Value operating system: a practical framework to measure outcomes-per-cost at the episode level.

Abstract

To specify a value operating system (VOS) and its executable metric-the Value Index (VI)-that expresses risk-adjusted outcomes-per-episode-cost on a 0-100 scale with 95% CIs, including transparency guardrails and equity checks, and to outline two prospective exemplars for clinical deployment. Methods framework with prospective service evaluation and a predefined sensitivity plan (weight-elicitation variants; alternative risk models; cost-driver decomposition and subgroup equity). Hospital-based integrated practice unit with hub-and-spoke pathways for sarcoma care; real-world-time data flows. All consecutive episodes within the sarcoma care cycle eligible for routine audit (diagnosis through follow-up), without additional sampling beyond standard care. (1) Cross-cycle optimisation versus intensification of preoperative therapy using VI to compare alternative pathways; (2) causal machine learning-assisted targeting of radiotherapy, using VI to evaluate net value in treated patients compared with candidates identified through the benefit model. Primary: VI (0-100) with 95% CIs. Secondary: component outcome and cost scores; cost-driver decomposition; data completeness/latency; subgroup equity. We define the VOS architecture, VI formulation, uncertainty treatment and governance guardrails (prospective registration, transparency of component scores/weights, equity checks and antigaming rules). We provide operational playbooks for both exemplars, including reporting templates and a priori sensitivity analyses to ensure interpretability and comparability over time and across subgroups. VOS/VI deliver an auditable, episode-level value signal that links outcomes meaningful to patients with the full episode cost, enabling clinical teams to iteratively redesign pathways while maintaining stewardship. The prospective evaluations will test usability, fairness and impact on cost-drivers, supporting scale-up and value-aligned contracting.