- Email: [email protected]
Beyond Structure-Process-Outcome: Donabedian’s Seven Pillars and Eleven Buttresses of Quality
JOURNAL
ON
QUALITY IMPROVEMENT
Avedis Donabedian, MD, internationally renowned leader in the formulation of quality assurance and quality improvement concepts, died November 9, 2000, at the age of 81. Dr Donabedian was born in Beirut, Lebanon, and he earned a medical degree from the American University of Beirut and a masters in public health degree from Harvard University. He had a long, illustrious academic career at the University of Michigan, where he was Nathan Sinai Professor of Public Health. He retired in 1988 but continued to lecture throughout the world until 1999. This memorial tribute is based on the letter nominating Dr Donabedian to receive the American Public Health Association’s highest honor—the Sedgwick Memorial Medal—and on a presentation given by Dr Schiff at the Donabedian Award session at the American Public Health Association’s 128th annual meeting in Boston on November 13, 2000, where the 2nd annual Donabedian Quality Award was presented to Dr Donald Berwick. FORUM
Beyond Structure–Process– Outcome: Donabedian’s Seven Pillars and Eleven Buttresses of Quality GORDON D. SCHIFF, MD T. DONALD RUCKER, PHD
I
n a letter written six months before his death, Avedis Donabedian, MD, lamented his failure to be known for more than the structure– process–outcome model for which he was widely recognized*: If I were you, I wouldn’t worry about the failure of the accursed structure–process–outcome paradigm to meet * Personal communication with author [G.D.S.], Mar 3, 2000.
Gordon D. Schiff, MD, is Director, Clinical Quality Research, Department of Medicine, Cook County Hospital, and Associate Professor of Medicine, Rush Medical College, Chicago. T. Donald Rucker, PhD, is Professor Copyright © 2001 by the Joint Commission on Accreditation of Healthcare Organizations
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your needs. As I have repeatedly said: structure– process–outcome is a servant, not a master. I never intended to build my reputation on this paradigm. I only offered it as a handy classification scheme. I know that it has deeper meanings, and it is this that I have tried to explore. My reputation should rest on the totality of my intellectual explorations, most of which are unrecognized or unappreciated.
In 1999, while preparing the nomination for the American Public Health Association’s Sedgwick
Emeritus, University of Illinois College of Pharmacy, Chicago. Please address requests for reprints to Gordon D. Schiff, MD, Department of Medicine, Cook County Hospital, 1900 West Polk Street, 1600-AX, Chicago 60612; phone 312/6336905; fax 312/633-3684; e-mail [email protected].
3
Copyright 2001 Joint Commission on Accreditation of Healthcare Organizations
169
THE JOINT COMMISSION Memorial Medal,* we had the opportunity to reflect on some of Dr Donabedian’s other contributions. In a memorial tribute to this giant of quality monitoring and improvement, we wish to share some of these far-reaching yet insufficiently recognized contributions he modestly labeled “explorations.”
Architect for Health System Redesign Rather than focus only on quality (as if this were not a large enough territory to impact), Dr Donabedian actually helped to systematize knowledge concerning public health and the organization of health care, including the epidemiology of patient needs for medical care, health care resources, and the design of program benefits as delivered through both the public and the private sectors. A past American Public Health Association president has characterized him as “one of the preeminent creative scholars in health care organization.”† Principles developed by Dr Donabedian during his career represent the conceptual foundation for optimizing any health care system while embracing the full range of preventive and medical treatment services. For each of these concepts, Dr Donabedian not only helped expand our vocabulary but was among their leading advocates. For many in the health policy field, our understanding has been largely shaped by his contributions. From his widely used Medical Care Chart Book1 (spanning 25 formative national health policy years) to his pioneering work on prepaid group practice, which had a major impact on subsequent health maintenance organization (HMO) legislation and the organizations themselves, Dr Donabedian’s concepts and designs have influenced a generation of public health policy students and practitioners. Counterbalancing his early advocacy of prepaid group practice (now transfigured into “managed care”) was his 1973 critique, considered by many to be largely validated in the years since he prophetically * The Sedgwick Memorial Medal is given to an individual who has contributed to research, administration, education, technical service, or any specialty of public health practice and to the association. † Eugene Feingold, MD, Professor, University of Michigan School of Public Health, Ann Arbor, Michigan, telephone communication with author [G.D.S.], Dec 15, 2000.
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predicted its problems.2 He warned that a capitatedpayment formula could lead corporate HMOs to strive to maximize enrollment and minimize service while also failing to produce expected cost savings. Moreover, he continued, “it is unrealistic to expect that by simply altering the payment mechanisms care will be reoriented toward prevention or health maintenance.”2(p 244) Dr Donabedian provided noteworthy insights for evaluating any health insurance proposal, as he strove to “penetrate the surface features in order to understand the basic issues that are concealed beneath.”3(p 345) In 1976 he wrote: There are two archetypical and opposing views about the nature of our problem. On one hand are those who believe our medical care system is essentially sound; that it is in a process of healthy growth and evolution; and that the major role of health insurance is to provide protection against the unpredictable costs of illness. On the other hand are those who believe that our medical care system has failed to produce health services efficiently or to distribute them equitably; and who regard a national health insurance scheme as not only a means to achieve protection against the cost of illness but also as a powerful force that should be used to reshape the medical care system itself.3(p 345)
While this latter view, with which Dr Donabedian identified himself, has been accepted in the quarter century that has elapsed since this insightful dichotomy, he also described “demonic forces” needing to be “effectively neutralized” to achieve this positive transformation—a warning unfortunately unheeded by policymakers during and since the 1994 Clinton health plan debacle. Thus for Dr Donabedian, quality assurance always had two components: system design, and quality monitoring, which he defined as “the process by which performance is periodically or continuously reviewed and when found to be deficient, first modified and then monitored once again.”4(p 81) Thus “system design and monitoring should be an inseparable mutually supportive pair. Design brings rough adjustments in performance; monitoring is responsible for fine tuning.”
A Model for Quality Distinctive elements that permeated Dr Donabedian’s work include his commitment to methodological rigor, continuous critique of existing approaches, promotion of consumer input into health policy and
MARCH 2001 JOURNAL Copyright 2001 Joint Commission on Accreditation of Healthcare Organizations
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evaluation, professional accountability, and a search for ways to create a supportive culture where highestquality care and relationships can flourish and where the ethical dimensions of professional work are emphasized. Dr Donabedian’s passion for the ethical and advocacy responsibilities of scholarship is evident throughout his writings. In 1986 he concluded a discussion of the relationship between cost and quality with a caveat. After noting the often ambiguous and inconclusive findings of much of the empirical research, particularly relating to longer-term effectiveness, he cautioned: It is fashionable these days to adopt a rather nihilistic stance in speculating about the value of health care, or at least additions to it. This is a healthy skepticism necessary to the investigator. At the same time, we ought to realize that speculations not based on conclusive evidence can be seized on as fact. Some . . . are avidly searching for a pretext to cut back on the investment in health care, particularly in the public sector. We must be certain that what we tell them is truth not merely conjecture.4(p 76)
It is for Dr Donabedian’s work related to health care quality that he became known internationally. But a sampling of just a few of his other basic yet profound classification schemes and themes suggests that his broader intellectual work (represented by his approximately 100 articles and 7 books) is deserving of wider recognition and appreciation. Perhaps Dr Donabedian was merely stating the obvious when he divided quality monitoring into informal and formal monitoring, differentiated between implicit and explicit monitoring criteria, and distinguished efficacy from effectiveness. However, by developing and popularizing such nomenclatures, he helped us to sharply focus a tangled blur of historical and contemporary quality assurance activities. Such dichotimizations were never designed to cast aspersions on one method while extolling the other. Instead, they represented his efforts to dig deeply to explore the depths of what each type of evaluation could contribute. For example, this consummate advocate of formal monitoring offered the highest praise for informal monitoring “that occurs through experiencing and sharing observations whenever colleagues work together to provide care.” 5(p 63) He even named names, identifying which of his heroes he most closely associated with each method.6
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Even his simple structure–process–outcome construct is powerfully enriched when we examine the 3 4 matrix he offered as a two-dimensional model. He placed each of his well-known triad elements on the horizontal axis. On the vertical axis, (1) access, (2) technical quality, (3) affect/relationship quality, and (4) continuity of care are tabulated as areas to which structure, process, and outcome are to be applied in health care.7 Such a matrix invites us to ponder, for example, ways the structure of an organization or institution relates to access, how its processes affect access (and vice versa), and interconnections between outcomes and access. No wonder Dr Donabedian found many applications of his triad to be flat and limiting.
Pillars and Buttresses At the November 2000 Donabedian Award session, organized by the American Public Health Association’s Quality Improvement Committee, one of the authors [G.D.S.] and others unearthed a buried treasure—a 60-page chapter in a now out-of-print book titled Striving for Quality.5 The synopsis is now available on the Internet,8 and the complete monograph is also worth seeking out. Dr Donabedian presents a sweeping overview of the effectiveness of quality assurance and discusses reasons for its modest successes and many failures. Following a poetic and prophetic review of factors that impede and facilitate the “quality monitoring enterprise,” Dr Donabedian then offers 11 essential principles “pertinent to its design, operation, and effectiveness.” Recalling another Dr Donabedian classic, “The Seven Pillars of Quality,”9 we realize that the structure–process–outcome triad was just a beginning blueprint for the house of quality that Dr Donabedian built. With his triad as the blueprint (or perhaps the foundation), and its seven supporting pillars (Table 1, p 172), this palace was crowned by a protective roof provided by the quality assurance function—a roof buttressed by these 11 essential principles (Table 2, p 173). The construction of these principles is like that of their brilliant middle-ages architectural counterparts—the flying buttresses—which gave strength and light to citadels of unprecedented stature and loftiness.10 As we contemplate Dr Donabedian’s contributions, perhaps none is more important than the most compelling lesson derived from his lifetime of work:
3
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THE JOINT COMMISSION Table 1. Seven Pillars of Quality* 1. Efficacy:
The ability of care, at its best, to improve health. 2. Effectiveness:
The degree to which attainable health improvements are realized. 3. Efficiency:
The ability to obtain the greatest health improvement at the lowest cost. 4. Optimality:
The most advantageous balancing of costs and benefits. 5. Acceptability:
Conformity to patient preferences regarding accessibility, patient-practitioner relationships, amenities, effects of care, and cost of care. 6. Legitimacy:
Conformity to social preferences concerning all of the above. 7. Equity:
Fairness in the distribution of care and its effects on health. * Adapted from Donabedian A: The seven pillars of quality. Arch Pathol Lab Med 114:1115–1118, 1990.
that empirical research, administrative decisions, health system structure/financing, and improvement efforts depend most fundamentally on a holistic conceptual framework.
Postscript: Quality Assurance Versus Quality Improvement? A final area of Dr Donabedian’s work that is underappreciated involves the contrast between quality assurance and quality improvement (for example, one of the authors [G.D.S.] is guilty of this transgression).11 While Dr Donabedian is often identified with the “outmoded” quality assurance model, as opposed to a more “modern” quality improvement approach, a decade ago he offered the following comments:
172
Recently, two rather distinct approaches to monitoring have been recognized as starkly contrasting types. In the first, responsibility is concentrated in the upper reaches of professional-managerial hierarchy. Criteria and standards are centrally determined. The purpose is to achieve adherence to the criteria. The method is identification of those who fail to comply, followed by some action, often punitive. In the second type, responsibility for quality is to a great degree dispersed, much of it being vested in persons (professional and other) who are closest to where care is actually provided. The method is used to identify deficiencies in quality, to analyze details in the process that accounts for the deficiency, and redesign the processes so the occasion for error is at least reduced and perhaps eliminated. The purpose is not to enforce conformance to criteria and standards, but to achieve continuing improvement in quality through self evaluating and self motivating participation.5(p 104)
While unable to settle on the best terminology to label these two approaches (he rejects managerial versus participatory as “too judgmental” and centrifugal versus centripetal as “overly mechanistic”), Dr Donabedian’s sympathies are clear. “We use many words to designate what we do,” he later wrote,12 and remarkably, just two days before his death, he recorded the following words to express his views on this subject. Expressing his regret at being unable to attend the presentation of the Donabedian Quality Award to Don Berwick, for whom he had “the highest admiration,” he concluded My disappointment [at my inability to attend] is sharpened because at various times and in various ways, we two have been depicted as rivals or at the least representatives of wildly differing philosophies. How can this be, when we follow similar pathways to similar goals? We have used different vocabularies, leaning more heavily on one aspect of quality or another, encompassing more or less, and so on. But the core has been constant. Only the peripheries have varied.13
Quality today, so much distracted by the peripheries, has lost a beacon to its core. J
MARCH 2001 JOURNAL Copyright 2001 Joint Commission on Accreditation of Healthcare Organizations
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Table 2. Dr Donabedian’s 11 Buttresses* of Quality Assurance: Principles Pertinent to the Design, Operation, and Effectiveness of Care 1.
Interdependency
6.
Everything appears to depend for its existence, for the forms it takes, and for its effects on everything else. Nothing can be viewed in isolation. Even formal quality monitoring itself is part of a larger system, and its introduction can be viewed as a disturbance in the ecosystem. 2.
3.
Congruence
Quality assurance should be congruent with professional ideology and organization of practice, should benefit from rather than upset interdependence among colleagues, and should reinforce rather than weaken group solidarity. We need to strike that elusive mark between professional accountability and autonomy that acknowledges both without slighting either. 5.
7.
Credibility
Those to be judged by quality monitoring enterprise need to believe findings are true; this depends on many factors, including completeness and accuracy of information and validity of criteria on which judgments of quality are to be based. Neither technological uncertainty nor dissension, whether professional or social, can provide a basis for credible quality monitoring.
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Ownership
Quality assurance should reflect an identification with, rather than an alienation from, the monitoring enterprise so that the feeling is that the enterprise is “ours” rather than “theirs.” 8.
Mutuality of Interests
Quality assurance needs to be in sync with self-interests, enlightened or otherwise, of the providers and the quality monitors. The apparent impotence of past monitoring efforts reflects the virtual irrelevance of the findings to the careers of individual health care practitioners. Mutuality of interests could overcome many of the obstacles to successful monitoring.
Consensuality
Quality assurance requires a coalescence of views and interests and a working alliance toward a common purpose, especially among centers of power in organizations, such as a hospital’s medical staff and administrative apparatus. 4.
As a corollary to credibility, quality assurance should be relevant to one’s perception of responsibility and to one’s circumstances, patients in general, and each patient in particular. Relevance to one’s own patients and own work is a precondition to the ability to persuade and motivate.
Organizational Dependency
Monitoring of care, followed by appropriate readjustments, requires formal organization in the health care system. We need the means to monitor and the capacity to change in response to monitoring results. These depend on and reside in organizations that finance or deliver care. The principle reveals itself in the fragmented nature of quality monitoring, much of it concentrated in hospitals, while other sectors also needing evaluation have received much less attention.
Relevance
9.
Facilitation
Resources or restructuring can help overcome physical or psychological impediments to quality assurance. 10. Coerciveness
Quality monitoring, whose origins lie in the contract between society and the professions, must have teeth to be successful. The legitimacy and necessity of coerciveness are not at issue; only the nature and degree of the quality monitoring’s intrusions need to be established. 11. Virtue—Personal and Public
This principle stands apart from the others, belonging perhaps to a different discourse altogether. For it seems that the pursuit of quality is, in essence, the moral dimension of professional life. A commitment to it allows almost any reasonably constructed quality monitoring mechanism to succeed. Without it, the most ingenious of creations will surely fail. * Our term (Dr Donabedian would have likely provided a more poetic metaphor). Adapted from text in Donabedian A: Reflections on the effectiveness of quality assurance. In Palmer RH, Donabedian A, Povar GJ (eds): Striving for Quality. Ann Arbor, MI: Health Administration Press, 1991, pp 59–128.
3
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THE JOINT COMMISSION References 1. Donabedian A: Medical Care Chart Book 8th ed. Ann Arbor, MI: Health Administration Press, 1986. 2. Donabedian A: An examination of some directions in health care policy. Am J Public Health 63: 243–246, 1973. 3. Donabedian A: Issues in national health insurance. Am J Public Health 66:345–350, 1976. 4. Donabedian A: On some studies on the quality of care. Health Care Financ Rev Annual Supple-
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ment:75–85, 1987. 5. Donabedian A: Reflections on the effectiveness of quality assurance. In Palmer RH, Donabedian A, Povar GJ (eds): Striving for Quality. Ann Arbor, MI: Health Administration Press, 1991, pp 59–128. 6. Donabedian A: Quality assessment and monitoring: Retrospect and prospect. Eval Health Prof 6: 363–375, 1983. 7. McLaughlin CP: Evaluating the quality control system for managed
care in the United States. Qual Manag Health Care 7(1):38–46, 1998. 8. Schiff GD: Reflections on reflections on the effectiveness of quality assurance. Eye on Improvement, in press, 2001. Available at www.ihi.org/resources/eyeoi/index.asp. 9. Donabedian A: The seven pillars of quality. Arch Pathol Lab Med 114:1115–1118, 1990. 10. Adams JL: Flying Buttresses, Entropy and O-Rings: The World of an Engineer. Cambridge, MA: Harvard University Press, 1991.
11. Schiff GD, Shansky R: Challenges of improving quality in the correctional setting. In Puisis M (ed): Clinical Practical of Correctional Medicine. Chicago: Mosby, 1998, pp 12–25. 12. Donabedian A: Quality stewardship in Codman’s life and work. Jt Comm J Qual Improv 24: 52–55, 1998. 13. Donabedian A: Recorded greeting to second annual American Public Health Association Donabedian Award Session Recorded Nov 7, 2000.
MARCH 2001 JOURNAL Copyright 2001 Joint Commission on Accreditation of Healthcare Organizations
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QUALITY IMPROVEMENT
Avedis Donabedian, MD, internationally renowned leader in the formulation of quality assurance and quality improvement concepts, died November 9, 2000, at the age of 81. Dr Donabedian was born in Beirut, Lebanon, and he earned a medical degree from the American University of Beirut and a masters in public health degree from Harvard University. He had a long, illustrious academic career at the University of Michigan, where he was Nathan Sinai Professor of Public Health. He retired in 1988 but continued to lecture throughout the world until 1999. This memorial tribute is based on the letter nominating Dr Donabedian to receive the American Public Health Association’s highest honor—the Sedgwick Memorial Medal—and on a presentation given by Dr Schiff at the Donabedian Award session at the American Public Health Association’s 128th annual meeting in Boston on November 13, 2000, where the 2nd annual Donabedian Quality Award was presented to Dr Donald Berwick. FORUM
Beyond Structure–Process– Outcome: Donabedian’s Seven Pillars and Eleven Buttresses of Quality GORDON D. SCHIFF, MD T. DONALD RUCKER, PHD
I
n a letter written six months before his death, Avedis Donabedian, MD, lamented his failure to be known for more than the structure– process–outcome model for which he was widely recognized*: If I were you, I wouldn’t worry about the failure of the accursed structure–process–outcome paradigm to meet * Personal communication with author [G.D.S.], Mar 3, 2000.
Gordon D. Schiff, MD, is Director, Clinical Quality Research, Department of Medicine, Cook County Hospital, and Associate Professor of Medicine, Rush Medical College, Chicago. T. Donald Rucker, PhD, is Professor Copyright © 2001 by the Joint Commission on Accreditation of Healthcare Organizations
VOLUME
27
NUMBER
your needs. As I have repeatedly said: structure– process–outcome is a servant, not a master. I never intended to build my reputation on this paradigm. I only offered it as a handy classification scheme. I know that it has deeper meanings, and it is this that I have tried to explore. My reputation should rest on the totality of my intellectual explorations, most of which are unrecognized or unappreciated.
In 1999, while preparing the nomination for the American Public Health Association’s Sedgwick
Emeritus, University of Illinois College of Pharmacy, Chicago. Please address requests for reprints to Gordon D. Schiff, MD, Department of Medicine, Cook County Hospital, 1900 West Polk Street, 1600-AX, Chicago 60612; phone 312/6336905; fax 312/633-3684; e-mail [email protected].
3
Copyright 2001 Joint Commission on Accreditation of Healthcare Organizations
169
THE JOINT COMMISSION Memorial Medal,* we had the opportunity to reflect on some of Dr Donabedian’s other contributions. In a memorial tribute to this giant of quality monitoring and improvement, we wish to share some of these far-reaching yet insufficiently recognized contributions he modestly labeled “explorations.”
Architect for Health System Redesign Rather than focus only on quality (as if this were not a large enough territory to impact), Dr Donabedian actually helped to systematize knowledge concerning public health and the organization of health care, including the epidemiology of patient needs for medical care, health care resources, and the design of program benefits as delivered through both the public and the private sectors. A past American Public Health Association president has characterized him as “one of the preeminent creative scholars in health care organization.”† Principles developed by Dr Donabedian during his career represent the conceptual foundation for optimizing any health care system while embracing the full range of preventive and medical treatment services. For each of these concepts, Dr Donabedian not only helped expand our vocabulary but was among their leading advocates. For many in the health policy field, our understanding has been largely shaped by his contributions. From his widely used Medical Care Chart Book1 (spanning 25 formative national health policy years) to his pioneering work on prepaid group practice, which had a major impact on subsequent health maintenance organization (HMO) legislation and the organizations themselves, Dr Donabedian’s concepts and designs have influenced a generation of public health policy students and practitioners. Counterbalancing his early advocacy of prepaid group practice (now transfigured into “managed care”) was his 1973 critique, considered by many to be largely validated in the years since he prophetically * The Sedgwick Memorial Medal is given to an individual who has contributed to research, administration, education, technical service, or any specialty of public health practice and to the association. † Eugene Feingold, MD, Professor, University of Michigan School of Public Health, Ann Arbor, Michigan, telephone communication with author [G.D.S.], Dec 15, 2000.
170
predicted its problems.2 He warned that a capitatedpayment formula could lead corporate HMOs to strive to maximize enrollment and minimize service while also failing to produce expected cost savings. Moreover, he continued, “it is unrealistic to expect that by simply altering the payment mechanisms care will be reoriented toward prevention or health maintenance.”2(p 244) Dr Donabedian provided noteworthy insights for evaluating any health insurance proposal, as he strove to “penetrate the surface features in order to understand the basic issues that are concealed beneath.”3(p 345) In 1976 he wrote: There are two archetypical and opposing views about the nature of our problem. On one hand are those who believe our medical care system is essentially sound; that it is in a process of healthy growth and evolution; and that the major role of health insurance is to provide protection against the unpredictable costs of illness. On the other hand are those who believe that our medical care system has failed to produce health services efficiently or to distribute them equitably; and who regard a national health insurance scheme as not only a means to achieve protection against the cost of illness but also as a powerful force that should be used to reshape the medical care system itself.3(p 345)
While this latter view, with which Dr Donabedian identified himself, has been accepted in the quarter century that has elapsed since this insightful dichotomy, he also described “demonic forces” needing to be “effectively neutralized” to achieve this positive transformation—a warning unfortunately unheeded by policymakers during and since the 1994 Clinton health plan debacle. Thus for Dr Donabedian, quality assurance always had two components: system design, and quality monitoring, which he defined as “the process by which performance is periodically or continuously reviewed and when found to be deficient, first modified and then monitored once again.”4(p 81) Thus “system design and monitoring should be an inseparable mutually supportive pair. Design brings rough adjustments in performance; monitoring is responsible for fine tuning.”
A Model for Quality Distinctive elements that permeated Dr Donabedian’s work include his commitment to methodological rigor, continuous critique of existing approaches, promotion of consumer input into health policy and
MARCH 2001 JOURNAL Copyright 2001 Joint Commission on Accreditation of Healthcare Organizations
JOURNAL
ON
QUALITY IMPROVEMENT
evaluation, professional accountability, and a search for ways to create a supportive culture where highestquality care and relationships can flourish and where the ethical dimensions of professional work are emphasized. Dr Donabedian’s passion for the ethical and advocacy responsibilities of scholarship is evident throughout his writings. In 1986 he concluded a discussion of the relationship between cost and quality with a caveat. After noting the often ambiguous and inconclusive findings of much of the empirical research, particularly relating to longer-term effectiveness, he cautioned: It is fashionable these days to adopt a rather nihilistic stance in speculating about the value of health care, or at least additions to it. This is a healthy skepticism necessary to the investigator. At the same time, we ought to realize that speculations not based on conclusive evidence can be seized on as fact. Some . . . are avidly searching for a pretext to cut back on the investment in health care, particularly in the public sector. We must be certain that what we tell them is truth not merely conjecture.4(p 76)
It is for Dr Donabedian’s work related to health care quality that he became known internationally. But a sampling of just a few of his other basic yet profound classification schemes and themes suggests that his broader intellectual work (represented by his approximately 100 articles and 7 books) is deserving of wider recognition and appreciation. Perhaps Dr Donabedian was merely stating the obvious when he divided quality monitoring into informal and formal monitoring, differentiated between implicit and explicit monitoring criteria, and distinguished efficacy from effectiveness. However, by developing and popularizing such nomenclatures, he helped us to sharply focus a tangled blur of historical and contemporary quality assurance activities. Such dichotimizations were never designed to cast aspersions on one method while extolling the other. Instead, they represented his efforts to dig deeply to explore the depths of what each type of evaluation could contribute. For example, this consummate advocate of formal monitoring offered the highest praise for informal monitoring “that occurs through experiencing and sharing observations whenever colleagues work together to provide care.” 5(p 63) He even named names, identifying which of his heroes he most closely associated with each method.6
VOLUME
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NUMBER
Even his simple structure–process–outcome construct is powerfully enriched when we examine the 3 4 matrix he offered as a two-dimensional model. He placed each of his well-known triad elements on the horizontal axis. On the vertical axis, (1) access, (2) technical quality, (3) affect/relationship quality, and (4) continuity of care are tabulated as areas to which structure, process, and outcome are to be applied in health care.7 Such a matrix invites us to ponder, for example, ways the structure of an organization or institution relates to access, how its processes affect access (and vice versa), and interconnections between outcomes and access. No wonder Dr Donabedian found many applications of his triad to be flat and limiting.
Pillars and Buttresses At the November 2000 Donabedian Award session, organized by the American Public Health Association’s Quality Improvement Committee, one of the authors [G.D.S.] and others unearthed a buried treasure—a 60-page chapter in a now out-of-print book titled Striving for Quality.5 The synopsis is now available on the Internet,8 and the complete monograph is also worth seeking out. Dr Donabedian presents a sweeping overview of the effectiveness of quality assurance and discusses reasons for its modest successes and many failures. Following a poetic and prophetic review of factors that impede and facilitate the “quality monitoring enterprise,” Dr Donabedian then offers 11 essential principles “pertinent to its design, operation, and effectiveness.” Recalling another Dr Donabedian classic, “The Seven Pillars of Quality,”9 we realize that the structure–process–outcome triad was just a beginning blueprint for the house of quality that Dr Donabedian built. With his triad as the blueprint (or perhaps the foundation), and its seven supporting pillars (Table 1, p 172), this palace was crowned by a protective roof provided by the quality assurance function—a roof buttressed by these 11 essential principles (Table 2, p 173). The construction of these principles is like that of their brilliant middle-ages architectural counterparts—the flying buttresses—which gave strength and light to citadels of unprecedented stature and loftiness.10 As we contemplate Dr Donabedian’s contributions, perhaps none is more important than the most compelling lesson derived from his lifetime of work:
3
Copyright 2001 Joint Commission on Accreditation of Healthcare Organizations
171
THE JOINT COMMISSION Table 1. Seven Pillars of Quality* 1. Efficacy:
The ability of care, at its best, to improve health. 2. Effectiveness:
The degree to which attainable health improvements are realized. 3. Efficiency:
The ability to obtain the greatest health improvement at the lowest cost. 4. Optimality:
The most advantageous balancing of costs and benefits. 5. Acceptability:
Conformity to patient preferences regarding accessibility, patient-practitioner relationships, amenities, effects of care, and cost of care. 6. Legitimacy:
Conformity to social preferences concerning all of the above. 7. Equity:
Fairness in the distribution of care and its effects on health. * Adapted from Donabedian A: The seven pillars of quality. Arch Pathol Lab Med 114:1115–1118, 1990.
that empirical research, administrative decisions, health system structure/financing, and improvement efforts depend most fundamentally on a holistic conceptual framework.
Postscript: Quality Assurance Versus Quality Improvement? A final area of Dr Donabedian’s work that is underappreciated involves the contrast between quality assurance and quality improvement (for example, one of the authors [G.D.S.] is guilty of this transgression).11 While Dr Donabedian is often identified with the “outmoded” quality assurance model, as opposed to a more “modern” quality improvement approach, a decade ago he offered the following comments:
172
Recently, two rather distinct approaches to monitoring have been recognized as starkly contrasting types. In the first, responsibility is concentrated in the upper reaches of professional-managerial hierarchy. Criteria and standards are centrally determined. The purpose is to achieve adherence to the criteria. The method is identification of those who fail to comply, followed by some action, often punitive. In the second type, responsibility for quality is to a great degree dispersed, much of it being vested in persons (professional and other) who are closest to where care is actually provided. The method is used to identify deficiencies in quality, to analyze details in the process that accounts for the deficiency, and redesign the processes so the occasion for error is at least reduced and perhaps eliminated. The purpose is not to enforce conformance to criteria and standards, but to achieve continuing improvement in quality through self evaluating and self motivating participation.5(p 104)
While unable to settle on the best terminology to label these two approaches (he rejects managerial versus participatory as “too judgmental” and centrifugal versus centripetal as “overly mechanistic”), Dr Donabedian’s sympathies are clear. “We use many words to designate what we do,” he later wrote,12 and remarkably, just two days before his death, he recorded the following words to express his views on this subject. Expressing his regret at being unable to attend the presentation of the Donabedian Quality Award to Don Berwick, for whom he had “the highest admiration,” he concluded My disappointment [at my inability to attend] is sharpened because at various times and in various ways, we two have been depicted as rivals or at the least representatives of wildly differing philosophies. How can this be, when we follow similar pathways to similar goals? We have used different vocabularies, leaning more heavily on one aspect of quality or another, encompassing more or less, and so on. But the core has been constant. Only the peripheries have varied.13
Quality today, so much distracted by the peripheries, has lost a beacon to its core. J
MARCH 2001 JOURNAL Copyright 2001 Joint Commission on Accreditation of Healthcare Organizations
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Table 2. Dr Donabedian’s 11 Buttresses* of Quality Assurance: Principles Pertinent to the Design, Operation, and Effectiveness of Care 1.
Interdependency
6.
Everything appears to depend for its existence, for the forms it takes, and for its effects on everything else. Nothing can be viewed in isolation. Even formal quality monitoring itself is part of a larger system, and its introduction can be viewed as a disturbance in the ecosystem. 2.
3.
Congruence
Quality assurance should be congruent with professional ideology and organization of practice, should benefit from rather than upset interdependence among colleagues, and should reinforce rather than weaken group solidarity. We need to strike that elusive mark between professional accountability and autonomy that acknowledges both without slighting either. 5.
7.
Credibility
Those to be judged by quality monitoring enterprise need to believe findings are true; this depends on many factors, including completeness and accuracy of information and validity of criteria on which judgments of quality are to be based. Neither technological uncertainty nor dissension, whether professional or social, can provide a basis for credible quality monitoring.
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Ownership
Quality assurance should reflect an identification with, rather than an alienation from, the monitoring enterprise so that the feeling is that the enterprise is “ours” rather than “theirs.” 8.
Mutuality of Interests
Quality assurance needs to be in sync with self-interests, enlightened or otherwise, of the providers and the quality monitors. The apparent impotence of past monitoring efforts reflects the virtual irrelevance of the findings to the careers of individual health care practitioners. Mutuality of interests could overcome many of the obstacles to successful monitoring.
Consensuality
Quality assurance requires a coalescence of views and interests and a working alliance toward a common purpose, especially among centers of power in organizations, such as a hospital’s medical staff and administrative apparatus. 4.
As a corollary to credibility, quality assurance should be relevant to one’s perception of responsibility and to one’s circumstances, patients in general, and each patient in particular. Relevance to one’s own patients and own work is a precondition to the ability to persuade and motivate.
Organizational Dependency
Monitoring of care, followed by appropriate readjustments, requires formal organization in the health care system. We need the means to monitor and the capacity to change in response to monitoring results. These depend on and reside in organizations that finance or deliver care. The principle reveals itself in the fragmented nature of quality monitoring, much of it concentrated in hospitals, while other sectors also needing evaluation have received much less attention.
Relevance
9.
Facilitation
Resources or restructuring can help overcome physical or psychological impediments to quality assurance. 10. Coerciveness
Quality monitoring, whose origins lie in the contract between society and the professions, must have teeth to be successful. The legitimacy and necessity of coerciveness are not at issue; only the nature and degree of the quality monitoring’s intrusions need to be established. 11. Virtue—Personal and Public
This principle stands apart from the others, belonging perhaps to a different discourse altogether. For it seems that the pursuit of quality is, in essence, the moral dimension of professional life. A commitment to it allows almost any reasonably constructed quality monitoring mechanism to succeed. Without it, the most ingenious of creations will surely fail. * Our term (Dr Donabedian would have likely provided a more poetic metaphor). Adapted from text in Donabedian A: Reflections on the effectiveness of quality assurance. In Palmer RH, Donabedian A, Povar GJ (eds): Striving for Quality. Ann Arbor, MI: Health Administration Press, 1991, pp 59–128.
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THE JOINT COMMISSION References 1. Donabedian A: Medical Care Chart Book 8th ed. Ann Arbor, MI: Health Administration Press, 1986. 2. Donabedian A: An examination of some directions in health care policy. Am J Public Health 63: 243–246, 1973. 3. Donabedian A: Issues in national health insurance. Am J Public Health 66:345–350, 1976. 4. Donabedian A: On some studies on the quality of care. Health Care Financ Rev Annual Supple-
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ment:75–85, 1987. 5. Donabedian A: Reflections on the effectiveness of quality assurance. In Palmer RH, Donabedian A, Povar GJ (eds): Striving for Quality. Ann Arbor, MI: Health Administration Press, 1991, pp 59–128. 6. Donabedian A: Quality assessment and monitoring: Retrospect and prospect. Eval Health Prof 6: 363–375, 1983. 7. McLaughlin CP: Evaluating the quality control system for managed
care in the United States. Qual Manag Health Care 7(1):38–46, 1998. 8. Schiff GD: Reflections on reflections on the effectiveness of quality assurance. Eye on Improvement, in press, 2001. Available at www.ihi.org/resources/eyeoi/index.asp. 9. Donabedian A: The seven pillars of quality. Arch Pathol Lab Med 114:1115–1118, 1990. 10. Adams JL: Flying Buttresses, Entropy and O-Rings: The World of an Engineer. Cambridge, MA: Harvard University Press, 1991.
11. Schiff GD, Shansky R: Challenges of improving quality in the correctional setting. In Puisis M (ed): Clinical Practical of Correctional Medicine. Chicago: Mosby, 1998, pp 12–25. 12. Donabedian A: Quality stewardship in Codman’s life and work. Jt Comm J Qual Improv 24: 52–55, 1998. 13. Donabedian A: Recorded greeting to second annual American Public Health Association Donabedian Award Session Recorded Nov 7, 2000.
MARCH 2001 JOURNAL Copyright 2001 Joint Commission on Accreditation of Healthcare Organizations