Donabedian model

The Donabedian model is a system of criteria by which people may judge the quality of health-care services. In this model, information from three categories may be assessed to reach a determination of overall quality. The main categories are structure, process, and outcomes. Structure involves the context in which the care was received. Process relates to all the actions that contributed to the health services. Outcomes include all the physical, mental, and emotional results of the health services, both short-term and long-term. Physician and researcher Avedis Donabedian created the Donabedian model between the 1960s and the 1980s. In the twenty-first century, it remained an important benchmark for assessing health-care quality. Following the outbreak of the COVID-19 pandemic in 2020, which particularly taxed health-care services across the world due to high case counts, several medical experts discussed using this scenario as a case study for assessing health-care quality according to the Donabedian model.

Background

Health care has always been a part of human life, but for thousands of years it was a primitive practice. Only in modern times has health care become a truly scientific and regulated practice of medical professionals. Modern patients seeking care have many options and different medical facilities from which to choose. These facilities, in turn, are increasingly pressed to improve their performance and offerings, both to better serve patients and to gain an edge over competitors.

In the middle of the twentieth century, many industries, including the health-care industry, began taking interest in the idea of quality. Quality has always been a measure of excellence, though traditionally it can be a subjective judgment. Industry experts sought not only to bring higher levels of quality to their work, but also to standardize methods of judging quality. Doing so would improve results for patients. It would also help patients, accrediting agencies, and other interested parties determine which practitioners and facilities had the highest consistent levels of excellence.

Many medical workers and theorists devised their own systems of judging quality. One of the most influential figures in this endeavor was Avedis Donabedian, a physician, researcher, and University of Michigan professor. In 1966, Donabedian wrote an article titled "Evaluating the Quality of Medical Care" (republished in 2005) that began roughly delineating a set of criteria by which medical personnel and facilities could be rated. Three of these criteria (structure, process, and outcomes) would provide the core of his most famous theories and writings.

Although "Evaluating the Quality of Medical Care" was well received by the medical community, Donabedian continued exploring, revising, and elaborating upon on his criteria for health-care quality over the following decade. He compiled his research into several books, beginning with Explorations in Quality Assessment and Monitoring, Volume I: The Definition of Quality and Approaches to Its Assessment in 1980. He released a follow-up volume, The Criteria and Standards of Quality, two years later. These works more fully established his quality criteria, ultimately known as the Donabedian model, and went on to become some of the fundamental principles of modern health care.

Overview

In his theories and writings from the 1960s through the 1980s, Donabedian created a framework of criteria by which the quality of medical facilities and personnel could be judged. The three main criteria in the so-called Donabedian model are structure, process, and outcome. Donabedian and later theorists often depicted them in a series of three boxes connected by arrows to represent their interconnected nature.

To Donabedian, these criteria were not the components of quality itself, however. Rather, they were categories of information by which quality could be judged. A sound quality judgment could only be achieved when these kinds of information were analyzed thoroughly and collectively. Quality itself, Donabedian believed, could be defined in different ways, depending on the goals and values of the health-care community and the broader society.

The first category of information is structure. This category refers to the context in which the care takes place—more specifically, the characteristics of the health-care organization. The information in this category is often the most clearly and easily observable. For example, the construction and layout of the facility itself, including its equipment and the number of available rooms and beds, are part of the structure category. This category also includes human resource elements, like the ratios of staff to patients and the average training level of staff, and other details, such as the different methods available for patients to pay their bills. Analyzing structure can help to assess the health-care experience and identify problematic areas that may affect patient care and satisfaction.

The second category of information is process. Process is a broad category encompassing all interactions among patients and their health-care providers. It relates to the overall experience of health care. Donabedian considered process likely to be the most important measurement of quality because of how much information it included. The process begins with the initial contact among patients and providers, including checkups and diagnoses of health problems. It extends through all related treatments, education imparted to patients and their families relating to self-treatment or preventative actions, and subsequent results. Evaluators in the process level may find information in many sources, including observation, interviews, or surveys of medical records.

The third and final category is outcome. Like process, outcome is a very broad category. It includes all effects of the health care on one or multiple patients. These effects may be physical, mental, or emotional and may occur in the short or long term. The most obvious outcome is whether the patient's ailment was successfully treated. Other outcomes involve whether the patient improved their health behavior or whether the patient was satisfied with the treatment received. Unlike structure, the outcome category can be very difficult to assess. It may involve studies of large populations of patients or lengthy case studies of health-related behaviors, changes, and attitudes. Additionally, evaluators face the challenge of differentiating outcomes based on the health care in question from all other unrelated factors in the life of a person or group of people. Despite this difficulty, the outcome category is likely the most important because it relates to the actual overall effectiveness of a health-care provider.

Bibliography

"Avedis Donabedian Papers: 1946-2000." University of Michigan, Bentley Historical Library, quod.lib.umich.edu/b/bhlead/umich-bhl-03136?view=text. Accessed 27 July 2024.

Donabedian, Avedis. "Evaluating the Quality of Medical Care." The Milbank Quarterly, vol. 83, no. 4, Dec. 2005, pp. 691–729.

Donabedian, Avedis. Explorations in Quality Assessment and Monitoring, Volume I: The Definition of Quality and Approaches to Its Assessment. Health Administration Press, 1980.

Donabedian, Avedis. Explorations in Quality Assessment and Monitoring, Volume II: The Criteria and Standards of Quality. Health Administration Press, 1982.

"Elements of an Evaluation Plan." U.S. Department of Health & Human Services, Agency for Healthcare Research and Quality, Jan. 2023, www.ahrq.gov/professionals/quality-patient-safety/talkingquality/assess/evaluationplan.html. Accessed 27 July 2024.

Moayed, Malihe Sadat, et al. "Factors Determining the Quality of Health Services Provided to COVID-19 Patients from the Perspective of Healthcare Providers: Based on the Donabedian Model." Frontiers in Public Health, vol. 10, 2022, doi.org/10.3389/fpubh.2022.967431. Accessed 17 July 2024.

Sollecito, William A., and Julie K. Johnson. McLaughlin and Kaluzny's Continuous Quality Improvement in Health Care. 4th ed., Jones & Bartlett Leaning, 2013.