Avedis Donabedian and the Birth of Healthcare Quality Assurance – An Overview of the Healthcare Market

One of the most prominent issues in health management today is the quality of health. The Institute of Medicine (IOM), which changed its name to the US National Academy of Medicine (NAM) in 2015, defines quality of health care as “the extent to which health care services for individuals and populations increase the likelihood of desired and consistent health outcomes. with up-to-date professional knowledge” (Institute of Medicine Committee on Quality of Health Care in America, 2001; McInerny & Sachdeva, 2013). Health care quality has become a major focus for healthcare organizations as the US healthcare industry continues to become more patient-centric and less physician-directed as its primitive paternalistic past (Cohn, 2004; “Health Care 2020 Part 2: Consumerism,” 2017; Leavitt , 2001). Quality care is very important in the health care system which estimates that as many as 98,000 people die each year due to hospital-related medical errors (Institute of Medicine Committee on Quality of Health Care in America, 2000). In 1966, Avedis Donabedian, a physician and professor of health services at the University of Michigan School of Public Health, published what became known as the Donabedian model in an important article entitled “Evaluating the Quality of Medical Care” (Ayanian & Markel, 2016; Donabedian, 1966). In this article, Donabedian explains how the quality of health services can be evaluated using the quality of care model and the triad of structure, process, and outcome (Donabedian, 1966). He would eventually elaborate on his structure-process-results model by further defining quality through the “seven pillars of quality” (Ayanian & Markel, 2016; Donabedian, 1990). An adequate analysis of the Avedis Donabedian requires a thorough examination of Donabedian background, theory, and models.

Although Donabedian’s prowess strengthened in the years following his publication in 1966, his youthful and professional background played an important role in the development of health-care quality theories and models. Avedis Donabedian was born in Beirut, Lebanon on 7 January 1919 into a Turkish-Armenian family (Best & Neuhauser, 2004; Donabedian, 1998). His parents were born in a small central Turkish town called Harput. Her hereditary relationship with health care began with her grandmother, who served as a local healer and midwife, though without formal training. Because of his great value to education, he sent his son, Donabedian’s father, to Euphrates University in Turkey, but due to political reasons, Donabedian’s father moved to Beirut, Lebanon to study medicine at the American University. Because Donabedian’s mother remained in her hometown to raise her sister, the massacres and deportations that characterized the Armenian Genocide began in Turkey. Her sister and extended family were not spared. When Donabedian’s father finished his medical studies in Beirut after a brief military absence, the family moved to Ramallah, an all-Christian city in Palestine (now Israel), where Donabedian’s father found work as a country doctor. Donabedian grew up an outcast but was still the child of a doctor in a small Arab town and attended a private Quaker school in Ramallah, called the Friends boys school, where he received an excellent education. After graduating from high school and with relatively limited options, Donabedian decided to move to Beirut, following in his father’s footsteps, and becoming a doctor (Donabedian, 1998). Donabedian received his bachelor’s degree in 1940 from the American University of Beirut and his medical degree (MD) from the same institution in 1944. Donabedian practices general medicine, now known as family medicine, at the English Mission Hospital in Jerusalem. Later, his thirst for knowledge of clinical administration and infectious disease epidemiology led him to Harvard University School of Public Health, where he earned a master’s degree in public health (MPH) and graduated Magna Cum Laude in 1955 (Best & Neuhauser, 2004; Donabedian, 1998) . Political uncertainty in Lebanon and the Middle East prompted Donabedian and his wife to settle in America, the “land of diversity”. Instead of returning after graduation, Donabedian agreed to work as a research assistant for Dr. Leonard Rosenfeld, fellow MD, MPH and researcher. From 1957 to 1961, Donabedian worked as a teacher of epidemiology and social medicine at New York Medical College. He was then recruited to the University of Michigan School of Public Health to teach health administration. During his career at the University of Michigan, Donabedian would become the Nathan Sinai Professor of Public Health (1979), author of a large body of literature on health services research, and professor emeritus until his death on November 9, 2000 (Best & Neuhauser, 2004; Donabedian, 1998).

While the Donabedian theories and models offer a means for examining health services, they also provide a conceptual framework for evaluating the quality of health services. In Donabedian’s lengthy 1966 paper entitled “Evaluating the Quality of Medical Care,” Donabedian presented the argument that we need to examine the quality of health provision through structure, process, and outcomes (Donabedian, 1966). This structure-process-outcome model, or “Donabedian model”, as it has come to be known, provides a flexible framework that can be applied to most situations in healthcare (McDonald et al., 2007). “Structure,” which describes the physical and organizational setting in which health services are provided, including the health-care facilities, personnel, equipment, and financing that support medical care. “Process”, which relies on “structure” to provide patient care mechanisms, describes the actions that make adequate delivery of health services possible. This typically includes diagnosis, treatment, patient education, and preventive maintenance care and naturally promotes better patient health outcomes. “Outcome” describes the effect of health services on the health status of patients and the population (Donabedian, 1988; McDonald et al., 2007). Information gathered from structures, processes, and outcomes can be analyzed to make inferences and draw conclusions about the quality of health services of a particular health care system (Donabedian, 2003). Although the patient’s underlying characteristics influence health outcomes, the Donabedian model deliberately does not consider patients’ social and economic barriers to quality healthcare, as these factors are not under the control of the medical profession (McDonald et al., 2007). In an article entitled “The Seven Pillars of Quality”, Donabedian outlines seven characteristics of health services which, in his opinion, determine their quality. These characteristics include: (1) efficacy, (2) effectiveness, (3) efficiency, (4) optimality, (5) acceptability, (6) legitimacy, and (7) equity. Efficacy describes the “capacity of treatment … to promote health.” Effectiveness refers to “the extent to which achievable health improvements are realized.” Efficiency describes “the ability to get the greatest health improvement at the lowest cost.” Optimality involves “balancing costs and benefits”. Acceptability refers to patient accessibility and comfort, a good doctor-patient relationship, how treatment affects quality of life, and the cost of care to patients. Legitimacy is the macroscopic version of acceptance. It describes the social impact of treatment. Finally, equity involves whether care is distributed fairly (Donabedian, 1990). Donabedian’s seven pillars of quality can serve as a reference guide for any healthcare institution seeking to provide healthcare that is “safe, timely, effective, efficient, fair and patient-centred”, as recommended by IOM (Ayanian & Markel, 2016; Institute of Medicine Committee on Quality of Health Care in America, 2001).


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