Making Quality Calculable: Reassembling the elements of calculation and judgment in
American healthcare, 1945-2010
This paper takes a historical approach to analyse two periods in American history. In each period,
the paper examines material related to the construction of “quality” in healthcare in the United
States.
The aim of the paper is to bring greater understanding to how calculation and judgment can be coconstitutive of one another, and indeed, are not separate and distinct, despite typical
understandings and assertions in research (academic and otherwise) that seems to grant them
separate epistemological status.
This paper examines medical literature (academic and medical association, predominantly) to
develop the concept of ‘quality’ in medicine. It finds that between the years 1945 and 1975, quality
was highly focused at the site of the physician, including the physician’s assessment of medical
quality. As stated in the paper, “quality was localized to the individual physician, his local
knowledge, his judgments, and ultimately his conscience.” A shift in this mode of thinking and
analysis took place such that between 1985 and 2010, quality in medicine was concentrated at the
site of the patient.
While this empirical and theoretical analysis produces an interesting history in and of itself, what
the paper also produces is a theoretical contribution concerning the way in which research
conceptualizes calculation and judgment as somehow independent of one another, akin to two ends
of a spectrum. Using this empirical site (quality assessment) the paper is able to tease out the way
in which calculation and judgment are not at all disconnected and somehow substitutable for each
other. Rather, the paper shows an intriguing, perhaps overlooked idea, which is that judgment and
calculation co-exist in relation to each other, in a somewhat co-constitutive manner.
The paper takes a very interesting empirical site (quality in medical care) which affects broad
sections of society in important ways. Therefore, its empirical topic is of broader interest than the
paper emphasizes. We may have further policy contributions (rather than ‘only’ theoretical
contributions) emerging from this paper as it is developed further.
The paper also brings a focus on the possibility of inattention in research to the notions of
judgment and calculation. I agree that somehow it feels intuivitely that research has privileged
“judgement” in a rather normative way, as you mention on page 4 of the paper. Yet, how would
more attention to this aid our research going forward, what could - theoretically and empirically this concept do for us? i.e. the paper is still lacking a strong case to be made concerning why it is
important that accounting research come to terms with this potential inattention, rather than
being a rather intriguing concept, this paper must be more firm in arguing its importance.
The paper has considerable potential. Further comments will follow in the presentation.