Before Method: The Capability Manifesto

The Capability Manifesto:  Quality as Capability.

Improvement is a capability science. Aristotle in his ‘Metaphysics’  made the distinction between the potential and actual. Improvement Science exists because of the gap between efficacy and effectiveness; between fact and value; between the general and the particular,. between ‘idea’ and act. The late Hilary Putnam [he passed away a few months ago] in his best selling book ‘ Collapse of the Fact – Value Dichotomy’ made the noble laureate Amartya Sen’s attempt to bring economics and ethics together through his ‘capability approach’, the central exemplar for fact- value entanglement. Martha Nussbaum’s and Amartya sen’s capability approach was largely inspired by Aristotle’s distinction and by the absence of the fact-value dichotomy in the otherwise empiricistic  Aristotlean science.

Quality requires an Aristotlean mind, not just in its encyclopedic breadth but in embracing a normative epistemology.  Persig in his ‘Zen of Motorcycle Maintenance’  offers a ‘metaphysics of quality’ that  derives from the Aristotlean description of ‘Arete’, that can be closely translated as ‘virtue’. It is thus common to quote ‘the philosopher’ thus : ‘excellence is not an action but a habit’ i.e it cannot be an accident. Dunamis the Greek work for potentia easily translates into modern English as capability or dynamic. Aristotle uses the word in a ‘strong sense’ to refer to ‘ how something could be done well’. Actuality is translated  Energea/ Entelechy [rightful completion] and in modern English loosely as Kinesis .  For Aristotle the transition required reason [knowledge] and desire [will]. Shewart and Deming provide ‘the method’.

Capability has different connotations in strategy [ dynamic capability ] and in statistical process control [as process capability]. Here, the manifesto is about capability as the ‘conditions that make quality possible’ and thus is about the relationship between quality and improvement and at a more abstract level between theory and practice. Popular ways of describing capability is the reflexive aim of ‘ getting better at getting better’ or as Dr Brent James would describe ‘virtuous healthcare’ by insisting on ‘doing good by doing well’. The tension between ‘good’ and ‘right’ has been with us since Kant through Habermas ,Rawls etc. A mechanistic , instrumental view of improvement would limit it to the pursuit of the ‘right way’ alone.

We often tend to view capability as quality. Yet quality is a current state, not something in the future. Capabilities are the conditions that make improvement possible. Capability is ability of a system. More specifically it is the ability/ attributes of the outcomes. Here, Quality is not used in terms of outcomes [ it should already be obvious that quality is not a process but an outcome . The control chart for example always plots outcomes] but as the pursuit of the basics. Thus capability is the answer to the question: What are the goals of healthcare?  This can be reinterpreted as : What is it that the public values about healthcare ?

Improvement Science is not merely about the implementation of evidence , the ratification of ideas or the survival of organisations. It is about the ‘validation of healthcare.’ It is the answer to the fundamental question : Does healthcare work? Improvement science is about creating the ‘critical space’. It is the ‘critical theory’ of healthcare. Critical not in terms of negative or even constructive criticism but in ‘elucidating the conditions for the possibility of healthcare’. If healthcare works , then what are the conditions that make it work.  The word ‘critic’ has this transcendental notion since the time of Kant. Charles Sanders Pierce who introduced the notion of ‘ abduction’ was so enamoured of Kant’s ‘The Critic of Pure Reason’ that he is said to have spent several hours daily reading it and is believed to have known it by-heart.

If one is uncomfortable with the idea that healthcare actually requires any justification , it is important to scrutinise the relationship between health and healthcare. The sociology of health literature has questioned this relationship which most healthcare professionals have taken for granted. Improvement science is in ‘essence’ the study of the ‘problematic’ of Healthcare.

Thus the ‘idea of capability’ has a rich conceptual legacy and in this manifesto we have merely borrowed it to provide the metaphysical ‘arguments for a better healthcare’:

  1. Capabilities treat processes / systems/ communities as resources. It is a ‘patterned activity’ not an ‘ one –time, idiosyncratic change in resource base’.
  2. Capabilities view processes and systems  along a maturity model. It is not a grading process but a graduation process.The maturity model thinking is attributable to Crosby : quality management maturity grid.
  3. Capabilities define processes in the future state : unlike flow charts that represent current perception. As potentials they are pre-systemic, pre-methodical .
  4. They are supra-sytemic and meta –systemic. Being presystemic and metasystemic they are understood as design. Thus can be decomposed into logical and conceptual and physical components .
  5. Organization currently do not manage capability: they think in terms of strategies and tactics. Capability is a systemic view point .Besides strategic management and operations management healthcare organisations  need to focus explicitly on capability management.
  6. Greater sensitivity to culture , context ,belief systems , values unlike the engineering model of process management [ efficiency / effectiveness]and technological model of creativity[ modernity] and the testimony model of evidence based medicine.[ technical rationality].  Capabilities provide a  thicker description of processes .
  7. Capability determines how and whether ‘healthcare systems’ are utilized. This utilization perspective is in contrast to the resource – based perspective of infrastructure development and system development. The key issue in developing countries is underconsumption of healthcare [ different from developed countries ] and when they consume they are overconsumers of therapy [ whether good or harmful ]and under consumers of prevention[not different from developed countries].
  8. Capability approach makes improvement local , specific and contingent . At the same time is not merely additional effort . It is a process of democratizing excellence.
  9. Not limited to the inputs and outcomes but what happens in the ‘encounter: ‘ how the needs are met’. Thus sustainability , spread , participation of user , disparity redressal are not add-ons but built within the a ‘wide- angle view’ of the process design.
  10. Capability approach lends itself to a. to provide situation analysis b. identify the frame work for evaluation and methods and tools for improvement.
  11. Views the consumer of healthcare as “ ‘learning’agent rather than patient “.
  12. Capabilities deconstruct currently prevalent ‘Resources bias’: resource rich therefore capability rich. Similarly, developing countries because of poor resources  view their capabilities as poor. The fallacy arises because we  tend to see all resources as purely ‘given’  and fail to recognise that there can be resources that are merely ‘derived’ resources . Capabilities thus  creates a context of resourcefulness. A new definition of accountability. A defiance of victim mentality. The default state is resource poor / capability rich. The developed countries are resource rich / capability rich. There is no condition of ‘capability poorness’ that is natural . Thus there is merit in using resources  to increase functioning or capabilities. To do that ,what needs to be altered is opportunity. Opportunity is not capability. Effective opportunity with effective change is systemness.
  13. Resources are not a given – they are always finite. Capability is used to create resources. Abundant Resourcefulness.[limited resources+ adequate imagination]
  14. Idea of opportunities that are not given but constantly ‘divined’. They can be designed or discovered.
  15. Capability consists of effectiveness[achievement or accountability] and agency[freedom or opportunity]. Effectiveness achievement and effectiveness freedom/agency achievement and agency freedom.
  16. What kind of opportunity and what kind of change? It is change- oriented opportunity.
  17. The path from opportunity to systemness is not linear. You can’t see systemness from opportunity but is ‘u’ process. The process is a fractal. The U-process between opportunity and change and further between change and systemness. Current methodologies of improvement science are focused on the C-S Process.
  18. Systemness warrants spread and sustainability.
  19. The entire process is a emergence . The systemness is embryonic in the opportunity and gets modelled by change. It moves from being – knowing – doing and having. Requires a philosophy of the present[ opportnunity ] and a philosophy of the future[ systemness] , not merely a philosophy of change .
  20. Capability operates beyond supply and demand, unlike cost-cutting.
  21. Capability is context sensitive.Not context determined. There are no problems but only problem situations. To transform you have two options: problem oriented or solution oriented. Opportunity is solution oriented. Problem orientation is structural in evaluation and implementation. Solution orientation is functional in evaluation and implementation. Capability is the ability to find valuable solutions to problems of your choice. A a- historical view of improvement as a right. It is a ‘patterned activity’ not an ‘ one –time, idiosyncratic change in resource base’.
  22. Improvement is a validated capability. Quality is validated opportunity and validated change. You can have improvement without quality but not quality without improvement. All change is not improvement and all improvement is not quality. Improvement science is improvement by quality. There are other ways of improvement: technology,policy, resources, regulation, rules, placebo, hawthorne.
  23. Improvement by quality can be strategy based or capability based. Strategy[ not alone , it must degenerate into work] can be capability and capability can be strategy[ ie strategic capability ].
  24. The chain of effect moves from small to big , local to global , present to future.
  25. Complexity of the past and the complexity of the future.
  26. The time span of opportunities[ window of opportunity] is different across the chain of effects . It is constrained/ fleeting in microsystem but allows for long-term thinking in the macro-system.
  27. The question is not whether there are methods for increasing opportunity , but whether all methods of improvement increase opportunity. All change is not isolated action, but change has a pretext. Opportunity infuses meaning to change.
  28. Strategy matrix:
Opportunity Change Systemness
Knowledge of Discipline + ++
Knowledge of Improvement + +++ ++++
Evaluation ++ +
EBM +++ ++
Implementation Science ++ +++ ++
Research ++
  1. Method model matrix
Scenario planning ++++ + +
Strategy Planning ++ + +
  1. Healthcare Improvement Index: that widens the narrative of improvement to include opportunity. The Improvement Life cycle : Opportunity – Change – Systemness.
  2. Systemness is the wellbeing or flourishing of systems. Currently they are evaluated narrowly in terms of outcomes such as effectiveness and stability of processes.There is a need to go beyond the input – out models. In developing countries all the more relevant  as the mere availablity of a resource does not guarantee its use. Thus there is a need to understand utilization as a system problem.
  3. The improvement milieu

Improvement is itself a complex . Complexity is not limited just to healthcare or medical knowledge.

  1. Also used as a descriptive tool to understand why some improvement initiatives succeed and others fail .More importantly why improvement science is not yet in vogue in developing , why certain professional groups or even certain individuals in particular are enthusiastic. The effectiveness of participatory resources.
  2. Comparison for capability can be used to adjust effectiveness and enhance adoption of best practices. For example , the efficacy of rrt’s should be considered under framework of the severity of patients on the floors, the nurse patient ratio, the proximity of critical units and the availability of ICU beds , the expertise of general staff in CPR etc.
  3. For quality to be professional rather than the mechanism of management control of the professions. Allowing the mastery the professional’s value or/and the outcomes the patients desire.


Dimensions of Healthcare Quality Comment
Access Cost Safety Timeliness Effectiveness Equity /gender etc. Capability sets chosen in the system.
Design-achievement Effectiveness
Design freedom Opportunity
Agency achievement Effectiveness
Agency freedom Opportunity


  1. Systemness is a composite but not necessarily unscrutable. It can be defined and measured depending on the chosen capability- sets within that system. Not only capture the design achievement [or design quality] as well as agency achievement or performance quality , but also include two other elements of agency freedom or choice/autonomy and final what is often ignored access/ right to design that is crucial factor in engagement . The famous expression “ every system is designed to get the results it gets “ makes sense only because we have assumed a framework that does not include design freedom. eg. in manufacturing industries, the production department cannot change the design. It could equally be expressed as  ‘no system can be designed to produce anything other than what it is designed for “. In this case, the tautology falls apart.  Therefore all systems must be designed.
  2. Problem situation vs problems.Most problems in daily work-life have obvious solutions. What problem situation requires to stand back and study the ‘solution’. How far should we go back . This problem ,or the same problem earlier .
  3. Capability and Learning

Learning is part of improvement. However, there is a subtlety involved in capability . It is the difference between ‘learn about’ and ‘learning to be’. Capability is ‘learning to be’. Capability is not the mere ability to do something but to make something, to become something. Learning to learn is a ‘learnable’ or ‘dynamic’ capability.

  1. Capability and Improvement.

Capability is about creating the conditions for improvement. However, improvement itself can create capability. Thus capability can also be seen as effects. While outcomes are ‘downstream effects’ , capability are ‘upstream effects’. The relation between capability and outcomes is nonlinear and linked by methods. Capability is quality before method.

  1. Capability and Competence

Competence is about the past. Capability is about the future i.e an ability in new situations. Capability is heutological. It is not built on certainty but on openness. The nature of collaborative knowledge is rhizomatic. Why is not a mere ability ? Just because you know you cannot do. There are interdependent , external necessary and sufficient conditions. It does not start small and grow. All its necessary and sufficient conditions must be present. Capability Maturity is merely additional. Capability is not the degree of match between theory and practice , but the conditions that allow theory and practice to come together. Capability is about sufficient conditions, though in ordinary parlance it is tempting to view them as merely necessary conditions.

  1. Capability and Process.

A process is resource dependent .Capability is about resourcefulness. Capability is a creative progress. Processes are driven by causes. Capability by possibility. Capabilities are free.They are limited only by the limits of imagination.

  1. Capability and System

Capability is the ability of the system to meet the needs . As needs will change , capability remains a ‘ongoing process’ rather than a fixed, ‘once and for all’ system. It is systemic , not a science.It is an micro- macro assemblage.

Equating hospitals with healthcare is a category mistake. Capability is a property of the community not the system.

  1. Capability and Quality.

Capability is a common or public good: Unlike Quality which  is a competitive good, Capability is a collaborative good. Quality is driven be demand and supply. Capability is free from economics: ‘opportunity and capability’ replace ‘demand and supply’. Capability is the ‘socialisation of quality’.

  1. Capability stays: Capability prioritizes sustainability and spread.

The socialization of quality , of not merely ‘doing work’ but also ‘ improving one’s work’ requires the broader idea of capability.  The post offers theoretical justification , leaving the empirical verification to practioners.

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