Avedis Donabedian

The quality of care. How can it be assessed

Before assessment can begin we must decide how quality is to be defined and that depends on whether one assesses only the performance of practitioners or also the contributions of patients and of the health care system; on how broadly health and responsibility for health are defined; on whether the maximally effective or optimally effective care is sought; and on whether individual or social preferences define the optimum. We also need detailed information about the causal linkages among the structural attributes of the settings in which care occurs, the processes of care, and the outcomes of care. Specifying the components or outcomes of care to be sampled, formulating the appropriate criteria and standards, and obtaining the necessary information are the steps that follow. Though we know much about assessing quality, much remains to be known.

Promoting Quality through Evaluating the Process of Patient Care

is set up, at the core of which is that little-understood entity, the patient-physician relationship. The decision to terminate care may be made primarily by the physician, primarily by the client, or mutually. In summary, the medical care process may be seen as a set of client behaviors and another set of provider behaviors, with complex interactions between them. The products of these interactions are

Quality, cost, and health: an integrative model.

This article presents an integrative model of the relations among health status, quality of care, and resource expenditure. It defines medical care quality in terms of outcomes, measured as the expected improvements in health status attributable to care. The consideration of how quality so defined is affected by the unconstrained, efficient use of resources for care leads to the specification of the absolutist definition of quality. Consideration of the incidence of individual and external costs and benefits of care provides the basis for distinguishing further between the individualized definition of quality, which depends upon individual preferences and ability to pay, and the social definition of quality, which includes consideration of external benefits, full social costs, and preferences for the distribution of welfare. An additional distinction is made between clinical efficiency and production efficiency. This article examines in detail the implications, for the selection of optimal strategies of care, of the three definitions of quality (absolutist, individualized, and social) and the two types of efficiency (clinical and production).

The criteria and standards of quality

Spend your few moment to read a book even only few pages. Reading book is not obligation and force for everybody. When you dont want to read, you can get punishment from the publisher. Read a book becomes a choice of your different characteristics. Many people with reading habit will always be enjoyable to read, or on the contrary. For some reasons, this the criteria and standards of quality tends to be the representative book in this website.

The Lichfield Lecture. Quality assurance in health care: consumers' role.

I hope that what I shall have to say would have pleased Lord Lichfield, under whose colours I speak. Reputed to have been a most humane and agreeable man, he would have approved, I believe, of the larger role I shall accord consumers in assuring the quality of health care. And, quite possibly, the squire so solicitous of his horses as to provide for them in his will (so long as life can be made agreeable to them) would not have minded if a little of his generosity should touch an Armenian professor recently put to pasture. But before I advance my main arguments, I need to define my terms and reveal my method.

The End Results of Health Care: Ernest Codman's Contribution to Quality Assessment and Beyond

E.A. Codmans conception and development of the end result idea in the 1910s are unduly neglected in the history of health care assessment. The idea entailed following patients long enough to determine if treatments proved successful and taking comprehensive measures to prevent new failures if outcomes were undesirable. Codmans work anticipated contemporary approaches to quality monitoring and assurance, establishing accountability, and allocating and managing resources efficiently, among other assessment features. Complexity and ambiguity in health care objectives, decision making, and role responsibilities as well as costs today hinder full application of his vision, but refinement of these factors proceeds in the directions Codman set forth.

Models for Organizing the Delivery of Personal Health Services and Criteria for Evaluating Them

My assignment is to describe models for organizing the delivery of personal health services-not only those forms that are extant, but also those that are (as the instructions read) incipient and possible. I am also asked to offer criteria that may be used to evaluate alternative modes of organization. This is a formidable task, as are all the other labors that the planning committee of the Sun Valley Health Forum, perhaps with more optimism than realism, has assigned to several of us. The task is particularly difficult because this is an assemblage of experts, who not only know the conventional wisdom of our field, but are responsible for its continual regeneration. Accordingly, I have confined myself to a remapping, as it were, of the territory assigned to me, with a view to focusing attention on certain of its major features. If I have been at all successful, the answers that we all seek will begin to emerge not from this presentation, but from the collective examination and judgment of this group. I shall consider, first, the criteria for evaluation, because features of organization derive their significance from a system of values that needs to be made explicit, so it can be subjected to scrutiny. Without a prior commitment to values it is not possible to say which features of organization are important, and for what reason.

Twenty Years of Research on the Quality of Medical Care 1964-1984

Since 1964 we have built on earlier work, with some refinements, particularly in the formulation of explicit criteria of process and outcome; the detailed standardization of case mix when outcomes signify quality; the prespecification of outcomes for follow-up, when adverse outcomes are only the occasion for later assessment of process; a greater emphasis on more subtle organizational characteristics in the study of structure; and the identification of the separate effects of structural attributes by multivariate analysis. We have also paid more systematic attention to questions of measurement, including the veracity and completeness of the record; the procedures of criteria formulation; and the reliability, validity, and screening efficiency of the criteria. A notable advance is the use of decision analysis to identify optimal strategies of care, including the introduction of patient preferences and monetary cost in the specification of such strategies, and the use of decisional algorithms to portray the criteria of quality.

Criteria, norms and standards of quality: what do they mean?

Quality assessment requires specification of: 1) a set of phenomena that are usually attributes of either process or outcome; 2) a general rule of what constitutes goodness; and 3) a precise numerical statement of what constitutes acceptable or optimal goodness with respect to each of these phenomena. The terms criteria, norms, and standards, as currently employed, do not correspond well with these three components, but they could be used effectively if the basic distinctions were understood. Alternatively, one could use, as corresponding terms, elements, parameters, and standards. The terms criteria, and norms would then be redefined and be available to be used more uniformly, while standards could be further differentiated according to method of measurement, configuration, level, and flexibility.

Follow-up study of chronically ill patients discharged from hospital

Abstract A study was made of 82 patients with selected illnesses of specified severity before and after discharge from the ward services of three general hospitals in a metropolitan community. An initial appraisal was made by a resident physician who evaluated the health status of each patient and made recommendations for care and supervision following discharge from hospital. After an average period of 3 months, each patient was visited by a student of social work who reconstructed the course of events following discharge and determined the extent to which the physicians recommendations were complied with and the reasons for non-compliance. The usual consequences of chronic illness—persistent disability, unemployment and recurrent and lengthy institutionalization—were amply evident in this group. So was the fact that the burden of continued care falls heavily upon the members of the family. Other sources of help were trivial by comparison. The recommendations made by the discharging physician constitute an interesting, and sobering, inventory of continued need for care. More than a half of all patients did not comply with one or more recommendations made by the physician. In addition, about 40 per cent of patients reported unmet need for one or more services touching upon many aspects of medical care. A variety of lessons relevant to the organized provision of care may be drawn from a consideration of the services needed and desired by patients and of the reasons for, and factors related to, non-compliance with medical recommendations.