that really what it all boils down to? Is that the baseline value or denominator? Because if that is the baseline value either chosen, implied or imposed, then health system reform is pointless because it will always be those with the loudest voices, or best connections who will trump any process.
If however, the system is built on another set of values there is a framework for decision making. Again I’m not suggesting that I know . . . but do values such as equity, beneficence, fairness, societal benefit, effectiveness have a place in the discussions of how the system is to operate and make decisions. I don’t think we want a system where users can make unjustified demands, or providers can make decisions that serve only their interests whether for the good or ill of the patient. . .
I do worry greatly about where we are headed – despite all we say about changing the system and how we deliver care – I’m not sure we have addressed/defined the fundamental values of the system. In a system that will never have enough funding, and in one that is increasingly challenged by the cost of care versus the funding of care, what does it value??
Thanks all for listening to my musings. It’s hard even for me to hear myself because the thoughts feel quite amorphous. I am convinced that unless we articulate system values, we will continue to struggle and more of the system’s true capacity to make decisions will be taken from it.
I completely agree with your comments Mark and I think you have articulated them well. It is a difficult subject to discuss but the conversation needs to begin. In the absence of the discussion and a transparent framework for decision-making based on the values we can agree to, the distribution of resources might not be fair and may in fact be discriminatory in some cases. Furthermore, imposing the act of non-transparent rationing on the physician might risk his/her integrity, causing eventual lack of public trust.
Barb – it is an interesting world that we work in. Resources are not infinite – in fact in many ways we don’t even come close to real need. And yet I think we make decisions every day both individual and policy wise that are not well thought out from an ethical perspective, or even from a sense of basic value added analysis. Why is mental health chronically underfunded when at the same time we have all manner of palliative chemotherapy agents/programs? – how these questions get played out in the real world is complex and painful
Clearly articulating societal values for health and wellness, as well as how we die becomes important as a framework for health care decision making.
I have just happened upon this discussion, with tremendous gratitude. I have worked in addictions (not in direct care provision however) for over 20 years, and in mental health as well for a part of that time. Within that sphere, I have had this discussion with service providers and managers for years: there are vastly inadequate resources available to meet demand, let alone need; how are you *planning* (rather than reacting) to make the best use of those resources? what are your criteria for those decisions? how are you managing the client flow between intake, service delivery, and exit, in order to make sure that the highest need clients (and how to you define those) are being served as priority?
I have never experienced these discussions being carried through to a decision point.
Further, I have worked in the systems aspect of health care for that period of time, to one extent or another, and I have no experience of similar discussions being completed in the larger service array (one cannot say ‘system’ of course).
Yet decisions *are* made, daily, by service providers at all levels within all parts of health care. They are, as was noted earlier, largely made covertly, and individually, and against no identified (let alone transparent) criteria or with clearly articulated and adhered to processes.
It is not only the courts who will make/are making these decisions. If we, as a society, don’t make them collectively, and thoughtfully, they will continue to be made this way–to our detriment as a society, and as individuals, whether service recipients or providers or significant others.
Dear Mark,
Greetings from Australia.
It is heart warming to see an Orthopedic Surgeon start a debate about healthcare system values. It is even more remarkable that you raise value leadership in your discussion.
Please permit a humble individual make the following observations and comments:
1. the world is getting more complex with constant discovery
2. the level of consciousness/awareness of issues is not the same at every individual person’s level
3. as cost to serve in health rises exponentially instead of linearly, autonomy becomes paramount in determination of outcome
Fundamentally, at a leadership level, healthcare delivery is to me an issue of individual autonomy versus community autonomy. Due to economic constraints, healthcare services have to balance who and how many we serve with which people to serve.
The reason why providers and lobbyists with the loudest voices often triumph is usually because no one else can make a counterpoint coherent and compulsive enough to sway decision makers.
Similarly, the reason why users often succeed in their demands are decision makers lack the sophistication to defend an established practice or position
The third group implicit in all this is the people who lose out (users or providers). You see where I’m heading with this
It is in human nature that the individuals seek the best possible outcome for themselves. So clearly thought out reasons often triumph over mute indifference or lack of clarity of thought.
Debate and articulation is the best course possible in raising awareness and organizing consciousness. I applaud your blog.
Whilst I agree that values such as equity, beneficence, fairness, societal benefit, and effectiveness have a place in the consideration of such value leadership discussion, I add the following for your consideration:
1. Social conscience
2. Community obligations
3. Human progress
In a talk I was listening to yesterday, one member of the audience raised the question as more patients survive the epidemic (de-identified to protect the speakers comment to come), does society create a burden on its healthcare cost in the future? The speaker responded, “in public health and policy circles, there is a general consensus that national control of death is bad”. However, in Norway, the elderly community believe in dignified death! So go figure
Perhaps I would like to encourage a focus on your debate to the follow value principle:
One vs many: how should we decide?
Albert Ip
It is interesting how these discussions often wind their way to issues of dying and how people die. I’m not afraid of that given that we spend 50 percent of health care on people in their last year of life – and I wonder if we do need a fundamental re-examination of the purpose of health care – is it to prevent death or is it to provide quality of life?
I think your final question should be one of the constant questions asked as we look at what health care is – what is the balance of the one versus the many?
I’m less and less convinced of the need to continue to progress health care. We actually have pretty good ideas of the direct determinants and indirect determinants of health and we pretty steadfastly refuse to do/attend to them. So do we continue to try and prolong life when we actively work against health on a daily basis? How much life is enough?
Again, I’m trying not to let my own biases run free here. I suspect they, are, even too evident already. I’d like the arena of loud voices to be a little less loud and a little less influential.
Well stated Mark.%featured% Maybe the values we seek to articulate stem from the need for better ways to identify. balance and resolve conflicting individual values people bring to health and health care practices.%featured% Are there a set of foundational values that provide the necessary framework for resolving these ethical dilemmas (value conflicts) that are inherently part of health care. How will we directly or implicitly articulate the values inherent with policies, regulations, organizational and operating priorities of health services while meeting the ongoing demands of providing high quality health care? Is the Romanow Report, Lalonde Report, Kirby Report, Canada Health Act … and numerous large scale official reports a good starting point for framing the foundational values of the Canadian, Territorial and Provincial Health Care Services? Is there commonality between the values underpinning Healthcare in Canada and more universal International Values?
What values are timeless and help us navigate the ongoing changing in society and health care services as well.
I think in addition to Amy’s values I would add Responsibility. As a provider I feel I should be responsible not only for the health and well being of my patient but also a responsibility to the community’s healthcare dollar. It is a responsibility that we deferred to others for too long.
I would like to offer a glimpse of hope that values are still alive and well in health care. Upon my hire at our facility I was oriented as all of its employees are. A significant portion of the orientation was spent on installing right from the beginning this Catholic Health System’s values:
Values
We are called to:
Service of the Poor – generosity of spirit, especially for persons most in need
Reverence – respect and compassion for the dignity and diversity of life
Integrity – inspiring trust through personal leadership
Wisdom – integrating excellence and stewardship
Creativity – courageous innovation
Dedication – affirming the hope and joy of our ministry
I can attest that these values are expressed and practiced. These events are sometimes small in nature and perhaps largely unnoticed, but I do believe this value system is at the underbelly of what most employees are doing. Examples such as guiding a tired, lost patient to the correct floor or a visitor of a sick family member to the cafeteria for a much needed cup of coffee, to the personal connection many physicians are noted to have given.
I am generally realistic more often than idealistic, however, I believe values are still alive and well, we just need to be looking for them and their examples.
I completely agree with you Mark. As a non-provider, I have spent a lot of time researching the law, ethics, policies and practice as they relate to the provision of care for vulnerable patients. I definitely see a disconnect between what the system is willing and able to provide vs what patients expect, based on their understanding of the CHA and Human Rights. I understand that this disconnect causes a lot of moral distress among providers.
I am frankly quite concerned about the care my elderly loved ones will receive and whether they will be covertly rationed from receiving care that would be beneficial to them. I have learned that you need to be cautious and be prepared to challenge providers in these situations- and not just accept what the physician says as gospel. It distresses me that we have a system where “the squeaky wheel gets the oil” because it is not in my nature to be aggressive. Perhaps I am naive, but I would like to be able to trust the integrity of the physician and to know that he/she is acting in the best interest of my family –subject to transparent limitations in the system- and not secretly withholding tests or information because he/she is focused on the best interest of society in the form of bed side rationing.
It is a fact that we can’t provide everything for everyone yet nobody seems to want to admit that openly. I think values must begin with ensuring a system that the public can trust. Limitations must be transparent and developed in a manner that is fair and non-discriminatory. The public has a right to know what treatment will not be offered so that they can either pursue the care at their own expense if they wish or plan for appropriate end of life care.
Mark, you have had the courage to initiate this important topic. Who has the courage to take the next step?
I very much agree with this article as someone who holds an MSN and has worked in hospital based nursing for 10 years. I’m also a CRNP. I see this struggle on a daily basis and hear the frustration expressed by coworkers fhat doesnt necessarily reach upper management. The healthcare system is struggling and too many good workers are jumping ship. It’s too tied in to money and measuring outcomes by how much money is made. I do think our healthcare system needs to have a measurable value system and that allocation of resources is a huge issue. Too much is spent on things which may seem nice and fancy at the time, but then if you cannot afford to educate nurses and providers properly and patient care suffers as a result.
Mark, obviously you have reflected on this. Any value framework developing in your mind you could put out here as. A Strawman for debate? Also any thoughts on how to measure value. Most unambiguous are $ or hrs?