NtC 36: The Donabedian Model

by Barry P Chaiken, MD
Navigating the Code is available at navigcatingthecode.com, Amazon, Kindle, B&N, and Audible.

In 1966, just as management and systems were growing prominent in business thinking, a doctor named Avedis Donabedian introduced a radically new concept in medical care delivery that was founded upon what we could call scientific thinking: structure, process, and outcomes. Dubbed the Donabedian Model, it framed the physician’s work around the concept of quality. His paper was enthusiastically received, and a book entitled An Introduction to Quality Assurance in Health Care followed.

In his thought and writing, Donabedian expressed the parallelism between the components of a computer and healthcare: input, processing, outcomes. Yet his primary focus was ever concerned with quality of care. Simply put, Donabedian said quality of care occurs when it is a synergy between the doctor, the patient, the healthcare system and its standards for care, and whether the final determination of quality care is determined by clinical outcomes and patient experience. Again, we can see Donabedian’s input, processing, and outcomes as the skeleton for his framing the concept of quality with structure, processing, and outcomes.

Seven Pillars of Quality

As he thought, studied, and wrote, Donabedian’s model came to be defined as the seven pillars of quality:

  • Efficacy: the ability of care, at its best, to improve health;
  • Effectiveness: the degree to which attainable health improvements are realized;
  • Efficiency: the ability to obtain the greatest health improvement at the lowest cost;
  • Optimality: the most advantageous balancing of costs and benefits;
  • Acceptability: conformity to patient preferences regarding accessibility, the patient-practitioner relation, the amenities, the effects of care, and the cost of care;
  • Legitimacy: conformity to social preferences concerning all of the above; and
  • Equity: fairness in the distribution of care and its effects on health.

Donabedian was a progressive physician who clearly gave much thought to his profession and the manner in which medical care was administered. It seems clear he was a staunch advocate of the Hippocratic Oath and committed to doing no harm to patients. He advocated that computer technology and information systems were essential to healthcare and wrote,

“Systems awareness and systems design are important for health professionals, but are not enough. They are enabling mechanisms only.”

But to this he added

“It is the ethical dimension of individuals that is essential to a system’s success. Ultimately, the secret of quality is love.”

Good Reads, Avedis Donabedian

Quality = f(structure, process, outcome)

Quality, then, is the end result of gathering information from Donabedian’s three components: structure, or context; process, or actions; and outcomes, or the effects of all three in providing consequential medical care. It is quality that can be posited, measured, evaluated, changed. And most important, quality is your personal and professional goal for everything you do in healthcare. If you feel it is not, then it is your goal to achieve. The purpose of this discussion of systems is to give you tools that will aid you in your efforts on behalf of quality. It is about more than simply being forgetful or careless. It is about total attention to detail, because the outcome of what you do as a clinician is saving lives. You know this. You may not have realized there were these clearly defined tools to help you structure your work to achieve a high level of consistent quality.

Today, the Donabedian Model is still as relevant and useful as when it was introduced. That is likely true because it is founded on a solid understanding of systems as reliable scientific structures, tightly integrated with the prime directive of healing human beings.

Thank you for joining me today. For more insights, subscribe to this podcast and my other video series, Future-Primed Healthcare, on my Dr Barry Speaks channel on YouTube. Thanks for your time today.

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