PE R S PE C T IV E
HIS TORY OF MEDICINE
Donabedian’s Lasting Framework for Health Care Quality
John Z. Ayanian, M.D., M.P.P., and Howard Markel, M.D., Ph.D.​​
T hough historians are often
hesitant to declare any event
a “first,” one might safely claim
that the contemporary health care
quality movement had its “found-
ing moment” in October 1965.
Less than 3 months after the
Medicare and Medicaid programs
were enacted, the newly created
Health Services Research Section
of the U.S. Public Health Service
convened a meeting in Chicago of
leaders from many health-related
fields. These leaders considered
the influence of social and eco-
nomic research on public health,
the organization of community
health agencies, and the quality
of health services.
One of these experts, Avedis
Donabedian, a professor of med-
ical care organization at the Uni-
versity of Michigan School of Pub-
lic Health, was commissioned to
review the research on quality
assessment. His formative work
was already known to readers of
the Journal, including a 1963 arti-
cle on administrative controls in
medical care.1 When the confer-
ence papers were published in
July 1966, Donabedian could not
have anticipated that his article,
“Evaluating the Quality of Medi-
cal Care,”2 would become one of
the most frequently cited public
health articles of the next 50
years. More important, this arti-
cle became the nucleus of his in-
fluential body of work on the
theory and practice of quality as-
surance and the emerging field of
health services research (see box).
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donabedian’s lasting framework for health care quality
Notable Publications on the Quality of Health Care by Avedis Donabedian.
Articles
Evaluating the quality of medical care: 1966. Milbank Mem Fund Q 1966;44:Suppl:
166-206. (Reprinted in Milbank Q 2005;83:691-729.)
Quality, cost, and health: an integrative model. Med Care 1982;20:975-92 (with J.R.
Wheeler and L. Wyszewianski).
The epidemiology of quality. Inquiry 1985;22:282-92.
Twenty years of research on the quality of medical care, 1964-1984. Eval Health Prof
1985;8:243-65.
The quality of care. How can it be assessed? JAMA 1988;260:1743-8.
The end results of health care: Ernest Codman’s contribution to quality assessment
and beyond. Milbank Q 1989;67:233-56.
The seven pillars of quality. Arch Pathol Lab Med 1990;114:1115-8.
A quarter-century of work on quality of care at the Institute of Medicine. In: Institute
of Medicine Council. For the public good: highlights from the Institute of Medi­
cine, 1970-1995. Washington, DC: National Academies Press, 1995:53-7.
Books
The definition of quality and approaches to its assessment. Ann Arbor, MI: Health
Administration Press, 1980.
The criteria and standards of quality. Ann Arbor, MI: Health Administration Press, 1982.
The methods and findings of quality assessment and monitoring: an illustrated
analysis. Ann Arbor, MI: Health Administration Press, 1985.
An introduction to quality assurance in health care. New York: Oxford University
Press, 2002.
As an immigrant and a non- lifelong interest in the ways in
practicing physician, Donabedian which medical care is delivered,
could assess the quality of U.S. in organizations ranging from
health care from a distinctive small clinics to large health care
perspective. As he would note in systems. In 1953, Donabedian was
1998, “I’m a double outsider in granted a scholarship to study
terms of seeing the value founda- epidemiology and health services
tions of the health care system. administration at the Harvard
I’m an outsider and, therefore, I School of Public Health, where
can see how these ‘natives’ think.”3 he forged lasting relationships
Donabedian was born in 1919 in with leaders in studying health
Beirut, Lebanon, to Armenian par- care, and in 1961 he was recruit-
ents who had been exiled from ed to the University of Michigan.
Ottoman Turkey during the Arme- For the rest of his career, he
nian genocide. Raised in Ramal- worked to define and develop
lah, Palestine, he followed in his methods to measure the quality
father’s path and studied medi- of health care, assessing how
cine. As a young physician, he clinical decision making affects
directed the faculty and student quality and analyzing the man-
health service of the American agement and governance of health
University in Beirut. care systems and resources.
This experience spawned his In his landmark 1966 article,
205
PERS PE C T IV E
Donabedian proposed using the
triad of structure, process, and
outcome to evaluate the quality
of health care.2 He defined “struc-
ture” as the settings, qualifica-
tions of providers, and adminis-
trative systems through which
care takes place; “process” as the
components of care delivered;
and “outcome” as recovery, resto-
ration of function, and survival.
These concepts remain the foun-
dation of quality assessment to-
day. Structure has long been
­assessed by means of board cer-
tification of physicians and Joint
Commission accreditation of hos-
pitals. Process and outcome mea-
sures are now vetted and en-
dorsed by the National Quality
Forum and National Committee
for Quality Assurance, and Medi-
care publicly reports the perfor-
mance of hospitals, nursing
homes, and health plans on such
measures. Furthermore, board cer-
tification programs for physicians
now strive to foster continuous
learning and monitoring of clini-
cal performance measures.
Long before the advent of elec-
tronic health records or comput-
erized health care data, Donabe-
dian’s article also presaged many
of the challenges that persist in
current efforts to assess the
quality of care.2 He underscored
the difficulties of assessing qual-
ity on the basis of medical rec-
ords or direct observation of clini-
cal encounters. He highlighted
the importance of representative
samples and clear measurement
standards. He emphasized the
need for valid measures of struc-
ture and process that could be
linked to outcomes and for reli-
able measures of quality that were
readily reproducible. He called for
a broader approach to quality
206
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donabedian’s lasting framework for health care quality
measurement that extended be-
yond the technical management
of illness to incorporate assess-
ments of prevention, rehabilita-
tion, coordination, and continu-
ity of care, the patient–physician
relationship, economic efficiency,
and societal values. The current
focus on value-based payment and
patient-centered outcomes can be
traced back to Donabedian’s con-
ceptual framework.
This framework provided the
foundation for an influential re-
port produced by the Institute of
Medicine in 1990, entitled Medi-
care: A Strategy for Quality Assurance.
Drawing extensively on Donabe-
dian’s work, the report defined
quality of care as “the degree to
which health services for indi-
viduals and populations increase
the likelihood of desired health
outcomes and are consistent with
current professional knowledge.”
Also in 1990, Donabedian out-
lined the “seven pillars of qual-
ity,” 4 which would be distilled 11
years later in the Institute of
Medicine report Crossing the Qual-
ity Chasm, which highlighted six
core aims for the 21st-century
health care system: to deliver
care that is safe, effective, patient-
centered, timely, efficient, and
equitable. Benchmarks related to
these aims have become com-
mon metrics in clinics, hospitals,
and health care organizations
around the world.
Donabedian concluded his
1966 article with an essential
question and a demand for evi-
dence: “More often one needs to
ask, ‘What goes on here?’ rather
than, ‘What is wrong; and how
can it be made better?’ This does
not mean that the researcher dis-
owns his own values or social
objectives. It does mean, however,
n engl j med 375;3  nejm.org  July 21, 2016
that the distinction between val-
ues, and elements of structure,
process or outcome, is recog-
nized and maintained; and that
both are subjected to equally criti-
cal study.”
Donabedian emphasized that
a focus on metrics is essential.
He also insisted that physicians
must recognize that the culture
and social systems in which they
practice can enhance or detract
from the quality of health care.
Therefore, we believe that Donabe-
dian would call on health care
professionals in our current era
to engage actively in leading and
shaping the pursuit of high-qual-
ity care in their organizations
and society.
Near the end of his life, Dona­
bedian was frequently hospital-
ized for complications of ad-
vanced prostate cancer. Once
again, he was an outsider look-
ing in and now experiencing
first-hand the structure, pro-
cesses, and outcomes of medical
care, observing “a system [that]
doesn’t work” from the perspec-
tive of a patient. In an interview
a month before he died in Novem-
ber 2000, he discussed the diffi-
culties he had with fragmented
care, while remaining committed
to his quest for high quality in
health care.5
Optimistic to the end and
cognizant of the social, emotion-
al, and ethical aspects of quality
improvement, Donabedian reflect­
ed, “Health care is a sacred mis-
sion . . . a moral enterprise and
a scientific enterprise but not
fundamentally a commercial one.
We are not selling a product. We
don’t have a consumer who un-
derstands everything and makes
rational choices — and I include
myself here. Doctors and nurses
PE R S PE C T IV E Donabedian’s Lasting Framework for Health Care Quality

are stewards of something pre-
cious. . . . Ultimately the secret
of quality is love. You have to
love your patient, you have to love
your profession, you have to love
your God. If you have love, you
can then work backward to mon-
itor and improve the system.”5
Donabedian thus underscored
his belief that efforts to improve
the structure, processes, and out-
comes of health care must be in-
separably linked with genuine care
and concern about the needs of
our patients. Given his lasting
framework for assessing the quali-
ty of health care around the world,
few words could better encapsulate
the legacy of Avedis Donabedian.
Disclosure forms provided by the authors
are available at NEJM.org.
From the Institute for Healthcare Policy and
Innovation (J.Z.A., H.M.), the Departments
of Internal Medicine (J.Z.A.) and Pediatrics
and Communicable Diseases (H.M.), the
Medical School (J.Z.A., H.M.), the Depart-
ment of Health Management and Policy,
School of Public Health (J.Z.A., H.M.), the
Gerald R. Ford School of Public Policy
(J.Z.A.), and the Center for the History of
Medicine (H.M.), all at the University of
Michigan, Ann Arbor.
1. Donabedian A, Attwood JC. An evaluation
of administrative controls in medical-care
programs. N Engl J Med 1963;​269:​347-54.
2. Donabedian A. Evaluating the quality of
medical care. Milbank Mem Fund Q 1966;​
44:​Suppl:​166-206.
3. Berkowitz E. History of Health Services
research project: interview with Avedis Do-
nabedian. Bethesda, MD:​National Informa-
tion Center on Health Services Research and
Health Care Technology and History of
Medicine Division, National Library of Med-
icine, April 16, 1998 (https:/​/​w ww​.nlm​.nih​
.gov/​hmd/​nichsr/​donabedian​.html).
4. Donabedian A. The seven pillars of qual-
ity. Arch Pathol Lab Med 1990;​114:​1115-8.
5. Donabedian A. A founder of quality as-
sessment encounters a troubled system first-
hand: interview by Fitzhugh Mullan. Health
Aff (Millwood) 2001;​20(1):​137-41.
DOI: 10.1056/NEJMp1605101
Copyright © 2016 Massachusetts Medical Society.
Donabedian’s Lasting Framework for Health Care Quality

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