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Ending the cycle of blame in US health care.

Despite unparalleled financial and human capital investments, the quality, safety, and value of US health care remain suboptimal.1 There is general agreement on the scope and implications of these trends, but far less consensus on the fundamental drivers of health system underperformance. The disconnect stems from the fundamental difficulty in identifying the causes behind complex policy problems. In biomedical research and clinical investigation, problems and questions are identified, hypotheses are generated, and data are collected; causality is built into the investigative process Similar assumptions are often applied to policy analysis, but the reality is inherently less precise. Stone2 has written extensively on how societies grapple with policy challenges, suggesting that such issues do not have inherent properties that make them more or less likely to be seen as problems. Rather, individual parties and stakeholders construct “causal stories” to attribute blame and responsibility in an effort to shape how societies conceive of and respond to policy challenges. According to Stone, many policy problems do not have objective causes, but subjective narratives about causation that gain variable traction in the public imagination.2 Stone’s model of causal stories is manifest in the current national dialogue on health care quality and improvement. Consider how the following narratives—prevalent among researchers, policy