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Implementing Quality Measures
for Accountability in
Community-Based Care
for People with Serious Illness

PROCEEDINGS OF A WORKSHOP

Laurene Graig, Sylara Marie Cruz, and Joe Alper, Rapporteurs

Roundtable on Quality Care for People with Serious Illness

Board on Health Care Services

Board on Health Sciences Policy

Health and Medicine Division

THE NATIONAL ACADEMIES PRESS
Washington, DC
www.nap.edu
THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW
Washington, DC 20001

This activity was supported by the Gordon and Betty Moore Foundation. Annual
support for the roundtable’s activities is provided by Aetna Inc., Altarum Institute,
American Academy of Hospice and Palliative Medicine, American Cancer Society,
American Geriatrics Society, Anthem, Inc., Ascension Health, Association of
Professional Chaplains, Association of Rehabilitation Nurses, Blue Cross and Blue
Shield of North Carolina, Blue Cross Blue Shield Association, Blue Cross Blue Shield
of Massachusetts, The California State University Institute for Palliative Care,
Cambia Health Solutions, Cedars-Sinai Health System, Center to Advance Palliative
Care, Centers for Medicare & Medicaid Services, Coalition to Transform Advanced
Care, Common Practice, Excellus BlueCross BlueShield, Federation of American
Hospitals, The Greenwall Foundation, The John A. Hartford Foundation, Hospice
and Palliative Nurses Association, Kaiser Permanente, Susan G. Komen, Gordon
and Betty Moore Foundation, National Coalition for Hospice and Palliative Care,
National Hospice and Palliative Care Organization, National Institute of Nursing
Research, National Palliative Care Research Center, National Patient Advocate
Foundation, National Quality Forum, The New York Academy of Medicine,
Oncology Nursing Society, Patient-Centered Outcomes Research Institute, Sentara
Healthcare, Social Work Hospice and Palliative Care Network, Supportive Care
Coalition, UnitedHealth Group, and the National Academy of Medicine. Any
opinions, findings, conclusions, or recommendations expressed in this publication
do not necessarily reflect the views of any organization or agency that provided
support for the project.

International Standard Book Number-13: 978-0-309-48207-3

International Standard Book Number-10: 0-309-48207-0
Digital Object Identifier: https://doi.org/10.17226/25202
Epub ISBN: 978-0-309-48210-3

Additional copies of this publication are available for sale from the National
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Copyright 2018 by the National Academy of Sciences. All rights reserved.

Printed in the United States of America

Suggested citation: National Academies of Sciences, Engineering, and Medicine.

2018. Implementing quality measures for accountability in community-based care
for people with serious illness: Proceedings of a workshop. Washington, DC: The
National Academies Press. doi: https://doi.org/10.17226/25202.
The National Academy of Sciences was established in 1863 by
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Academies.

For information about other products and activities of the National

Academies, please visit www.nationalacademies.org/about/whatwed
o.
 PLANNING COMMITTEE FOR A WORKSHOP ON
IMPLEMENTING QUALITY MEASURES FOR ACCOUNTABILITY
IN COMMUNITY-BASED CARE FOR PEOPLE WITH SERIOUS
ILLNESS1

AMY KELLEY (Co-Chair), Associate Professor, Icahn School of

Medicine at Mount Sinai
AMY MELNICK (Co-Chair), Executive Director, National Coalition for
Hospice and Palliative Care
STEVE CLAUSER, Program Director, Improving Healthcare Systems,
Patient-Centered Outcomes Research Institute
LAURA HANSON, Professor and Director, University of North
Carolina Palliative Care Program
PAMELA S. HINDS, Director of Nursing Research and Quality
Outcomes, Children’s National Health System
REBECCA A. KIRCH, Executive Vice President of Healthcare Quality
and Value, National Patient Advocate Foundation
MURALI N. NAIDU, Vice President, Chief Clinical Officer, Sentara
Healthcare
WENDY PRINS, Senior Advisor, Quality Innovation, National Quality
Forum
CHRISTINE RITCHIE, Professor, University of California, San
Francisco, School of Medicine
JOAN TENO, Professor of Medicine, Oregon Health & Science
University

Project Staff
LAURENE GRAIG, Director, Roundtable on Quality Care for People
with Serious Illness
SYLARA MARIE CRUZ, Research Assistant
SHARYL NASS, Director, Board on Health Care Services, and
Director, National Cancer Policy Forum
ANDREW M. POPE, Director, Board on Health Sciences Policy
Consultant
JOE ALPER, Consulting Writer

__________________
1 The National Academies of Sciences, Engineering, and Medicine’s planning
committees are solely responsible for organizing the workshop, identifying topics,
and choosing speakers. The responsibility for the published Proceedings of a
Workshop rests with the workshop rapporteurs and the institution.
 ROUNDTABLE ON QUALITY CARE FOR PEOPLE WITH
SERIOUS ILLNESS1

LEONARD D. SCHAEFFER (Chair), Judge Robert Maclay Widney

Chair and Professor, University of Southern California
JAMES A. TULSKY (Vice Chair), Chair, Department of Psychosocial
Oncology and Palliative Care, Dana-Farber Cancer Institute; Chief,
Division of Palliative Medicine, Brigham and Women’s Hospital;
Professor of Medicine and Co-Director, Center for Palliative Care,
Harvard Medical School
JENNIFER BALLENTINE, Executive Director, The California State
University Institute for Palliative Care
ROBERT A. BERGAMINI, Medical Director, Palliative Care Services,
Mercy Clinic Children’s Cancer and Hematology, representing the
Supportive Care Coalition
AMY J. BERMAN, Senior Program Officer, The John A. Hartford
Foundation
PATRICIA A. BOMBA, Vice President and Medical Director,
Geriatrics, Excellus BlueCross BlueShield
SUSAN BROWN, Senior Director, Health Education, Susan G.
Komen
GRACE B. CAMPBELL, Assistant Professor, Department of Acute
and Tertiary Care, University of Pittsburgh School of Nursing,
representing the Association of Rehabilitation Nurses
STEVE CLAUSER, Program Director, Improving Healthcare Systems,
Patient-Centered Outcomes Research Institute
JEFF COHN, Medical Director, Common Practice
PATRICK CONWAY, President and Chief Executive Officer, Blue
Cross and Blue Shield of North Carolina
DAVID J. DEBONO, National Medical Director for Oncology,
Anthem, Inc.
CHRISTOPHER M. DEZII, Lead, Quality and Measure
Development, State and Federal Payment Agencies, U.S. Value,
 Access and Payment, Bristol-Myers Squibb Company
ANDREW DREYFUS, President and Chief Executive Officer, Blue
Cross Blue Shield of Massachusetts
CAROLE REDDING FLAMM, Executive Medical Director, Blue Cross
Blue Shield Association
MARK B. GANZ, President and Chief Executive Officer, Cambia
Health Solutions
ZIAD R. HAYDAR, Senior Vice President and Chief Clinical Officer,
Ascension Health
PAMELA S. HINDS, Director of Nursing Research and Quality
Outcomes, Children’s National Health System
HAIDEN HUSKAMP, 30th Anniversary Professor of Health Care
Policy, Harvard Medical School
KIMBERLY JOHNSON, Associate Professor of Medicine, Senior
Fellow in the Center for the Study of Aging and Human
Development, Duke University School of Medicine
CHARLES N. KAHN III, President and Chief Executive Officer,
Federation of American Hospitals
REBECCA A. KIRCH, Executive Vice President of Healthcare Quality
and Value, National Patient Advocate Foundation
TOM KOUTSOUMPAS, Co-Founder, Coalition to Transform
Advanced Care
SHARI M. LING, Deputy Chief Medical Officer, Center for Clinical
Standards and Quality, Centers for Medicare & Medicaid Services
BERNARD LO, President and Chief Executive Officer, The Greenwall
Foundation
JOANNE LYNN, Director, Center for Elder Care and Advanced
Illness, Altarum Institute
DIANE E. MEIER, Director, Center to Advance Palliative Care
AMY MELNICK, Executive Director, National Coalition for Hospice
and Palliative Care
JERI L. MILLER, Chief, Office of End-of-Life and Palliative Care
Research, National Institute of Nursing Research, National
Institutes of Health
R. SEAN MORRISON, Director, National Palliative Care Research
Center
MURALI N. NAIDU, Vice President, Chief Clinical Officer, Sentara
Healthcare
BRENDA NEVIDJON, Chief Executive Officer, Oncology Nursing
Society
HAROLD L. PAZ, Executive Vice President and Chief Medical Officer,
Aetna Inc.
SHARON SCRIBNER PEARCE, Vice President, Policy, National
Hospice and Palliative Care Organization
JUDITH R. PERES, Long-Term and Palliative Care Consultant,
Clinical Social Worker and Board Member, Social Work Hospice and
Palliative Care Network
PHILLIP A. PIZZO, Founding Director, Stanford Distinguished
Careers Institute; Former Dean, and David and Susan Heckerman
Professor of Pediatrics and of Microbiology and Immunology,
Stanford School of Medicine
WENDY PRINS, Senior Advisor, Quality Innovation, National Quality
Forum
THOMAS M. PRISELAC, President and Chief Executive Officer,
Cedars-Sinai Health System
JOANNE REIFSNYDER, Executive Vice President, Clinical
Operations and Chief Nursing Officer, Genesis Healthcare,
representing the Hospice and Palliative Nurses Association
JUDITH A. SALERNO, President, The New York Academy of
Medicine
DIANE SCHWEITZER, Acting Chief Program Officer, Patient Care
Program, Gordon and Betty Moore Foundation
KATRINA M. SCOTT, Oncology Chaplain, Massachusetts General
Hospital, representing the Association of Professional Chaplains
KATHERINE SHARPE, Senior Vice President, Patient and Caregiver
Support, American Cancer Society
JOSEPH W. SHEGA, Regional Medical Director, VITAS Hospice
Care, representing the American Geriatrics Society
CHRISTIAN SINCLAIR, Outpatient Palliative Oncology Lead,
Division of Palliative Medicine, University of Kansas Health System,
representing the American Academy of Hospice and Palliative
Medicine
TANYA STEWART, Senior Medical Director, UnitedHealthcare
Retiree Solutions
SUSAN ELIZABETH WANG, Regional Lead for Shared Decision-
Making and Advance Care Planning, Southern California
Permanente Medical Group, Kaiser Permanente

Roundtable on Quality Care for People with Serious Illness Staff

LAURENE GRAIG, Director, Roundtable on Quality Care for People
with Serious Illness
SYLARA MARIE CRUZ, Research Assistant
PATRICK BURKE, Financial Associate
SHARYL NASS, Director, Board on Health Care Services, and
Director, National Cancer Policy Forum
ANDREW M. POPE, Director, Board on Health Sciences Policy

__________________
1 The National Academies of Sciences, Engineering, and Medicine’s forums and
roundtables do not issue, review, or approve individual documents. The
responsibility for the published Proceedings of a Workshop rests with the
workshop rapporteurs and the institution.
 Reviewers

This Proceedings of a Workshop was reviewed in draft form by

individuals chosen for their diverse perspectives and technical
expertise. The purpose of this independent review is to provide
candid and critical comments that will assist the National Academies
of Sciences, Engineering, and Medicine in making each published
proceedings as sound as possible and to ensure that it meets the
institutional standards for quality, objectivity, evidence, and
responsiveness to the charge. The review comments and draft
manuscript remain confidential to protect the integrity of the
process.
We thank the following individuals for their review of this
proceedings:

MAUREEN HENRY, National Committee for Quality Assurance

TED LONG, NYC Health + Hospitals
DEBRA SALIBA, University of California, Los Angeles, JH Borun
Center for Gerontological Research
ERIC SCHNEIDER, The Commonwealth Fund
LEANNE YANNI, Bon Secours Palliative Medicine

Although the reviewers listed above provided many constructive

comments and suggestions, they were not asked to endorse the
content of the proceedings nor did they see the final draft before its
release. The review of this proceedings was overseen by KATHRYN
McDONALD, Stanford School of Medicine. She was responsible for
making certain that an independent examination of this proceedings
was carried out in accordance with standards of the National
Academies and that all review comments were carefully considered.
Responsibility for the final content rests entirely with the rapporteurs
and the National Academies.
 Acknowledgments

The National Academies of Sciences, Engineering, and Medicine’s

Roundtable on Quality Care for People with Serious Illness wishes to
express its sincere gratitude to Planning Committee Co-Chairs Amy
Kelley and Amy Melnick for their valuable contributions to the
development of this workshop. The roundtable also wishes to thank
all of the members of the planning committee, who collaborated to
ensure a workshop complete with informative presentations and rich
discussions. Finally, the roundtable wants to thank the speakers and
moderators, who generously shared their expertise and their time
with workshop participants.
We are grateful to the Gordon and Betty Moore Foundation for its
sponsorship of this workshop. Ongoing support from the many
annual sponsors of the roundtable is critical to its work. The
roundtable’s sponsors include Aetna Inc., Altarum Institute,
American Academy of Hospice and Palliative Medicine, American
Cancer Society, American Geriatrics Society, Anthem, Inc., Ascension
Health, Association of Professional Chaplains, Association of
Rehabilitation Nurses, Blue Cross and Blue Shield of North Carolina,
Blue Cross Blue Shield Association, Blue Cross Blue Shield of
Massachusetts, The California State University Institute for Palliative
Care, Cambia Health Solutions, Cedars-Sinai Health System, Center
to Advance Palliative Care, Centers for Medicare & Medicaid Services,
Coalition to Transform Advanced Care, Common Practice, Excellus
BlueCross BlueShield, Federation of American Hospitals, The
Greenwall Foundation, The John A. Hartford Foundation, Hospice
and Palliative Nurses Association, Kaiser Permanente, Susan G.
Komen, Gordon and Betty Moore Foundation, National Coalition for
Hospice and Palliative Care, National Hospice and Palliative Care
Organization, National Institute of Nursing Research, National
Palliative Care Research Center, National Patient Advocate
Foundation, National Quality Forum, The New York Academy of
Medicine, Oncology Nursing Society, Patient-Centered Outcomes
Research Institute, Sentara Healthcare, Social Work Hospice and
Palliative Care Network, Supportive Care Coalition, UnitedHealth
Group, and the National Academy of Medicine.
 Contents

ACRONYMS AND ABBREVIATIONS

INTRODUCTION
Quality Measures for Accountability in Community-Based Serious
Illness Care
Organization of Workshop and Proceedings
THE PATIENT–FAMILY PERSPECTIVE
GAPS, CHALLENGES, AND OPPORTUNITIES IN IMPLEMENTING
QUALITY MEASURES FOR ACCOUNTABILITY
Measuring High-Quality Care
Challenges in Implementing Quality Measures for Serious Illness
Care
Discussion
INNOVATIVE APPROACHES TO IMPLEMENTING QUALITY MEASURES
FROM THE PERSPECTIVES OF HEALTH CARE PROVIDERS AND
PAYERS
Lessons from Blue Shield of California’s Palliative Care Program
Aspire Health’s Model of Home-Based Palliative Care
Anthem’s Perspective on Quality Measures
Discussion
MEASURE REVIEW AND ENDORSEMENT REDESIGN AT THE
NATIONAL QUALITY FORUM
INNOVATIVE APPROACHES AND POLICY LEVERS FOR
IMPLEMENTING QUALITY MEASURES FROM THE PERSPECTIVES OF
PUBLIC PROGRAMS
Meaningful Measures Initiative at CMS
CMS Quality Payment Program
Caring for Patients with Chronic Complex Illnesses at the U.S.
Department of Veterans Affairs
Medicare Advantage Programs
A Congressional Perspective
Discussion
FUTURE USE OF QUALITY MEASURES FOR ACCREDITATION TO
SUPPORT ACCOUNTABILITY FOR HIGH-QUALITY CARE
Accreditation and Certification at The Joint Commission
Measurement in the Context of Hospice and Home Health Care
Challenges of Quality Improvement
Discussion
SUPPORTING CLINICAL COMMUNITIES FOR QUALITY AND
ACCOUNTABILITY
A Health Care Information Technology Company’s Approach to
Support Accountability
Real-World Implementation of Quality Measures
Discussion
CHARTING A PATH FORWARD
REFERENCES

APPENDIX A: Statement of Task

APPENDIX B: Workshop Agenda
 Boxes and Figures

BOXES
1 Key Definitions
2 Suggestions Made by Individual Workshop Participants on
Implementing Quality Measures for Accountability in
Community-Based Care for People with Serious Illness
3 Measures Drive Improvement If . . .

FIGURES
1 A nested population model of serious illness
2 Simulation of various approaches to identify patients with
serious illness
3 The redesigned consensus development process for measure
endorsement at NQF features two cycles per year
4 NQF’s prioritization initiative process
5 NQF’s measure prioritization criteria
6 Focus areas for the CMS Meaningful Measures Initiative
7 2016 survey results of high-risk PIM and PACT patients
8 Percentage of Medicare beneficiaries hospitalized or deceased
in 2015 by 2014 high-need status
9 Percentage of high-need and non-high-need patients enrolled
in low-quality Medicare Advantage plans
10 Comparison PCQN pain report
 Acronyms and Abbreviations

CAHPS Consumer Assessment of Healthcare Providers and

Systems
CHIP Children’s Health Insurance Program
CMS Centers for Medicare & Medicaid Services

EHR electronic health record

HCBS Home- and Community-Based Services

IOM Institute of Medicine

MDS Minimum Data Set

MedPAC Medicare Payment Advisory Commission
MIPS Merit-Based Incentive Payment System
MRI magnetic resonance imaging

NCQA National Committee for Quality Assurance

NQF National Quality Forum

PACT Patient Aligned Care Team

PCQN Palliative Care Quality Network
PIM PACT Intensive Management
POLST physician’s orders for life-sustaining treatment
PTCD pontine tegmental cap dysplasia
UCSF University of California, San Francisco
UNC University of North Carolina at Chapel Hill

VA U.S. Department of Veterans Affairs

VHA Veterans Health Administration
 Proceedings of a Workshop

INTRODUCTION1
Millions of Americans of all ages face the challenge of living with
serious illnesses such as advanced cancer, heart, or lung disease. Many
people with serious illness are increasingly cared for in community
settings. While the number of community-based programs to provide
care for those with serious illness has grown significantly, the quality of
care provided is not consistent across geographic locations or care
settings (Teno et al., 2017). Care for the serious illness population often
features gaps in coordination across sites of care and poor patient and
family perceptions as to the quality of care provided (Kelley and
Bollens-Lund, 2018). In an effort to better understand and facilitate
discussions about the challenges and opportunities related to identifying
and implementing quality measures for accountability purposes in
community-based serious illness care, the Roundtable on Quality Care
for People with Serious Illness of the National Academies of Sciences,
Engineering, and Medicine held a public workshop on April 17, 2018, in
Washington, DC. The workshop featured a broad range of experts and
stakeholders including clinical care team members, researchers, policy
analysts, patient advocates, representatives of federal agencies, as well
as those involved in health care accreditation and the development of
quality measures. Workshop presentations explored the current state of
quality measurement for people with serious illness, their families, and
caregivers, with the aim of identifying next steps toward effectively
implementing measures to drive improvement in the quality of
community-based care for those facing serious illness (see Box 1 for
key definitions).
The roundtable serves to convene stakeholders from government,
academia, industry, professional associations, nonprofit advocacy
groups, and philanthropies. Inspired by and expanding on the work of
the 2014 Institute of Medicine (IOM) consensus study report Dying in
America: Improving Quality and Honoring Individual Preferences Near
the End of Life (IOM, 2015a),2 the roundtable aims to foster ongoing
dialogue about crucial policy and research issues to accelerate and
sustain progress in care for people of all ages experiencing serious
illness.
In his introductory remarks to the workshop, James Tulsky, chair of
the department of psychosocial oncology and palliative care at the
Dana-Farber Cancer Institute, thanked the Gordon and Betty Moore
Foundation for supporting the workshop and other ongoing efforts to
improve quality measurement.3 He pointed out that such work is
essential to providing the best care to people with serious illness,
reminding the workshop audience, “As we all know, if you do not
measure it, you cannot improve it.” Tulsky went on to note the difficulty
of measurement for the serious illness care population, but added that
is why “it is important that we talk about and think deeply” about this
topic.
Amy Melnick, executive director of the National Coalition for Hospice
and Palliative Care, and the workshop planning committee co-chair,
pointed out that the workshop aimed to further the discussion by
exploring the “real-world application of measurement that makes a
difference.” In stressing the implementation of measures for
accountability, Melnick noted that workshop speakers would address
issues such the importance of capturing information in a non-
burdensome way for clinicians and patients, as well as being cognizant
of the unintended consequences that may arise from measures
implementation. Melnick noted that ultimately the goal is to arrive at
“that right set of feasible, valid, actionable, and meaningful quality
measures.” She added that “the values and preferences of people with
serious illness, their families, and their caregivers, has to drive the
accountable measurement system we are seeking.” Amy Kelley,
associate professor at Icahn School of Medicine at Mount Sinai, and the
workshop planning committee co-chair, underscored the workshop’s
focus on implementation of existing measures rather than measures
development, though she acknowledged there is clearly more work to
be done in that area. Kelley also pointed out that the goal of the
workshop was to build on lessons learned and think about actionable
next steps “rather than simply admiring the problem.”

BOX 1
Key Definitions
New community-based palliative care models are meeting the
needs of those with a serious illness who are neither hospitalized
nor hospice eligible, through provision of care in patient homes,
physician offices/clinics, cancer centers, dialysis units, assisted and
long-term care facilities, and other community settings.
Community-based palliative care services are delivered by clinicians
in primary care and specialty care practices (such as oncologists),
as well as home-based medical practices, private companies, home
health agencies, hospices, and health systems (NCPQPC, 2018).

Home- and Community-Based Services (HCBS), as defined

by Medicare, are types of person-centered care delivered in the
home and community. HCBS are often designed to enable people
to stay in their homes, rather than moving to a facility for care
(CMS, 2018a).

Hospice care focuses on caring, not curing, and in most cases

care is provided in the patient’s home. Hospice care also is
provided in freestanding hospice centers, hospitals, and nursing
homes and other long-term care facilities. Hospice services are
available to patients of any age, religion, race, or illness. Hospice
care is covered under Medicare, Medicaid, most private insurance
plans, health maintenance organizations, and other managed care
organizations (NHPCO, 2018).
 Palliative care is specialized medical care for people living with
serious illness. It focuses on providing relief from the symptoms
and stress of serious illness. The goal is to improve quality of life
for both the patient and the family. Palliative care is provided by a
team of palliative care doctors, nurses, social workers, and others
who work together with a patient’s other doctors to provide an
extra layer of support. It is appropriate at any age and at any
stage in a serious illness and can be provided along with curative
treatment (CAPC, 2018; NASEM, 2017).

Serious illness is a health condition that carries a high risk of

mortality AND either negatively impacts a person’s daily function or
quality of life, OR excessively strains his or her caregivers (Kelley
and Bolluns-Lund, 2018).

Quality Measures for Accountability in Community-Based

Serious Illness Care
The workshop aimed to contribute to ongoing efforts to implement
meaningful measures for accountability purposes for people with
serious illness cared for in community settings. Workshop presentations
and discussions made clear that this is neither an easy nor
straightforward process, as a number of speakers noted a broad range
of issues and challenges to be addressed, not least of which is an
absence of agreement as to what quality is and how to most effectively
measure it. A number of workshop speakers referred to Donabedian’s
framework, which identified structure, process, and outcomes as the
essential foundation for evaluating the quality of health care (Ayanian
and Markel, 2016; Donabedian, 1966).4 Several speakers noted that
structure, process, and outcomes all have to be measured and the
relationships between them understood in order to identify specific
steps to improve quality. A number of workshop participants
acknowledged important tensions and tradeoffs that need to be
considered, and the importance of understanding the benefits and
limitations of each type of measure. Several speakers also stressed that
building measurement capacity among providers is critical to improving
quality.
A number of workshop participants noted that the conceptual
definition of serious illness, which is broader than palliative care or
hospice alone, necessitates greater alignment across the entire health
care system, public and private payers, and specialties. Patients with
serious illness tend to have multiple chronic conditions and are seen in
multiple settings by a diverse set of health care providers, yet the
overarching goal is to improve care for patients in every care setting.
Measures alignment presents its own set of challenges, however, as
perceptions of quality measurement differ across specialties given
variations in care settings and patient populations. Moreover, speakers
noted the need to identify approaches to measure accurately function,
frailty, and social risk among people with serious illness.
In considering measurement for accountability in the context of
serious illness care, a number of speakers underscored the importance
of measuring the patient experience and incorporating the values and
preferences of the patient, family, and caregiver into patient care. As
several of the workshop’s discussions and presentations highlighted, the
system itself is often “deaf to the people that it cares for,” as
characterized by workshop participant Amy Berman, senior program
officer at The John A. Hartford Foundation. Progress toward
accountability for quality may require new measurement paradigms that
rely less on clinical guidelines and more on capturing the experience,
goals, and quality of life of people with serious illness, as noted by Sean
Morrison, chair of the department of geriatrics and palliative medicine
at Mount Sinai. Current approaches to gathering information through
electronic health records (EHRs), claims analyses, surveys, and
accreditation protocols do not provide the critical data necessary to
develop measures to enable the clinicians and the broader health care
system truly to “hear” the needs, preferences, and values of seriously ill
patients, their families, and caregivers.

Organization of Workshop and Proceedings

The workshop opened with an interview of the personal experiences
of a patient and a family caregiver that highlighted the importance of
listening to and truly hearing the expressed values and preferences of
the patient, family, and caregiver, and ensuring that those values and
preferences are incorporated into patient care. This opening session
provided the real-world context for the importance of understanding
what matters most to patients and their families.
Session One laid the foundation for the sessions that followed, with a
discussion of the current state of quality measures for the care of
people with serious illness, a conceptual definition of serious illness (see
Box 1), and that the challenge of measuring function needs to be
addressed in order to improve identification of the seriously ill
population. Session speakers discussed the various types of measures
and data sources, each of which presents its own opportunities and
challenges. Speakers emphasized a focus on meaningful measures that
drive real improvement and the need to consider alignment of
measures across specialties and payers.
Session Two explored the implementation of quality measures from
the perspective of health care providers and private-sector payers. The
session highlighted the importance of engaging with clinicians and
patients in the measurement process. Speakers addressed the
challenges and opportunities of implementing quality measures in the
health plan/health system context, including integration of quality
measures into payment contracts and alignment of quality measures
with broader organizational goals.
Shantanu Agrawal, chief executive officer and president of the
National Quality Forum (NQF), provided the workshop’s keynote
address. Agrawal described NQF’s process of reviewing and endorsing
performance measures, which has undergone a significant redesign.
Agrawal spoke about leveraging the existing evidence base for serious
illness care, prioritizing measures according to how well they drive
quality, and the importance of including patients and caregivers in the
measure development process. Agrawal also highlighted the process of
eliciting feedback on measures after they have been used by clinical
teams.
Session Three complemented the earlier discussion about measures
implementation in private-sector plans with an examination of
implementing quality measures in public programs with examples and
lessons learned from Medicare and Veterans Health Administration
(VHA) programs. The session also included a view from Congress in
terms of the policy opportunities to advance quality measures.
Session Four shifted the focus to a discussion of quality measures for
accreditation and how accreditation might serve as a lever to support
accountability for high-quality care for people with serious illness.
Speakers addressed what shape a future accreditation system for
community-based serious illness care might take, and the need to align
data cross the various care settings that people with serious illness
encounter.
Session Five provided a view into what elements are needed to
create a culture of quality measurement and quality improvement
among interprofessional clinical care teams; how to use clinical
registries to capture patient data in a non-burdensome way to improve
quality; and the role of EHRs in quality improvement. The session also
included a discussion of the quality measures implementation process,
including the readiness for change, interprofessional team support, and
the unintended consequences of measures implementation.
The workshop ended with the final session featuring experts in the
field of serious illness care reflecting on the day and the lessons
learned. They highlighted the major themes and notable messages they
had heard from the workshop presentations and discussions.
Workshop speakers, panelists, and workshop participants presented a
broad range of perspectives and insights. This proceedings describes
the presentations and discussions that occurred throughout the day.
Generally, each speaker’s presentation is reported in a section
attributed to that individual, following the flow of the workshop
described above. Headings of each section correspond to the focus of
the specific workshop session. A summary of suggestions for potential
actions from individual workshop participants is found in Box 2. The
workshop Statement of Task can be found in Appendix A and the
workshop agenda can be found in Appendix B. The workshop speakers’
presentations (as PDF and audio files) have been archived online.5

THE PATIENT–FAMILY PERSPECTIVE

Robert Bergamini, medical director for palliative care at Mercy Clinic
Children’s Cancer and Hematology and chair-elect of the Supportive
Care Coalition, opened the workshop with a session that focused on the
patient–family perspective. Bergamini moderated the discussion with
Martha Herrera, parent navigator at Children’s National Health System
and caregiver for her 8-year-old daughter, who has pontine tegmental
cap dysplasia (PTCD), a rare genetic developmental disorder,6 and
Gwen Darien, executive vice president for patient advocacy at the
National Patient Advocate Foundation and a three-time cancer survivor.
When introducing herself, Darien likened the patient and caregiver
experience to jazz, where the musicians have both an individual and a
group identity. When it comes to the patient and caregiver experience,
she explained, much of that experience is universal and much is
individual. She also noted that improving the system of serious illness
care will not occur without first understanding the individual’s
experience.

BOX 2
Suggestions Made by Individual Workshop
Participants on Implementing Quality
Measures for Accountability in Community-
Based Care for People with Serious Illness
Incorporating the Patient, Family, and Caregiver Voices
Reward and support the implementation of measures that focus
on those individuals with serious illness and ensure that such
measures reflect both the patient and caregiver voices. (Melnick)
Physicians need to take the time to learn about patients and
their caregivers, find out what their lives are like outside the
clinic, and engage in compassionate explaining. (Herrera,
McCann, Saliba)
Appreciate that trust is bidirectional: Doctors need to trust their
patients as much as their patients trust them. (Darien, Herrera)
Health care providers need to help patients with serious illness
and multiple issues to transition through the various aspects of
care. (Bergamini, Darien)
Address provider dismissiveness or lack of quality time with a
patient by implementing more measures focused on patient and
caregiver goals. (Herrera)
Create measures that are important to patients and caregivers
and drive real improvement in quality. (Baron, Burstin, Darien,
Duseja, Hanson)
Produce measures that support an integrated, systematic view of
care that reflects the experience of patients with serious illness
over the course of their illness. (Burstin, Krebbs)
Design measures that reflect how patients interact with the
dozens of medical specialties that can play a role in the care of
patients with serious illness. (Burstin)
Ensure that clinicians truly hear the concerns of patients and
caregivers so that the health care system is not “deaf” to the
people for which it cares. (Berman)
Move away from checkboxes and get to what matters for
patients and families. (Bergamini)
Engage patients when implementing measures and think about
measures that would make the patient’s experience better. If it
does not matter to patients, it should not matter. (Baron)
Involve patients and caregivers in identifying patient- and
caregiver-centric measure concepts during the development
process and throughout the testing and implementation phases.
(Agrawal)
Change the system of serious illness by considering and
understanding the individual’s experience. (Darien)
Untether the disease aspect from measurement and focus on the
goals of care from the perspective of the individual and the sum
of their conditions and social needs. (Berman)
Weight existing quality measures based on high-need patients,
rather than developing new measures to provide information
specific for high-need Medicare Advantage patients who need
higher-quality care. (Mor)
Consider ways to leverage the patient and caregiver voice;
engaged patients and caregivers are key levers to improve
quality. (Rokoske)
 To ensure that patient and family experience measures are
adequate, make certain they are coupled with clinical quality
measures that identify poor-quality clinical care. (Henry)
Take into account patient self-reports of function, which are very
reliable and highly predictive of outcomes, for outcome
measures. (Saliba)
Recognize that measurement is dependent on timing and can
vary based on where the patient and the family are in their life
and prognosis. Take into account that measures that result in ill-
timed treatment and behaviors may be harmful to the patient.
(Teno)
Do not assume that patients and families want less care. Rather,
focus on ensuring patients and families can access care that they
want and need. (Teno)
Work to measure effectively the quality of the serious illness
conversations that team members have with patients. (Lanz)
Reach agreement on what is important to patients and families.
(Morrison)
Begin to develop measures to provide a picture of how entire
communities are doing. (Lynn)

Implementing Meaningful Quality Measures for

Accountability
Focus on implementing measures to drive improvement that are
scientifically acceptable, backed by evidence linking the
measures to actual outcomes, reproducible, operationally
defined, feasible, powered by data that can be captured at an
acceptable cost and burden in the process of clinical care, are
actionable to address gaps in care quality, and responsive to
changes in the system. (Hanson)
Avoid an overemphasis on process measures, which has led to a
lack of accountability and a “check the box” mentality that does
not embrace the complexity of caring for patients with serious
illness. (Lanz, Teno)
Work toward identifying and implementing a balanced set of
measures that embrace the complexity of serious illness and are
actionable. Understand that one size does not fit all. (Teno)
Eliminate measures that do not add value and do not drive
meaningful improvement. Stop measuring aspects of care that
do not improve the system. Do not measure simply because
something is measurable. Do not be afraid of going without
measures. (Burstin, Hanson, Teno)
Understand whom a measure is missing and whom it is catching,
strike a balance between the two that is appropriate for the
purpose of the measure, and understand the unintended
consequences of getting that balance wrong. (Kelley)
Recognize that, until measures reach the point where they
account for every possible contraindication or exclusion, it will be
unrealistic to expect 100 percent as a goal for that measure,
which allows for a more relaxed view of quality measures and
eliminates the fear of having to be perfect. (Krebbs)
Ensure that accountability spans the entire continuum of care,
unlike measures, which tend to be monolithic or applicable to
specific silos of care. (Mor)
Look to other industries where innovation drives measures, as
opposed to in health care, where performance measures are
used as a lever to spur innovation. (Schneider)
Avoid going straight to outcome measures when the structures
are not in place to report those measures, and instead
implement the other pieces needed to get to the outcome
measures. (Henry)
Take into account that implementation is a non-linear, staged
activity that goes beyond collecting data and requires continual
evaluation, assessment, and adaptation, and encourage
clinicians to see it for the larger picture as well. (Saliba)
Look to nursing homes, which have been a good model for
implementing measures that led to improvements in care, to
provide lessons for the serious illness population. Also, learn
from existing quality initiatives such as Nursing Home Compare,
Consumer Assessment of Healthcare Providers and Systems, and
the Hospice Item Set. (Hanson)
Use varied types of measures (combination of structure, process,
and outcome) and remember that improved care, rather than
perfect measures, is the ultimate goal. (Baker, Hanson)
 Recognize that outcomes are the product of complex interactions
(structures) among individuals, teams, technology, and payment
systems. (Baron)
Align measures across medical specialties, across public and
private payers, and across levels of measurement to include the
entire population of those with serious illness and not only those
in palliative care or hospice. (Burstin, Duseja)
Include instrumental activities of daily living, not just activities of
daily living, when measuring function. (Saliba)
Identify the elements of an intervention that worked in one
setting that need to be reproduced for the intervention to work
versus those elements that need to be adapted to the local
organizational culture. (Saliba)
Given that Medicare Advantage plans’ payment is weighted by
case mix, weight quality measures more heavily based on high-
need patients. (Mor)
Understand that measures do not have to be all-inclusive of a
care provider’s entire interaction with the patient. Instead, think
about what are the most essential and comprehensive measures
to have. (Pantilat)
Consider a new measurement paradigm, including the need for
new measurement techniques to assess quality for people with
serious illness. (Morrison)
Recognize that the timeliness of feedback or measures is critical
in driving improvement, as care providers are constantly taking
care of people. (Naidu)

Engaging with Clinical Care Team Members

Center conversations about health care quality on why providers
chose to work in the profession they did—to provide excellent
care to patients—which will help to ensure successful
conversations. (Baron, Rokoske)
Focus measures on structure rather than processes or outcomes,
which will more likely lead to measures that matter and more
likely engage providers. (Baron, Krebbs)
Embrace the idea of co-creation and have providers in the room
to inform decisions on measures to deploy. (Baron, Duseja,
 Krebbs)
Focus on implementing and using a small number of feasible
measures and building measurement capacity among providers.
(Hanson)
Support clinicians to consider information technology as a way to
help them answer questions that they care about concerning
their practice. (Baron)
Do not neglect actionable steps for clinicians to improve the
quality of care they provide, which is often lost with the focus on
outcome measures. (Rokoske)
Inform care teams about the reason for measuring certain things
and provide comparison to peer groups. Solicit feedback on the
usefulness of the measures from care teams and patients.
(Burstin, Lanz)
Seek feedback from those using the measures. (Agrawal,
Burstin)

Improving Data Sources and Collection

Ensure that data collection is integrated into the workflow.
(Pantilat)
Team members should engage with data when they can see the
data, use them, and share them. (Pantilat)
Address inadequacies of current data that offer a poor measure
of function, cognition, and care needs. (Kelley)
Shift to more reliable and valid data sources, including clinical
registries, to drive toward patient-reported outcomes. Consider
unmeasured medical and social complexity. (Burstin)
Appreciate that data from claims, electronic health records, and
patient and caregiver surveys are all important because they
provide a way to triangulate to a truth about quality care.
(Hanson)
Standardize data collection for the assessment of functional
status in the post-acute world outside of the hospital. Currently,
nursing homes, home health, and hospices all collect different
data sets using different instruments. (Lynn, McCann, Pantilat)
Draw on the richness of data from home and community-based
care. (McCann)
 Collect data directly from patients via mobile applications that
could be used for quality measurement and assessing functional
status. (Duseja, Mor)
Collect data for functional measures in a healthy population as
an indicator to identify people with progressive illness in order to
get them quick, appropriate care. (Bishop)
Consider multiple denominators when crafting measures in order
to address the issues of unintended consequences. (Kelley,
Krebbs)
Test measures on patients to further develop the usefulness and
to continually improve measures and care. (Fields)

Working with Health Care Organizations and Payers

When palliative care is provided within an organization’s goals,
align structures so they are not competing with capitated
payment, reimbursement structures, or other programs. (Fields)
Explore shifting from disease-specific measures to broader
measures at the population level as a means of focusing health
care systems on the need for overall system improvement,
rather than developing interventions for specific populations.
(Duseja)
If measurement includes engagement rates, how long a patient
is engaged in a program, or changes in program usage, align
processes and structures in a health plan to support the
palliative program and treatment teams. (Fields)
Do not waste resources by duplicating measurements.
Duplicating does not improve care value. (Krebbs)
Recognize that measures are imperfect and measurement is
more dependent on its methodologies. Use that understanding
of measurement to achieve perfection within the goals for
measurement. (Krebbs)
Acknowledge the value of informal measures, such as admission
rates to hospice or time spent in chemotherapy, to provide
information for cost targets or chronic-based episodic cost of
care models. (Krebbs)

Engaging with Policy Makers

 Engage effectively with the relevant congressional committees
and the staff with the goal of aligning federal reimbursement
rates with best practices when planning the process of
implementing measures. (Shipp)
Engage with congressional staff in the weeks following
enactment of the budget bill, for example, which is a window of
opportunity to advance quality measures. (Shipp)

For Herrera, the challenge of caring for her daughter, Angelica, began
with the search for a proper diagnosis. When Angelica was about 3
months old, Herrera noticed that she was not responding to sounds.
Her pediatrician dismissed Herrera’s concerns as the ill-informed worries
of a 19-year-old mother who was likely suffering from postpartum
depression. A second pediatrician also attributed Herrera’s concerns to
her young age, told her she was expecting too much from her daughter,
and referred her to a mental health specialist. A third pediatrician
blamed colic for her daughter’s difficulty sleeping and failure to engage.
Angelica was nearly 7 months old when the fourth pediatrician Herrera
saw referred her to Children’s National Health System for a hearing test,
which revealed that her daughter was deaf. That diagnosis led to
magnetic resonance imaging (MRI) to try to pinpoint the cause of her
daughter’s hearing impairment. The MRI revealed a brain anomaly and
a diagnosis of PTCD. At that point, Herrera’s daughter was nearly 3
years old. Herrera was presented with two options for dealing with her
daughter’s deafness: cochlear implants or nothing. Herrera chose the
implants, a decision she questions now knowing that learning sign
language would have been a third option.
Herrera shared that, in her current role helping younger parents and
non-English-speaking families navigate the health care system, she sees
parents struggling to communicate with clinicians and clinicians failing
to respect parents’ concerns. She finds this is particularly the case if the
parents are young, lack formal education, or have difficulty with
English. Herrera observes that parents become reluctant to bring their
children to the doctor for fear of learning that something else is wrong
with their child. This could be remedied, according to Herrera, if
clinicians take the time to learn about the patients and their caregivers,
find out what their lives are like outside of the clinic, and engage in
what she termed “compassionate explaining.”
Bergamini remarked that Herrera’s story reminded him of what the
person in charge of his residency once told him: his goal should be to
do what a young parent can do intuitively, which is to know something
is wrong with his or her child from 50 feet away. He added that
spending the time to get to know a patient has become increasingly
challenging given that clinicians within the predominantly fee-for-
service reimbursement system are typically paid based on the number
of patient encounters and procedures.
Darien observed that Herrera’s experience points to the need for trust
to be mutual, with doctors trusting their patients as much as their
patients trust them. She also noted that young adults often have the
same discounting experience as young parents, recalling when she was
diagnosed with non-Hodgkin’s lymphoma she was treated as if she was
a hypochondriac because she was young and complaining about chest
pain.
Darien spoke to the issue of survivorship and the failure of health
systems to help with the transition from having cancer to being in
remission. Treating, she said, is not the same as healing. “I have been
treated extremely well by extremely competent, gifted physicians, but I
have not been healed by those same physicians in the same way,”
stated Darien. She added that a vital lesson for patients, caregivers,
and providers is to understand that “healing has to be part of what we
do with our communities, not just treating the disease.” Bergamini
noted that this was a crucial point in terms of the care that individuals
with serious illness receive. In his view, clinicians are accustomed to
diagnosing and treating acute illness and getting through a specific
episode of illness, but are not well versed in helping seriously ill
patients with multiple issues transition from one “compartment” to
another.
Darien also said she does not believe time is always the answer, just
as money is not always the answer. She recounted how one of her
oncologists rarely spent more than 10 or 15 minutes with her, but
during that time, she truly listened to Darien. Bergamini pointed out
that listening and understanding is not intuitive for many providers.
Herrera noted that one advantage of her institution being a teaching
hospital is that medical students and first-year residents are eager to
learn about their patients’ conditions and concerns. Another benefit of
working at Children’s, she said, is that she and her five navigator
colleagues are consulted before a new program is implemented to
provide a parent’s perspective on whether parents will engage with the
program. “Starting the new initiative with the parent’s input really helps
them get it right from the beginning” and to think about it being a
patient-focused initiative, noted Herrera.
During the question-and-answer session following the presentations,
Amy Berman, senior program officer at The John A. Hartford
Foundation, asked Herrera and Darien if they could recommend a
measure that would address the challenges they faced. Herrera replied
that more measures around patient and caregiver goals would be
useful, including ways to provide realistic timelines to families that
would help them figure out how to balance caregiving with the rest of
life’s demands, including caring for other children in the family.
Darien pointed out that the issue is not deciding on individual
measures, but reframing the way measures reflect what is important to
the patient and caregiver rather than what is important to the health
care system. For Darien, many measures seem like what she called
“hospitality measures,” with a focus on how good the hospital food is,
rather than on whether the food is helping with the healing process, or
how the furniture looks, rather than how comfortable it is for patients
and their long-term guests. “Quality measures have to be meaningful to
patients and to patients’ outcomes and quality of life rather than
meaningful to payment models and to checking the box,” emphasized
Darien.
Lauren Cates, board chair and executive director of Healwell, as well
as immediate past president and founding director of the board of the
Society for Oncology Massage, said her organization talks with health
care professionals about how being honest about their own mortality
affects the care they provide and the importance of speaking honestly
to patients when delivering a diagnosis. Both Herrera and Darien
agreed that facing one’s mortality is very difficult and that it can be
confusing to many patients when providers use percentages of possible
survival while delivering a prognosis. Bergamini offered the question he
hates the most as an oncologist is when parents want to know the
chances of their child being cured. “One of the most difficult things to
learn is how to discuss prognosis,” said Bergamini. “People will
remember those words forever.” Bergamini closed the session, noting it
set “a great tone for the day as we try to get away from the
checkboxes and get to what matters to patients and families.”

GAPS, CHALLENGES, AND OPPORTUNITIES IN IMPLEMENTING

QUALITY MEASURES FOR ACCOUNTABILITY
In her introduction to the first panel session, Amy Kelley, associate
professor at the Icahn School of Medicine at Mount Sinai, pointed out
that the focus of the workshop’s discussions is on implementing
measures that exist today and not on developing new measures,
though she acknowledged that work remains to be done in that area.
She then offered a conceptual definition that holds serious illness to be
a health condition that carries a high risk of mortality, though not
bound by prognosis, and either negatively affects a person’s daily
function or quality of life or excessively strains their caregivers (Kelley
and Bollens-Lund, 2018). Kelley noted that the experiences shared by
Herrera and Darien are “emblematic of why that conceptual definition
stands as it is.”

Measuring High-Quality Care

Laura Hanson, professor of Geriatrics and Palliative Medicine at the
University of North Carolina at Chapel Hill (UNC), director of the UNC
Palliative Care Program, and co-lead of the Measures Core for the
Palliative Care Research Cooperative, defined high-quality care as the
structural elements of the health care system and the processes that
clinicians implement that increase the likelihood of the desired health
outcomes and are consistent with current professional knowledge (IOM,
1999). “That attachment between structure, process, and outcome7 is
part of how we think about measuring or capturing health care quality,”
said Hanson.
The data to drive measures of high-quality care come from many
sources, including claims data, clinician reports embedded in the EHR,
and patient or caregiver surveys. Hanson emphasized that all three
sources of data are important because together they provide a way to
triangulate quality of care, and the different measures enable us to
“learn different angles of the truth.” Hanson pointed out that a
fundamental measurement challenge involves determining the
denominator population for serious illness. Referring back to the
opening session, Hanson noted that “the reality of the patient and
caregiver story is that people with serious illness are everywhere in the
U.S. health care system. They are found in multiple settings and are
being cared for by a diverse set of health care providers.” She noted
that it is hard to account for all of those who are experiencing serious
illness, and yet the goal is to improve care for all of them in every
setting. Those individuals who are in specialty palliative care and
hospice provide some information, but that denominator has a
downside because it only captures those people who have gained
access to those parts of the health care system.
In order for measures to drive effective quality improvement, Hanson
explained, they need to meet certain requirements (see Box 3). First,
measures need to be important and relevant, and for something that is
important to patients and caregivers, account for a large population,
and thus have public health impact. Second, measures need to be
scientifically acceptable, backed by evidence linking the structure and
process measures to actual outcomes, and have strong operational
definitions. Measures need to be reproducible so that those doing the
measurement are capturing information in the same way. Third,
measures need to be feasible, which means the data can be captured
during the clinical care process, with an acceptable cost and burden to
the health care system, clinical team, patients, and caregivers. Fourth,
measures need to be usable and actionable today to address gaps in
care quality. Finally, the measures themselves must be responsive: “If
there is a difference in quality of care, the needle has to move,” Hanson
explained.

BOX 3
Measures Drive Improvement If . . .
 Important/relevant
Large population—public health impact
Impact on patients/caregivers (key stakeholders)

Scientifically acceptable
Evidence linking structure/process to outcome
Strong operational definition (reproducible, valid)

Feasible
Can be captured in clinical care
Acceptable burden/cost

Usable and actionable

Currently in use
Able to be acted on in response to gaps in care

Responsive
Measure improves with better care

SOURCE: As presented by Laura Hanson, April 17, 2018.

Perhaps surprisingly, Hanson remarked, nursing homes have proven

to be good models for implementing measures that lead to
improvements in care and can provide lessons for the serious illness
population. For example, in an attempt to improve quality of care, the
Centers for Medicare & Medicaid Services (CMS) established Nursing
Home Compare, a combination of measurement sources including
safety inspection results, a mandated minimum data set that uses EHR
data, staffing reports, and claims data to produce a publicly available
star rating8 for all Medicare and Medicaid certified nursing homes. While
this set of measures may not be perfect, said Hanson, it is robust
because of the diverse sources of data. More importantly, as Hanson
pointed out, these measures have helped drive improvements in care
because they led to public reporting and feedback, helped national- and
state-level partnerships and coalitions target areas where caps in
quality existed, prompted efforts to improve clinician training and
engagement, and triggered support for quality improvement effects. In
addition, surveyor training and guidance created an environment in
which the regulatory arm has become part of the measurement and
improvement process.
In closing, Hanson shared her key takeaway points. Focusing on
implementing and using a small number of feasible measures, as well
as building measurement capacity among providers, is critical to
improving quality, she posited. Another key point Hanson identified is to
combine structure, process, and outcome measures from multiple
sources—not only the EHR or surveys—to get a comprehensive view of
the quality of care. Hanson ended her remarks by emphasizing the
importance of learning from existing quality initiatives involving serious
illness populations, such as Nursing Home Compare; the Consumer
Assessment of Healthcare Providers and Systems (CAHPS),9 which is
providing lessons on how to expand across settings; and the Hospice
Item Set,10 which has measures that are applicable directly to serious
illness care. Hanson pointed to the most important lesson as the need
to “keep our eyes on the prize.” The prize, she emphasized, is improved
care and “not perfect measurement.”

Challenges in Implementing Quality Measures for Serious

Illness Care
For Joan Teno, professor of medicine at Oregon Health & Science
University, there are several challenges to implementing quality
measures for serious illness care. First, an overemphasis on process
measures has led to a lack of accountability and a “check the box”
mentality that does not embrace the complexity of caring for patients
with serious illness. A second key challenge that Teno identified is
understanding who is in the denominator population. Third, too often,
said Teno, what is easily counted becomes what is measured even if
that measure paints an incomplete picture of the care being delivered
and can even harm patients. For Teno, the “Holy Grail is goal-
concordant care.”
While acknowledging that the Medicare hospice benefit has
transformed care for a subset of individuals with serious illness, Teno
said it does not fit the trajectory of diseases today. Lung cancer, for
example, is now becoming a chronic disease and people are living with
the disease for many years, she explained, yet the payment system
does not reflect this new disease trajectory. One key step going
forward, she suggested, is to “celebrate” the Medicare hospice benefit,
but learn from its shortcomings and embrace quality from the very
beginning. Another important lesson for Teno is the importance of
having a balanced set of measures that embraces the complexity of
serious illness. She added a final lesson learned from the Medicare
hospice benefit: one size does not fit all. “We really need to have
payment systems that reflect who the patient is,” Teno explained.
“What is easily counted is not necessarily what you measure.” As an
example, she recalled one health system that measures the number of
physician’s orders for life-sustaining treatment (POLST) forms that are
completed, even though a small study had shown that while nearly all
have a POLST form, only a few nursing home residents remembered
talking about the form. “You may complete the POLST form, but if you
do not have that conversation, you are going to harm patients,” warned
Teno. She gave the example of POLST forms that had been filled out
and indicated aggressive care, but only a few patients had remembered
filling them out—meaning that those forms had the potential to be
incorrect or misunderstood. She noted that does not mean one should
stop measuring things or trying to improve care; “it means we need to
get it right.”
Another difficult problem for developing measures for accountability,
Teno said, is that the sample size must be sufficient. “This is all about
reliability,” she emphasized. She noted that only about 70 percent of
hospices conduct a sufficient number of interviews to report on the
quality of care they deliver.11
In conclusion, Teno said there is an urgent need to develop new
accountability measures that can populate a balanced set of measures
that are actionable and embrace complexity. Also needed is a policy
solution for the “small N problem” and careful thought to measurement
of goal concordance of care while avoiding unintended consequences
from those measures. As a final thought, Teno commented that if value
is based on a preference-weighted combination of quality and outcomes
without quality measures, value will end up being based solely on cost.
Helen Burstin, executive vice president and chief executive officer of
the Council of Medical Specialty Societies, discussed several other
measurement challenges. Burstin emphasized the importance of
removing measures that do not add value and do not drive meaningful
improvement, creating greater alignment from various stakeholders in
focusing on the entire population of those with serious illness and not
only those in palliative care or hospice. She further emphasized shifting
to better data sources, including clinical registries, to drive outcomes
and, perhaps more importantly, patient-reported outcomes. She warned
against using measures for accountability that serve no other role. “We
need to find a subset of measures that can be used for accountability
but also for improvement,” said Burstin. Supporting points made by
previous speakers, Burstin emphasized that measures need to be
outcome-oriented, actionable, and meaningful to family and caregivers.
Measures need to support an integrated, systematic view of care that
reflects the experience of patients with serious illness over the course
of the trajectory of their illness. In addition, measures need to reflect
how patients interact with the dozens of medical specialties that can
play a role in the care of patients with serious illness.
Burstin observed there has been a lack of feedback from either those
being measured or those who are using the measures regarding which
measures are effective and which should be eliminated. Moreover, many
measures are used because they can be measured, not because they
are appropriate or actionable, and that needs to stop, said Burstin. In
her view, “It is okay to stop measuring something if it is not helping
just because it fits a box on your chart of what we feel like we need to
measure.”
Burstin emphasized the need to align measures across medical
specialties, across public and private payers, and across levels of
measurement. “We want to be able to think about how our state or
federally reported measures relate to what we are increasingly
measuring at the plan and system level and then how that ultimately
comes down to the clinician level as well as the individual patient level
across the trajectory,” Burstin explained. “It is hard to imagine what
your improvement strategy is when you are pinging from level to level
and measures that are not aligned.”
Burstin called for a shift to sources that are more reliable and valid
for what is being measured. For example, claims data can capture
usage, but not many of the other domains that are important, such as
medical and social complexity or frailty. Her hope is that the
measurement field can work with medical specialty societies and others
who are building clinical registries to capture the important data that
will be included in those registries and that are not available in a
preexisting data set. Those data will help to inform measures of patient-
focused outcomes that are so important for the population of
individuals with serious illness.
Returning to the conceptual definition she provided at the start of the
session, Kelley reminded the workshop attendees that there are many
challenges to operationalize that conceptual framework. The first
challenge is that, while it is relatively easy to measure costs, utilization,
mortality, and other quantifiable attributes and create regression
models that predict those things, it is harder to measure need, which is
fundamental to the conceptual definition. At the same time, rolling out
services or demanding accountability requires being able to find the
people for whom those services are going to make a difference, that is,
those with high needs.
Kelley identified the tradeoff between sensitivity and specificity,12
which has implications for feasibility and cost-neutrality if used for
eligibility. It is important, asserted Kelley, to understand whom a
measure is missing and whom it is catching, strike a balance between
the two depending the purpose of the measure, and understand the
unintended consequences of getting that balance wrong. A third
challenge relates to the inadequacy of the data currently available.
Kelley identified the missing components as measures of function,
cognition, and care needs, which are fundamental to identifying the
seriously ill population. In her view, achievable approaches for
improving the lack of data are within reach. The final challenge Kelley
identified is that there are likely to be multiple denominators for various
purposes and populations. She gave the example of seriously ill
patients, such as those with heart failure, who are seeing a large
number of specialists, but have not enrolled in a hospice program.
Kelley underscored the need to identify the population of patients with
serious illness with the data that is available before starting to look for
patient-reported measures and other data sources.
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 CHAPTER VIII

ARISTOTLE (384–322 B. C.)

Aristotle in the Academy and Lyceum. Many notable pupils
gathered around Plato during his mastership of more than forty
years. Plato’s nephew, Speusippus, succeeded him as leader of the
Academy, and for the next three hundred and fifty years the
Academy is called by various names. It is the Older Academy under
Speusippus and later; then it is known as the Middle Academy; and
then, about 120 B. C., it is known as the New Academy. The history
of the Academy is, however, a part of the Hellenic-Roman Period. It
is sufficient to say here that the leaders succeeding Plato in the
Academy added but little to philosophical speculation, although
much to empirical research. The important fact is that the sceptre in
philosophy passed from the Academy when Plato died and his
greatest pupil Aristotle left it. Just as Plato stood among the pupils
of Socrates as Socrates’ most discriminating interpreter, so among
the pupils of Plato there was one preëminent pupil,—Aristotle.
Aristotle was too great a man to be subordinated to the leadership
of Speusippus. Upon the death of Plato he left the Academy, and
fourteen years later he returned to Athens and founded the Lyceum,
which became under his mastership the most influential Athenian
school. The Lyceum was an inclosed space of ground, like the
Academy. It was situated just outside the walls of Athens, on the
right bank of the Ilissus. It was dedicated to Apollo, decorated with
fountains, gardens, and buildings, and contained one of the great
gymnasia of Athens. It was frequented by philosophers, and is
known to have been the favorite walk of Aristotle and his pupils,
whence they got their name of Peripatetics. Theophrastus, the most
eminent pupil of Aristotle, bought a property near the grove and
bequeathed it to the school. It was a religious foundation, like the
Academy. The method of choosing the scholarchs varied at different
times. The name Lyceum is from the same root as Lycian, and was
given to Aristotle’s school from the fact that the grove was dedicated
to the Lycian Apollo.

Here, in the Lyceum, Greek philosophy was brought to its most

complete expression. Here all the threads of Greek cosmological and
anthropological undertakings were finally woven together. Here an
adjustment was accomplished between Aristotle’s two great
predecessors, Plato and Democritus; and materialistic and idealistic
realism crystallized in a theory of development. The great form of
Aristotle rises to speak the final word of pure Greek civilization, at a
time when the custody of Greece had passed from the hands of the
Athenians, the Spartans, the Thebans in succession to the
Macedonians. He was the most influential thinker that history had
seen. In his formative power upon human thought he has scarcely a
peer. Dante called him “the master of those who know.” “In my
opinion,” said Cicero, “Aristotle stands almost alone in philosophy.”
Eusebius said of him, “Aristotle, nature’s private secretary, dipped his
pen in thought.” Goethe remarked, “If now in my quiet days I had
youthful faculties at my command, I should devote myself to Greek,
in spite of all the difficulties I know. Nature and Aristotle should be
my sole study. It is beyond all conception what that man espied,
saw, beheld, remarked, observed.”

The portrait that we draw of Aristotle is very different from that

of Plato. Instead of the deeply poetic temper, the man who sees all
things in an ideal unity of infiniteness and vastness, we have before
us now the scientist in search of facts, the accurate man of good
sense, whose imagination does not soar above the clouds, but at the
same time has extraordinary fertility in historical and scientific
theoretical explanations. His was a life filled with the love of truth.
His learning took up into itself the entire range of human knowledge
in such a way as to include its earlier development. And what is
more, he showed an equal interest in all departments. Aristotle was
more of a scientist than Plato, for the theoretical rather than the
ethical interest was fundamental in his work. He is the
personification and completion of pure Greek learning.

Biography of Aristotle, 384–322 B. C.

Brief Chronological Sketch of Aristotle’s Life.

First Period—Aristotle the Student—37 years.

384–347 B. C.
384 Born in Stagira in Macedonia.
367 Entered the Academy. Remained 19 years.
347 Left the Academy upon the death of Plato.
Second Period—Aristotle the Traveler—12
years. 347–335 B. C.
347 Went to the courts at Atarneus and Mytilene in Asia
Minor.
343 Returned to the court of Macedon at Pella, in
response to the summons of King Philip, to teach
the young prince Alexander. Remained 4 years.
340 Went from Pella to Stagira to engage in scientific
work. Remained 5 years.
Third Period—Aristotle the Leader of the
Lyceum—13 years. 335–322 B. C.
335 Founded the Lyceum in Athens. Taught and
 administered the school 12 years.
323 Fled to Chalcis.
322 Died in Chalcis.

Aristotle’s Biography in Detail.

1. First Period, 384–347 B. C.—Early Influences. Aristotle

was born in Stagira in Macedonia. His father was court physician to
King Amyntas, the founder of the Macedonian power and the father
of King Philip. He came from a long line of physicians (the caste,
Asclepiad) who traced their origin to Asclepius. Little is known about
the early years of Aristotle except that his father and mother died,
leaving him in the guardianship of Proxenus of Atarneus. (Atarneus
is the state in Asia Minor which he later visited.) It can scarcely be
doubted that he was destined by his family to be a physician, and
that the empirical works of Hippocrates and Democritus were the
first elements of his early education. Aristotle grew up in this
atmosphere of medicine of Macedonia, which explains his respect for
the results of experience and his accuracy in details,—all of which
contrasts him with the Attic philosophers.

He was sent by Proxenus to the Academy in 367 B. C., at the age

of eighteen, and he remained there for nineteen years, or until he
was thirty-seven. He was not merely a pupil in the school, but his
brilliancy won for him immediately a prominent position there. He
became a teacher, an attractive writer, and champion of the literary
spirit of the school. Even while he was a member of the Academy he
became a famous man. It is difficult to say just how much influence
the Academy had upon the casting of his thought. His scientific
inclinations were formed before he went to the Academy; he got his
immense scientific erudition in Asia Minor and in Stagira later, after
he left the Academy. Probably the spirit of the Platonic school turned
his attention to ethical and metaphysical theories, and probably it
was due to his stay in the Academy that he became interested in
rhetorical and purely cultural studies. At the same time his own
influence must have been very great in forming the policy of the
Academy, and he was probably responsible for its turning its
attention to scientific matters.

The sources from which Aristotle drew the material of his

philosophical science were therefore (1) his inherited taste for
medicine and empirical science; and (2) the influence of the
Academy in ethical, metaphysical, and cultural subjects. Both these
factors appear throughout the philosophical development of
Aristotle. On the other hand, it must not be forgotten that probably
Aristotle’s influence upon the Academy was as great as that of the
Academy upon him. His own persistence along the line of empirical
science shows itself in his period at Atarneus, Mitylene, and on his
return to Stagira. Much has been said about an estrangement
between Aristotle and his teacher, Plato. This is probably idle gossip.
Aristotle held his master in great esteem, as he himself testifies in
his Ethics. Aristotle was an independent and original mind, and
probably even in the school he would point out defects in Plato’s
thought, when his aged teacher would lead his theories upon
mistaken lines. Plato said that his pupil Xenocrates needed the spur,
while Aristotle needed the bridle. Aristotle was called the brain of the
Academy.

2. Second Period, 347–335 B. C.—Traveler and Collector.

When Plato died, and his nephew Speusippus became scholarch of
the Academy, Aristotle, in company with Xenocrates, went to the
court of Hermeias, ruler of Atarneus and Mitylene. Hermeias was
another pupil of Plato at the Academy. Here Aristotle married twice,
and here he resided for six years. In 343 B. C. he obeyed the
summons of King Philip to come to Pella and become the tutor of
Alexander. He acted in this capacity for four years, and seems to
have been more fortunate than Plato as instructor of a king. His
influence upon Alexander was very great. Without losing himself in
the impracticable, Aristotle seems to have impressed high
philosophical ideals upon the noble spirit of his kingly ward.
Alexander says of Aristotle, “To my father I owe my life, to Aristotle
the knowledge how to live worthily.” During the tedium of the
protracted campaign in Bactria, Alexander sent for the tragedies of
Euripides, Sophocles, and Æschylus. The Ethics of his teacher was
always with him. The ideals of statesmanship, the wide purposes in
political control, the greatness of the aims of the young conqueror,
as well as his self-control, his aversion to meanness and petty
things, and his sublime moderation were due in part to the teachings
of Aristotle. Never was there a more fortunate conjunction of two
great minds than here.

In 340 B. C., when Alexander entered upon his administrative

and military duties, Aristotle became independent of the Macedonian
court. He spent the most of these four years (340–335 B. C.) in
scientific work at Stagira, in intimate companionship with his young
friend Theophrastus, who later succeeded him as scholarch of the
Lyceum. “Among the special subjects of study in the school of Mieza
and Stagira, natural history formed a part.... Alexander at one time
contributed eight hundred talents to forward his former teacher’s
investigations in zoölogy, placed at his disposal a thousand men
throughout Asia and Greece, with instructions to follow out
Aristotle’s directions in collecting and reporting details concerning
the life, conditions, and habits of animals, and in every way made
his campaigns serve the purpose of scientific investigation.” 33 The
reports of the ancients concerning the vast sums placed at Aristotle’s
disposal for use in scientific investigation are of course exaggerated.
That he made large collections during this period, as well as later, is
certain. This was possible to him, first, because he was a rich man
himself, and second, because of his relations to the courts at
Atarneus and Macedonia.

3. Third Period, 335–322 B. C.—Administrator of the

Lyceum. When Alexander entered upon his campaigns in Asia, and
Aristotle felt himself free from immediate duty to him, he went to
Athens and founded the Lyceum. This school very soon arose above
the Academy, and became the model of later societies of scholars of
antiquity. Its greatness partook of the greatness of Aristotle,—in the
universality of its interests, in the orderliness of its administration,
and in methodical coöperation. For twelve years he was the
executive, teacher, administrator, and inspiration of this school—
developing his philosophy, accumulating materials, and instructing
his pupils. The enormous product of the school could not have been
the work of one pair of hands. Nevertheless the writings, the
immense collections, the ethical and political treatises, show a unity
that speaks of one master-mind that had them under direction.
When the Athenians began to rise against the Macedonian rule,
Aristotle’s position in Athens as a friend of Alexander became unsafe.
He fled to Chalcis, excusing himself, so the tradition goes, because
he wished to spare the Athenians a second crime against philosophy.
He died in Chalcis the next year (322 B. C.).

A comparison of these three periods of Aristotle’s life discloses

the uniformity of that life, from beginning to end. He was, from the
time he entered the Academy to the founding of the Lyceum, a
teacher. Even as pupil of Plato his original mind was influencing the
Platonic teaching into new channels. During his second period he
was a traveler, to be sure; but he was more,—a collector and a king’s
tutor. He was always Aristotle, the philosophical teacher. Hence the
periods of his life cannot be so sharply marked as Plato’s, and the
lines that are drawn point only to phases of a life that had unity, like
his doctrine. His life is a regular development from sources in his
first period, and with no later deviating influence.

The Writings of Aristotle. On every page of Plato’s dialogues

you meet Plato; in Aristotle’s writings the personality of the author is
subordinated to his science. The collections of writings transmitted
under the name of Aristotle do not give even an approximately
complete picture of the immense activity of the man. They form,
indeed, a stately memorial, even after the spurious writings have
been omitted, but their bulk is small compared with what we know
was the product of his literary workshop. Forty treatises have been
preserved. A catalogue of the library of Alexandria in 220 B. C.
includes a list of one hundred and forty-six others, which have since
been lost. Aristotle was writer, lecturer, teacher, and the
administrator of the Lyceum. His leadership of that school, his
careful direction of his coöperators in research and study, was not
only an instruction but an impulsion to independent scientific study
for all time. His great collections of scientific data can be explained
only by their being the combined efforts of many different forces,
guided and schooled by a common master. The world was ready to
take an account of stock, and Aristotle was the first encyclopædic
philosopher.

1. The Popular Writings, published by Aristotle himself.

These were intended for a circle of readers wider than his own
school. No one of these works is extant in complete form. They were
written by Aristotle during his life in the Academy. They were
dialogues in form; in content they were discussions of justice,
wealth, wisdom, rhetoric, politics, love, conduct, prayer, generosity,
education, government, etc. They were less artistic than Plato’s
dialogues, but more original and striking; and they were full of
happy inventions and rich thought, expressed in florid diction. The
ancients spoke often of Aristotle’s “golden flow of thought,” but this
cannot truthfully apply to any save these lost writings.

2. The Compilations. These were excerpts from scientific

works, collections of zoölogical, literary, historical, and antiquarian
data, which Aristotle and his pupils had gathered together. Only a
few fragments of the total remain. There were critical notes upon
the Pythagoreans, reports of extracts of Plato’s dialogues, a
descriptive basis for zoölogy with illustrations, collections of previous
rhetorical theories and models, histories of tragedies and comedies,
discussions about Homer, Hesiod, Archilochus, Euripides, and other
poets; there were historical miscellanies and reports concerning one
hundred fifty-eight Greek state constitutions.

3. The Didactic Writings. These have in part been preserved,

and they make up the collection of what we have of Aristotle’s
writings. They have a consistently developed terminology, but they
are wanting in grace and beauty of presentation. The plan of the
books is generally the same: the problem is precisely stated; then
follows a criticism of various attempted solutions; then a discussion
of the salient points of the problem; then a marshaling of the facts;
and, finally, an attempt to get a conclusive result. The method is
modern in its scientific procedure and the contrast with Plato is
striking. Yet it must not be inferred that these books of Aristotle are
orderly. There are repetitions, haste, unequal development of parts,
and unfulfilled promises. These books were nothing else than the
written notes which he had made the basis of his lectures and had
intended to form into text-books in some future time. Only parts of
the Logic seem to have been completed for text-book purposes.

These didactic writings are simply arranged as follows (Wallace):

1. The treatise on Logic called Organon.

2. Speculative Philosophy.

First Philosophy or Theology or Metaphysics.

Mathematics (writings not extant).

Physics (including the history of animals and the psychology).

3. Practical Philosophy.

Ethics.

Economics.

Politics.

4. Poetic Philosophy.

Art.

Poetry.
 Rhetoric.

Aristotle’s Starting-Point. The two early influences in

Aristotle’s mental development offer an explanation for his
philosophical point of view. These influences were his empirical
training in medicine and his conceptual training in the moral ideals of
the Academy. Plato had convinced him that if there were to be any
true science, it must be founded on concepts that are unchanging.
His own scientific training, however, reinforced by the influence of
Democritus, made him respect the value of empirical facts. While the
philosophical problem for Aristotle was the same as that for Plato,
the difference between them was in the main a matter of emphasis
due to their different starting-points. Plato started with the refutation
of the Protagorean theory of perception, and consequently he
emphasized the value of the conceptual world; Aristotle, however,
felt that Plato had overestimated the conceptual world, and he
emphasized the importance of empirical facts. Both when a member
of the Academy and later, he strongly contended against Plato’s
evaluation of the world of Ideas, because they so transcended the
sense world that they neither explained nor illuminated it. Aristotle’s
reaction against Plato’s theory furthermore gives us a more correct
notion of what Plato really taught. If conceptions are to enter into
knowledge, they must not exist in the clouds of abstraction. He
maintained that Plato had increased the difficulty of the problem by
adding a second world of entities quite distinct from the world of
nature. The same problem that Plato confronted still exists
unanswered, said Aristotle. It is the problem of the twofold world. If
Ideas are apart from things, we could not know that they existed,
we should not be able to know anything about them, nor should we
be able to explain the world through them. It is true that Plato, in
his later draft, had conceived Ideas to be teleologically related to the
physical things, but how could this be if they were apart from
things? Thus in his reaction from Plato’s theory of Ideas, Aristotle
reëstablished the world of perceptual fact. This is the starting-point
of Aristotle.
 The Fundamental Principle in Aristotle’s Philosophy. The
first question then is, How did Aristotle reëstablish the perceptual
fact? What means did he employ to give the perceptual fact a
reality? The answer to this question will be the statement of
Aristotle’s fundamental principle. It will show his advance over Plato
by showing his new estimate of the perceptual world. Plato accepted
the Protagorean doctrine of perception, but also gave it a new value
by placing perceptions beside conceptions in the world of reality;
Aristotle developed Plato’s teaching about perceptions by linking
them inseparably with conceptions. Aristotle felt that Plato’s
difficulties arose from the lack of close relationship between
conceptual Being and perceptual fact. What is that linkage? What
binds abiding reality and changing phenomena so closely? The
linkage is development. Development is the relation between
conception and perception. It is the fundamental principle in the
philosophy of Aristotle throughout and places a new estimate upon
the value of perception. Perceptual facts apart from conceptions
have no reality; conceptions apart from perceptions are mere
abstractions. In the world of reality conceptual Being resides in the
perceptual facts, and the perceptual facts express conceptions. They
always exist together in a linkage or relationship that is teleological,
purposeful—the linkage of development. An abstract statement of
this relationship is, “Aristotle felt the conceptual necessity of the
empirically actual.” Perhaps the clearest statement of this
fundamental principle can be made in the terms of evolution. It is
this: true reality is the essence which unfolds in phenomena. Notice
that this sentence has two parts equally freighted: reality is an
unfolding essence; reality is in phenomena. The true universal must
be thought as realizing itself through its development in particulars;
the true concept as realizing itself through its development in
percepts; the true abiding Being as realizing itself in its development
through change. On the one hand, reality is the essence of things;
on the other, reality has existence only in things.

True reality is the individual.

 The individual consists of two aspects: (1) conceptual being, and
(2) perceptual change.

These two aspects always stand in a relationship.

That relationship is developing purpose.

Here is the key to the teaching of Aristotle that seems to open

the doors of its many chambers. In his metaphysics reality is the
individual developing from possibility to actuality. In physics
individual phenomena get a reality through their development from
lower to higher types. In psychology the individual person is real
when the particulars, the physiological and psychological states,
develop toward the soul, which is their truth. So, too, in the great
system of logic in which Aristotle was pioneer, he is simply trying to
give the particular judgment a meaning by showing its linkage to the
universal judgment. Everywhere the starting-point of Aristotle is the
perceptual fact. Everywhere his purpose is to reëstablish it by
showing its relation to abiding conception in the individual.

It may be well to remark, however, that Aristotle does not

altogether succeed in constructing a consistent theory. In spite of his
criticism of Plato’s transcendent Ideas, in many places Aristotle does
not overcome Plato’s dualism. Frequently he differs from Plato more
in words than in meaning. We shall observe some of his
inconsistencies in their place. We shall see that Aristotle as he meant
to be was different from Aristotle as he was. Aristotle as he meant to
be—Aristotle as the opponent of Plato’s dualism—develops a
philosophy from a single fundamental principle. Aristotle as he was,
reverts at many critical points to Plato’s dualism.

Aristotle’s principle of development may appear at first blush very

much like the modern principle of evolution. As a matter of fact it
was very different. In all Greek philosophy after Socrates the study
of morals was fundamental. The ideal of Socrates, Democritus, Plato,
Aristotle, and the later Schools was a moral ideal. Being moral it was
fixed, and it fixed all the changes of life to it as a centre. Nature was
to the Greek a museum of types oscillating around a perfect form.
There was no evolution in the sense of progress. There was
development within the individual—the boy becomes a man, the
seed becomes a flower; but there was no evolution from genus to
genus. Indeed, any variation of the individual from its type was
considered a defect.

Aristotle’s Logic. Aristotle felt that there must be a science of

the methods of science; and so successful was he in its formulation
that it has practically remained as he transmitted it. We are struck
by the way in which he divided science into the special sciences,
each with its well-defined field. It was perfectly natural that he
should also, with his great power of abstract reasoning, discuss the
body of rules for legitimate thinking. In science there must be an art
of investigation, just as in rhetoric there is an art of persuasion. At
an early period these logical writings were collected under the name
Organon, because the Lyceum regarded them so intimately
connected with scientific procedure as to be the instrument or
“organ” of all knowledge. Certain parts of Aristotle’s Organon are of
doubtful genuineness. The important sections are the Analytics, a
masterly logical groundwork of the conclusion and proof, and the
Topics, which treats of the inductive methods of probability. Aristotle
therefore made logic a preliminary and separate study, as it should
be. It became the preface to his scientific work.

We shall briefly discuss Aristotle’s logic, because it is an

exemplification of his general philosophical principle. Among the
subjects in the history of philosophy, logic is perhaps the only one
that has had no internal history. Aristotle was the pioneer in the
subject. He left it so finished that scarcely any changes of
consequence could be made in it. The external history of the
Aristotelian logic has, however, been notable. A portion of the
Categories and De Interpretatione was most influential in the history
of the Middle Ages. The Logic had been misunderstood and
misapplied by Aristotle’s own School, so that when it came into the
hands of the Schoolmen it had acquired the reputation of being only
an abstract formal logic. As thus interpreted it was used by the
Schoolmen and attacked by the philosophers of the Renaissance.
Such a view of Aristotle’s logic is unjust to the author. He had
conceived logic in its wholeness to be the true method to be used in
investigating practical scientific problems.

The Sophists had proposed rules of practical value in the study of

individual cases; Socrates had tried to fix upon some universal
principle as the basis of knowledge; Aristotle made a comprehensive
study of the regular forms of thought and the rules that govern the
arrangement of these forms in right thinking. In true Platonic fashion
he conceived physical events in nature to be due to some universal
cause. If, therefore, logical procedure be scientific, it must follow the
ways of nature: logic must deduce particular perceptions from some
universal idea. The necessary thought-relations in which the
particular stands will then appear. Deduction of the particular from
the universal is the true scientific method, used in the explanation of
nature-phenomena; so in proof the same deductive reasoning should
be used. In scientific study we are trying to show the conceptual
necessity of an empirical fact; in proof we are showing the
conceptual necessity of the particular term. Whether we are
explaining an event or proving a conclusion, we are employing the
same logical process. Aristotle thus regarded his logic as the true
scientific method for practical service, not as a merely abstract
discipline in verbal hair-splitting.

Socrates and Plato confined themselves to the study of the

concept or simple term. Aristotle also studied the concept. Indeed,
he tried to find out what concepts are fundamental in our thinking,
so fundamental that they are our thought reduced to its lowest
terms. He names ten of these fundamental concepts and calls them
categories. But Aristotle goes farther than Socrates and Plato, and
makes his real point of departure the judgment. A single term does
not express truth. For truth we must have two terms connected by
the verb “is,” i. e. some relation must be shown between them. This
is a judgment. Reasoning is still more complex. It is the putting
together or showing the relation between two judgments. This
process takes the form of the syllogism. The first task of deduction is
to present the laws of the syllogism. These will then be the laws of
scientific investigation. According to these, particulars can be derived
with certainty from universal propositions, provided such universals
are established. The syllogism is in the form of two premises and a
derived conclusion. It contains three terms. The problem is to infer,
from the relation that one of these terms bears to the two other
terms, what the two bear to each other. The principle employed is
that of subordination; and the differentiations of the syllogism can
be many, depending on the quality and quantity of the premises and
the distribution of the middle term. The working of the syllogism in
inference has a certainty so great that Aristotle called it apodictic.

But there is another side to the syllogistic besides the deduction

of proof or the explanation of empirical fact. This is the
establishment of the premises. All deduction presupposes absolute
premises. All deduction is grounded on something not deduced; all
proof on something not proved; all explanation on something that
has not been explained. These presuppositions are universal
propositions that can be known only immediately through intuitions.
Aristotle is not altogether clear as to what these intuitions are. He
names such axioms as the law of contradiction and the law of the
excluded middle, and some special propositions which apply only to
particular sciences. Since the premises which we actually use are not
open to proof, but only strengthened as to the validity of their
application, we must use the method of induction in our search for
them. We accumulate data from opinions and varied experiences,
and then we ascend to a generalization which we take as a premise.
The results of induction cannot therefore be in themselves certain.
The results are only probable, and can have the character of
knowledge only as they explain phenomena. Aristotle means by
induction something different from the present use of the term.
Induction in modern times means a kind of proof; Aristotle means a
method of discovery of relatively universal terms where the
absolutely universal cannot be obtained.

There is an ideal involved in this conception of logic that is

interesting. In a perfectly intellectual society there would be a
perfect science in which all particular facts could be derived with
absolute certainty from premises absolutely known. Life and logic
would be identical. We should then be certain not only as to our
proof but as to our premises. Logic has sometimes been used very
effectively in this way. When the mediæval church conceived its
dogmas to be the ultimate premises of truth, it could deduce from
them complete rules for living. To the mediæval mind the perfect
science was formulated by deducing it from the dogma of the
church. The dogmas were the absolute premises. The Renaissance
did not doubt the infallibility of the traditional dogmas so much as
the logical method, and Aristotle, who had been so long artificially
identified with the proof of ecclesiastical dogma, was set aside.

Aristotle, moreover, showed great insight into the present relation

of thought and reality. The sequence of facts in our experience, he
pointed out, is exactly the reverse of what it is in reality. What is first
in reality comes last in our experience, and what is first in our
experience is last in reality. To illustrate: the mission of the Athenian
State in the eternity of things did not appear until every event in its
history had occurred. A perfect being would see the universal ground
before the historical particulars derived from it, while we look from
the particulars to their universal causes. Logic and metaphysics
agree; but they stand in inverted parallelism to historical and
psychological processes. Knowledge is a development from the
senses into the Ideas, and yet, on the other hand, Aristotle never
fails to remind us that this development is the expression of an idea
which has been present from the beginning.

Aristotle’s Metaphysics.
 1. Development is Purposeful. The conception of relation is,
of course, quite as fundamental in Aristotle’s theory of metaphysics
as in his logic. In logic knowledge of the particular is possible
through its relationship to the universal; in metaphysics the
relationship is the relationship of development—the particular has
significance and value through the universal essence that unfolds
from within it. If Aristotle shows genius for abstract thinking by
becoming the “Father of Logic,” he shows equal genius for abstract
thinking in his metaphysical conception of development. He believed
that metaphysics applies the same conditions to things that logic
discovers in thought. But in metaphysics the relationship is not the
abstract relationship that Aristotle saw in Plato, but the vital relation
of development in the life and change of nature.

We have already stated the fundamental principle in Aristotle’s

teaching as an unfolding essence in phenomena. The unfolding is
the relationship of development. Reality does not consist in the
particular things of nature, nor in something outside nature, but in
this essential linkage of the perceptual and conceptual in nature. As
the world is spread out before us, it presents objects that are
dynamic, however much they may appear to be static. Everywhere
matter is in the process of forming. The world is a forming, not a
formed nor a formless world. So, also, if you undertook to describe
any individual object in the world, you would have to define it as a
forming or developing thing. A tree, for example, would not be
adequately defined or described by enumerating its parts at any one
moment; but you must describe it as a unitary organism developing
from a seed. The reality of the world is the development of its
meaning in its history; the same is true of the reality of any
individual thing in the world. The world and the things therein have
an unfolding essence.

The next point to be observed about Aristotle’s conception is that

the relationship of development is between two terms. The
individual must have two aspects: there must be that out of which
the development is passing, and that into which it is passing.
Aristotle calls these two aspects of development respectively Matter
and Form. Every object of nature consists of Form and Matter, and
these two terms have passed into history. To Aristotle everything is
Matter becoming Form, or, in other words, Form realizing itself in
Matter. The tree has its Matter which is becoming Formed, and its
Form into which the Matter is growing. The principle which unites
the two is development,—the principle of the individual. Matter,
then, is the possibility or potentiality of an individual thing—it is the
thing given potentially; Form is its actuality or reality. If you
emphasize merely the stages in the development, you are regarding
merely the occurrences; if, however, you emphasize the stages of
development as aspects of a unity, you see its essence.

The relationship of development between two terms thus

becomes under Aristotle’s hands the relation of purpose. Aristotle
calls this self-realization of the essence in phenomena by the
technical word entelechy, i. e. in opposition to the earlier
conceptions of nature Aristotle conceived nature teleologically.
Teleology or purpose we found Plato using in his second draft of the
Ideas, but more as a postulate than as an efficient means of
explanation. Aristotle uses teleology as his positive fundamental
principle of nature.

2. Aristotle’s Two Different Conceptions of Purpose.

Aristotle illustrated his conception of the purposeful relation in
nature from two very different types: (1) the development of
organisms; (2) the development that takes place when an artisan
moulds plastic material. Manifestly here are two different kinds of
teleological activities. In organic growth the Form that realizes itself
in Matter is immanent in the organism; the artist, on the other hand,
superimposes the Form upon the plastic material. In the case of
organisms Matter and Form are separable only by abstraction, and
are only two aspects of a development which is identical from the
beginning to the end; in the case of artistic construction the Matter
is first a possibility existing by itself, and the purpose of the artist is
later added unto it. In the case of organisms Aristotle speaks of two
causes,—the material and the formal; in the case of artistic
construction he employs four causes,—the material, the efficient, the
formal, and the final. Aristotle did not expressly formulate these two
different conceptions of purpose, but he completely applied them in
practice. On the one hand he regarded individual things as self-
realizing, and on the other he looked upon them as realized in other
things. This seemingly harmless difference is really very
fundamental, for it is the difference between Aristotle as he meant
to be—Aristotle as the critic of Plato’s dualism—and Aristotle who
reverts to Plato’s teaching. We find therefore two Aristotles; one a
dynamic monist, the other a transcendent dualist. We cannot say
that Aristotle as he meant to be is the true Aristotle, for he is a
dualist in very many important doctrines.

Aristotle’s conception of purpose as exemplified by organisms is

his original conception, and is what he intended to be the basis of
his philosophy. Here the truly real is the individual determined by its
own Form. It is the dynamic and not the artistic view of life. Activity
is directed to an end not without but within itself. The individual is a
complete organic unity at rest within itself. The individual is primarily
the essence or substance. Of the ten categories which he
enumerates, substance from this point of view is to Aristotle the
most important. The nine other categories only describe the states
or relations of the substance. The essence of the individual is the
substance; and Aristotle conceives the substance as the species or
universal in the thing. It is pointed out that even here Aristotle is
guilty of a dualism in the double meaning in which he uses
substance. But the conception of Aristotle here is of an immanent,
dynamic reality. He has in mind the self-contained unity of the
individual, whether that be a tree, a man, or the universe.

Aristotle’s conception of purpose as exemplified by artistic

products preponderates over his original conception of purpose.
When he regards the individual objects in the world, not as self-
contained but as relative to one another, he has a different
conception of the world. In this case the individuals are not realities
but have reference to a reality transcending them. The world is still a
developing world, but the essence that unfolds itself is not in
phenomena. It is a goal for which phenomena strive. The fulfillment
of the purpose is beyond. Individual things are only a scale of values
relative to some transcendent standard. To illustrate: the bud, the
blossom, the fruit, have not their realization in themselves, but as
food; again, the growing tree, the timber lying on the ground, the
timber in the house, have their realization in the completed house;
again, in the world at large, the original nebulous matter of the
universe, the first-formed worlds, the early years of this earth, the
succeeding centuries, the 20th century of this world, are only a scale
of values for something in the future.

In facing such facts, Aristotle had to depart from his original

conceptualistic standard of the world as an organic unity and of
individual things having their meaning in themselves. View a thing
by itself, and it seems to be a self-contained reality which unfolds for
itself alone. View a thing with reference to other things, and its
reality is in something else. Here is Aristotle no longer as he meant
to be, but as he really was. He is now Plato’s pupil. Each thing now
is to be regarded, not as containing in itself the two aspects of Form
and Matter, but as the possibility of something and the actuality of
something else. The blossom is the possibility or Matter of the fruit
and the Form or actuality of the bud. The nineteenth century is the
Form of the eighteenth and the Matter of the twentieth. But
development has a limit above and below, according to Aristotle:
below, in Matter that is without Form; above, in Form that is without
Matter. Pure Form is God, who excludes from Himself all Matter or
possibility, because He is perfect. Pure Matter is the lower limit,
which is entire possibility, and exists only to be formed. Here is a
dualism as distinct as Plato’s, which Aristotle not only did not
overcome but which he developed. In the same way that Plato
contrasted Ideas and empty space, Aristotle contrasted God as pure
Form and Matter as pure possibility.
 In this final dualistic form in which Aristotle left his teaching,
there are three specific doctrines which the student must consider
carefully. They are important because they had great influence in
later orthodox theology and in theories of nature. These special
doctrines are (1) Aristotle’s conception of God; (2) his conception of
matter; (3) his conception of nature.

3. Aristotle’s Conception of God. In the Aristotelian system

the assumption of an upper final term of pure Form was necessary,
because Matter as the possible and potential is not endowed with
the power of motion and generation. To Aristotle development is not
a process with temporal beginning and ending, but is a kind of
closed circuit. Since reality is in itself a developing essence, motion is
as eternal as reality. We should not ask, therefore, When did the
world begin, and when will it end? but we can legitimately ask, What
is the nature of reality that keeps motion alive? When we examine
individual things, we find, according to Aristotle’s explanation, that
motion is the result of the influence of Form upon Matter. There is
inherent in matter an impulse to be formed, and there is inherent in
Form an active forming purpose. But we may search individual
things in vain for the causal explanation of motion, since every Form
is in turn the Matter for a higher Form. The chain would be endless
and not intelligible if there did not exist a pure Form, which is
unmoved. God as the unmoved mover is the cause of the world-
motion, but God must be the cause in a different sense from the
physical causes, which are themselves moved. God operates as a
cause upon Matter, not as a mechanical cause but as pure Form,—as
a final or teleological cause. God is the cause in the sense that God
excites in Matter the impulse to be actual, like God.

This prime mover is similar to Plato’s Idea of the Good. As to its

form it is eternal, unmovable, unchangeable, wholly independent
and incorporeal, and yet the cause of all generation and change.
God is the perfect Being in whom all possibility is actuality. As to its
content God is pure thought. But in respect to his thought God is not
like human thought, which is concerned with external phenomena
and changing things. God is thought that has nothing else for its
object than itself and its own unchanging content. God is “thought
of thought.” God’s contemplation of himself is his own blessed life.
Here in Aristotle is a momentous conception formed for the first time
in the history of thought. Monotheism is for the first time
conceptually framed and scientifically grounded. The monism of
Aristotle’s predecessors passes over into a theism. God is not only
immaterial in the sense that Plato defined the Ideas, but he is
spiritual. In Aristotle’s transcendent God, conceived as pure self-
consciousness, we have the ripest fruit of Greek philosophy.

4. Aristotle’s Conception of Matter. The other and lower limit

of Aristotle’s dualism is Matter, “first Matter,” as Aristotle called it. In
itself it is wholly unformed and mere possibility. But it is unlike pure
Form in this respect,—it never exists in itself. God exists apart from
Matter, but since Matter is mere possibility, Matter never exists apart
from Form. Matter has a double character. On the one hand Matter is
that which as an accessory cause makes the world of phenomena
possible; on the other hand it is the source of the lawless and
purposeless in nature. Through its seeking to be formed it makes the
presentation of the Idea possible, and yet it stands as a deterrent
principle to the full presentation of the Form. On the one hand it is
the sine qua non of physical nature, shows itself in real physical
effects, and is the basis of mechanical causation, motion, and
impact. On the other hand it stands in the way of the Forms
actualizing themselves fully, and it prevents the universe from
perfecting itself as God is perfect. While Matter is not an indifferent
negative (as in Plato’s teaching), but the necessary substratum of
corporeal things, it is however the indeterminate, and the ground of
the accidental and purposeless in nature. Matter is the infinite and
unlimited, and is the source of unusual phenomena, like
monstrosities and abortions. Both fate and accident are due to the
retarding influence of Matter, because it obstructs the successful
working out of Form. Quite in accord with Greek thought, Aristotle
conceived necessity and chance to be fundamentally the same, and
the Greek custom of drawing lots shows the universality of the
notion.

5. Aristotle’s Conception of Nature. Nature is therefore to

Aristotle a far more complex world than Plato had conceived it.
Nature has a double character to Aristotle, as his twofold conception
of causation shows. Nature is composed of mechanical and
teleological causes. Purpose and necessity are the two principles of
motion in the world, and in this twofold conception of causation did
Aristotle reconcile Plato and Democritus. However much Aristotle
concedes to the Democritan idea of mechanical necessity, it is
evident that in his conception of nature the principle of teleology
predominates over the mechanical. The highest actuality is God, and
he is a final or teleological cause; and all results of value in nature
come through final causes. Final causes are primary causes;
mechanical causes are secondary causes. There would be no motion
whatever in the universe but for the highest final cause, God. Yet
God is the unmoved mover, and matter cannot move itself. Motion
occurs because matter feels the impulse to form itself like God. How
different this Aristotelian conception of nature from our modern
scientific conception of an impersonal nature under a mechanical
causation that is universal! The teleological conception of nature and
natural events was very strongly intrenched in the human mind
during the Middle Ages, and was not dislodged easily by modern
investigation. Nature was a living thing to Aristotle. It was at once
intrinsically spontaneous, and self-determined and uniform. Its
spontaneity was not that of capricious chance. Its uniformity was
that of purpose and end. On the other hand, the Aristotelian
conception of nature is not the same as either the Christian doctrine
of created nature or Darwin’s theory of evolution. The world of
Aristotle had always existed; it is a limited world in space, but not in
time. Also the divine reason always existed in it. Yet its evolution is
not a progressive climbing sort, like the Darwinian, in which new
species evolve. It means only that there is a relationship of rank and
value among nature objects. Nature is a unity. Teleological change
occurs within it.
 Nature is therefore a connected system of living beings in the
process of development from Form to Form, approximating the Deity
and existing as the potentiality of the Deity. There is a graded scale
of things of relative worth. But the double standard of estimating the
worth of nature-objects—that of mechanical necessity and that of
teleological cause—makes two different series, which find their union
only at the end in God. From our foregoing description of the nature
of God, it will be seen that he has two essential characteristics: he is
Being who ever rests within himself and remains like himself; and he
is a pure reason. He therefore combines in himself the two nature
series in their most ideal character. Nature-objects in the series of
mechanical necessity have as their ideal character just that
uniformity, regularity, and order that we find in the abiding Being of
God. The greater the uniformity, the more nearly like God. Nature-
objects, in the teleological series, have as their ideal characteristic
the reason of God. The more nearly rational such a living being is,
the more nearly is it like God. In the one line the series of
phenomena ascends from the disorder of the terrestrial universe to
the absolute uniformity of the stars, which are close to God. In the
other line the series ascends in teleological values from the
mechanical and vegetative characteristics of organisms to their
rational activity. Both series terminate in God. The stars have rational
intelligence and the most uniform motions. Aristotle conceived
Physics as the science that includes the first series, and the second
series he conceived to be included by Psychology, Ethics, and
Politics.

The Mechanical Series,—Aristotle’s Theory of Physics. The

general astronomical assumptions of the time determined Aristotle’s
theory of the physical world. He adopted the old Pythagorean
conception of the limited world-all: a hollow sphere made up of
concentric crystalline spheres. In opposition to the Pythagoreans, he
conceived the earth at the centre. It is spherical and stationary.
Around it the crystalline spheres revolve, in which the moon, sun,
five planets, and fixed stars are placed. The fixed stars are in the rim
of the great sphere, are outside all, and are nearest therefore to
God, who animates all. God as it were holds the world-all in the
hollow of his hand. He moves the whole, which in turn moves the
fifty-five concentric crystal spheres within. The principle of the
movement of fixed stars is that of the Deity, while the principle of
the other spheres is that of the spirits which reside in them. The
movement of the planets have an influence upon terrestrial life.
Aristotle made the usual Pythagorean division between the celestial
and the terrestrial parts of the world-all, which has had so much
influence upon theology. The motion of the world-all is most perfect,
being a circle; its form is most perfect, being a sphere. The celestial
part of this world-all, which is the region lying near the periphery, is
most like God. The motion of this heaven is circular, and it is the
place of uniformity, perfectness, and changeableness. The stars do
not change nor pass away. They are superhuman beings, who in
their regularity are like the blessed gods. The terrestrial part of the
world-all below the moon has motions in straight lines. This is the
theatre of imperfection and irregularity, of increase and diminution.

There are many interesting discussions by Aristotle upon

particular physical matters, such as space, time, the elements. His
conception of motion shows how the series of uniform nature-
motions lead up to the second series of teleological values. In nature
there are three kinds of motion: change of place (mechanical);
change in quality (chemical); change in substance (organic). While
change of place is the lowest kind of motion, it is necessary to
chemical and organic changes. Yet Aristotle refuses to allow that
qualitative changes can be reduced to quantitative changes, but
maintains that quality is self-subsistent. Organic change, or change
in substance, on the contrary, has a higher Form of reality than the
lower changes. This stand taken by Aristotle, in refusing to reduce
qualitative to quantitative determinations, shows how
comprehensive and sane a scientist he was. It introduces us to a
psychology and an ethics that are intimately linked to physics, and at
the same time have realms of their own. Let us now turn to the
series of qualitative nature changes, or to psychology, ethics, and
politics.
 The Teleological Series: The Qualitative Changes of
Phenomena.

1. The Psychology of Aristotle. As the first experimental

psychologist, Aristotle intimately connected his studies in psychology
with his studies in biology and medicine. Man is a part of the world
of nature, and psychology is in part a comparative study. As we pass
upward from the mechanical changes, we find chemical changes of
quality, and then changes of organic life. Studying the organic realm,
we find organisms to consist of souls of relative ranking. There are
vegetative souls, sensitive souls, and rational souls. Plants have
vegetative souls with the powers of assimilation and propagation;
besides vegetative souls animals have sensitive souls, with the
powers of appetition and locomotion; man possesses, besides both
these souls, the rational soul. Here is a series of teleological
relationships, where the purpose of the organism is explained only
by the activity of its soul. The soul builds up its body as a system of
organs, and as an organology the theory of Aristotle has great
significance. Nature strives ever upward, even in the inorganic
processes, through an unbroken series of creations to its highest
Form in man. Each step in the upward progress is the realization of
an entelechy, or purpose, and constitutes for the moment the goal of
the impulse to strive. The whole world is striving to realize the
perfect Form. The lower ends, the mechanical and vegetable and
appetitive Forms, are not lost but are utilized in the process; for they
are the Matter upon which the Forms higher than themselves are
built. Every member is both Form and Matter in the whole series.

The psychology has therefore two parts: (1) the general theory
of animal souls, which possesses rich suggestions; (2) the doctrine
of the Nous as the distinctive characteristic of man. These are the
empirical and speculative sides to Aristotle’s psychology.

Man is an epitome of all the changes in the universe. He has

vegetative, appetitive, and rational souls. Yet there is unity in man,
for the lower souls are subservient to the reason and exist for it. The
appetitive soul is the Form of the vegetative soul, the Matter of the
Rational soul, etc. Accordingly, Aristotle defines the soul as the
entelechy of the body, because bodily human activity is enlisted in
the service of the reason. Reality in man is an unfolding purpose,
just as it is in nature. The real self is this unfolding rational self,
whose possibility is the body; whose actuality is pure reason. The
mind is actualized body, the body is potential mind.

Aristotle made many contributions to psychology about the origin

and value of the several sensations, about the feelings of pleasure
and pain and the desires. He shows his remarkable genius in
pointing to the necessity of a unity of consciousness, which he calls
the “common-sensibility.” His discussion of the Nous, or reason, is of
importance for two reasons: first, because it leads to and illuminates
his ethical theory; and second, because it is an example of his
deviation from his original conceptual position. The reason,
according to his first intention, is the unfolding purpose of the body,
—it is the immanent essence of the body. As Aristotle finally left his
discussion of the Reason, it is as transcendent as his God, or as any
Idea of Plato. The Nous, or Reason, is not a Form of the body, but a
Form of the soul. It is purely immaterial, simple, unchangeable, and
incapable of suffering. It does not originate with the body as a
function. It comes from without as a godlike activity, and will remain
after the body passes away. Its fundamental activity is thought, and
its object is those ultimate principles of Being which are the ultimate
premises of logical thinking.

Aristotle’s theory of the Reason is considerably complicated by his

division of it into two parts,—the active and the passive Reason.
Within itself, the Reason is to be distinguished as Form and Matter.
The passive Reason is the Matter for the active Reason, and the
active Reason is the Form for the passive Reason. By the passive
Reason Aristotle evidently means the individual and developing man.
The active Reason can alone persist after death, but whether
absorbed in the Deity or not he does not say. Immortality to Aristotle
in any case is not a perpetuation of the individuality.
 2. The Ethics of Aristotle. We have seen that nature
phenomena are of two classes,—those mechanically related, and
those related as to their purposes or ends. Physics is concerned with
the first class; psychology is concerned with the second class. But in
a special way are ethics and politics sciences of the phenomena of
the second class—sciences of teleologically related phenomena.
Moral life is an unfolding essence having a possibility and an
actuality. The Possibility or Matter of the ethical life is our feelings,
temperament, disposition, impulses, and perceptions—just those
psychological factors that make up the endowment of the human
personality. The ultimate Form or actuality of the ethical life is the
reason. The reason as the goal of the moral being determines its
character. Man is distinctly a rational being. Virtue is the process of
the ethical life from its possibilities to its actuality; it is the essence
of the ethical life. Virtue is that continuous state of mind that makes
rational activity possible. So much for the factors that make the
ethical situation; the natural endowments of the mind are its
material, the reason is its goal, while the means of developing the
natural endowments into rational activity is virtue.

The situation would be simple enough for us as moral beings if,

in our striving, each had only himself and his own development to
consider. But man lives in a world of men, and his highest good is
determined somewhat by his environment,—by riches, bodily
comforts, success. These are not essentials but only accessories, and
the lack of them is only a limitation. The essential factor is the
rational activity. Nevertheless, these modify the definition of what we
mean when we define rational activity as the highest Good or Form
of the moral life. For the question which Aristotle proposes in his
notable treatise of Ethics is, What is the end or supreme good of
human action? The highest Good for a man among men is
Happiness, or well-being; that includes not only rational activity, but
also the pleasures that accrue to such activity. But what is
happiness? It is an end in itself, and not the means to anything else;
it is the result of functioning, a state of conscious vitality; it accords
with the law of excellence of that functioning. Perfect happiness is,
therefore, partly the result of one’s own individual effort, partly
dependent on circumstance. While virtue is the measure of the
worth of different pleasures, yet pleasures do not always attend our
acts in our present society. The greatest Good is happiness, but
since this depends in part on external goods, the goal to which we
should directly attend—the factor within our control—is rational
activity.

There are two classes of virtues based on the two kinds of

rational life,—the practical virtues and the dianoetic virtues. The
practical virtues are those of conduct based upon the rational control
of the impulses; the dianoetic virtues are those of intellectual activity
based upon the development of the perceptions. The perfect moral
development of human nature will consist (1) in the perfect
development and true regulation of the feelings and desires in moral
excellence; and (2) a perfect development of the intellectual
faculties for rational culture.

(a) The Practical Virtues. The essential thing for the individual to
regard, therefore, is the training of his will by right rational insight.
He should seek to direct his impulses by reason, and not only once
but so many times that the impulses will become rational habits.
This is what Aristotle means by training in virtue. It is continuity in
rational activity; it is a permanent development toward reason; it is
the unfolding of the real Self. Aristotle had regard for the facts of life
when he differed from Socrates, who said that virtue is knowledge.
Aristotle did not conceive the will as psychological power
independent of the reason. He doubted if rational insight was more
powerful than the impulses, when the test comes. Experience often
shows that although we may know what is right, an impulse will
often drive us into habits not guided by reason. This presupposes for
Aristotle a will that is free to choose among the desires that one
which will lead him along the path that reason points out.

It is impossible to formulate a rule for the acquirement of the

particular virtues. Each virtue must be treated by itself. The only
principle for guidance is that the reason should always seek the
mean between two extremes. Thus courage is the mean between
cowardice and rashness; temperance between intemperance and
insensibility; friendliness between obsequiousness and brusqueness,
etc. Moderation is the watchword in the cultivation of the practical
virtues.

(b) The Dianoetic Virtues are the means toward the attainment
of pure rationality for one’s self. The dianoetic virtues are higher
than the practical. They unfold the pure formal activity of the Nous,
and give the most noble and perfect pleasure. Man finds through
them his possible participation in the divine happiness. These
intellectual virtues may be either theoretical or practical insight; in
the latter case, Aristotle means knowledge of the right in art, and
knowledge of justice. But the purest is Wisdom (θεωρία), which is
knowledge for its own sake. It is the knowledge that God has of
himself. Man may approximate this.

In Aristotle’s ethical theory there appear three features that are

distinctly Greek. (1) The leading question that he asks at the
beginning of the Ethics, What is the end or Supreme Good of human
action? is Greek. The modern writer asks, What is the nature of
duty? (2) The emphasis on the “mean” is Greek. The idea of the
“mean” was the fundamental principle in Greek life, and appeared in
such literature as Gnomic poetry and Plato. (3) The subordination of
individual ethical conduct to the conception of the state is Greek.
Aristotle says that politics will have to settle the question of the
Supreme Good, for the Good of the state and that of the individual
are identical.

The Political Philosophy of Aristotle. In the present real

world rational activity rather than happiness is the chief concern of
man. Happiness is, however, his highest Good, which he can attain if
his environment favors him. The political environment is a moral
factor to be considered. The state should be the fulfillment of the
morals of the individual, and should also be his ethical trainer. That
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