Avedis Donabedian is our penultimate Quality Improvement (QI) hero in our series of blogs. Born in Beirut, Lebanon in 1919, he studied as a doctor and made his way into quality improvement, becoming a key influence and innovator in improvement in healthcare. His early systems-based approach to medical quality led to him creating the classic structure-process-outcome model - or Donabedian model that is still used across QI to this day.
Avedis Donabedian was born in Lebanon in 1919 and studied at the Quaker school in Ramallah. His father was a doctor and Donabedian followed in his footsteps to study medicine at the American University of Beirut.
He received his degree in 1940, his Masters in 1944 and his first post was at the English Mission Hospital in Jerusalem. He then went on to work at the American University of Beirut, where he became the university’s medical officer.
In the 1950s, he moved to the USA to study epidemiology and health services at Harvard. He graduated from there in 1955 and remained in the USA thereafter.
From 1957 - 1961 he was a researcher and teacher at the New York Medical College from and then went on to work at the School of Public Health at the University of Michigan.
In 1966 he wrote the article which would go on to define and shape his life’s work: ‘Evaluating the quality of medical care.’
He started to explore quality in healthcare measures as three distinct areas: structure, process and outcome. We’ll look at this in further detail later on in this article.
He went on to write 11 books and many articles on the topics of quality in health care – including a trilogy of books on quality, assessment and monitoring. He died in Michigan, USA, in 2000 leaving behind a legacy and a huge impact on Quality Improvement in healthcare.
Throughout his life Donabedian received many awards and recognition. He won the Dean Conley Award in 1969, the George Welch Medal in 1976 and the Baxter American Foundation Health Services Research Prize in 1986.
Quality assurance in the healthcare system
Let’s see how Donabedian’s career contributed to his position as a leading innovator on quality assurance in the healthcare system. He is frequently cited as an influential and ground-breaking figure within quality assurance in healthcare.
In the book 'Evidence-based Practice: An Integrative Approach to Research, Administration and practice' he is named as 'one of the most influential persons in quality improvement within healthcare'.
‘Quality Assurance in Our Health Care System’ is the title of a 1986 paper by Donabedian which was published in the American Journal of Medical Quality. The paper starts with Donabedian’s wise words: ‘Quality assurance is not a luxury that we may or may not choose to acquire. It is a necessity that embodies our commitment and obligations as a society, in general, and as health care professionals, in particular.'
In the article ‘Evaluating the Quality of Medical Care: Donabedian's Classic Article 50 Years Later;” (published in The Milbank quarterly vol. 94,2 in 2016) Donald Berwick and Daniel M Fox say of Donabedian’s work: ‘It is a masterpiece. With his typical precision and thoroughness, Donabedian covered the entire field of quality measurement as it was understood at the time. To this day, his subheadings would compose an adequate framework for a course syllabus on measuring the performance of health care.’
High praise indeed for Donabedian’s influence and legacy.
The Donabedian structure-process-outcome model of quality
Let’s drill down further into the insights and theories that Avedis Donabedian produced throughout his career. Let's see particularly the ‘structure-process-outcome model’, also known as the ‘Donabedian model.’
In 1966, Donabedian shared his model for evaluating the quality of care for improvement. He broke it down into three components: structure, process and outcomes. This became the framework for evaluating quality in healthcare, as he shared the theory that ‘three dimensions of care can be evaluated: structure, process and outcome.’
Donabedian proposed that structure, process, and outcomes are closely linked and each element influenced and affected each other. So, structure measures affect process measures, which go on to affect outcome measures.
Let’s drill down into this a little further:
‘Structure refers to the manner in which care is delivered, including facilities, equipment, and human resources
Process refers to all of the interactions between patients and providers, including diagnoses, treatments, preventive care, and patient education.
Outcomes are all of the effects of health care on health status of patients and populations, including changes in health status, behaviour, knowledge, satisfaction, and quality of life.’
Looking at this theory through today’s lens it might seem an obvious and practical framework - ‘but only because Donabedian’s approach has become the paradigm for quality measurement in health care. Despite the wide dissemination of the structure-process-outcome triad, Donabedian’s original work remains worth reading.’
The report ‘A model for measuring quality care’ by NHS England and Improvement looks at how Donabedian contributed to the world of quality assurance in healthcare. However, it states: ‘the reality is that cause and effect are more complex, particularly within the NHS with so much variability in individual patients. The selection of relevant measures can be developed using driver diagrams.’
This diagram talks through the Donabedian model for quality of care and how it can be applied:
Figure 1: The Donabedian model for quality of care (Source)
As Donabedian is such a hugely influential and ground-breaking pioneer in the QI space, there is so much more you can read about him. You might want to take a look at this book which features some of our other QI heroes: ‘Codman, W. Edwards Deming, and Avedis Donabedian. "Quality improvement and safety science: Historical and future perspectives." Evidence-based practice: An integrative approach to research, administration, and practice (2014)’
Let’s leave you with this quote from the creator of the structure-process-outcome model:
“Ultimately the secret of quality is love… If you have love, you can then work backward to monitor and improve the system.”
- Avedis Donabedian