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September 23, 1988, Vol 260, No. 12 >
ARTICLE | September 23, 1988

The Quality of Care: Title and subTitle BreakHow Can It Be Assessed? FREE

Avedis Donabedian, MD, MPH
[+] Author Affiliations

This article was written for the AMA Lectures in Medical Science: it is the basis for a lecture in that series given on Jan 11, 1988, by invitation of the Division of Basic Sciences, American Medical Association, Chicago.

Reprint requests to 1739 Ivywood Dr, Ann Arbor, MI 48103.


JAMA. 1988;260(12):1743-1748. doi:10.1001/jama.1988.03410120089033
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References

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.

(JAMA 1988;260:1743-1748)

REFERENCES

1 +
Donabedian A: The Definition of Quality and Approaches to Its Management, vol 1: Explorations in Quality Assessment and Monitoring . Ann Arbor, Mich, Health Administration Press, 1980;.
2 +
Eraker S, Politser P:  How decisions are reached: Physician and patient . Ann Intern Med 1982;;97:262-268.
3 +
Donabedian A:  Models for organizing the delivery of health services and criteria for evaluating them . Milbank Q 1972;;50:103-154.
4 +
McNeil BJ, Weichselbaum R, Pauker SG:  Fallacy of the five-year survival in lung cancer . N Engl J Med 1978;;299:1397-1401.
5 +
McNeil BJ, Weichselbaum R, Pauker SG:  Tradeoffs between quality and quantity of life in laryngeal cancer . N Engl J Med 1981;;305:982-987.
6 +
McNeil BJ, Pauker SG, Sox HC Jr, et al:  On the elicitation of preferences for alternative therapies . N Engl J Med 1982;;306:1259-1262.
7 +
Donabedian A, Wheeler JRC, Whszewianski L:  Quality, cost, and health; An integrative model . Med Care 1982;;20:975-992.
8 +
Torrance GW:  Measurement of health status utilities for economic appraisal: A review . J Health Econ 1986;;5:1-30.
9 +
Donabedian A:  Quality, cost, and clinical decisions . Ann Am Acad Polit Soc Sci 1983;;468:196-204.
10 +
Donabedian A:  Evaluating the quality of medical care . Milbank Q 1966;;44:166-203.
11 +
Palmer RH, Reilly MC:  Individual and institutional variables which may serve as indicators of quality of medical care . Med Care 1979;;17:693-717.
12 +
Donabedian A:  The epidemiology of quality . Inquiry 1985;;22:282-292.
13 +
Kessner DM, Kalk CE, James S:  Assessing health quality--the case for tracers . N Engl J Med 1973;;288:189-194.
14 +
Rhee KJ, Donabedian A, Burney RE:  Assessing the quality of care in a hospital emergency unit: A framework and its application . Quality Rev Bull 1987;;13:4-16.
15 +
Williamson JW:  Formulating priorities for quality assurance activity: Description of a method and its application . JAMA 1978;;239:631-637.
16 +
New York Academy of Medicine, Committee on Public Health Relations: Maternal Mortality in New York City; A Study of All Puerperal Deaths 1930-1932 . New York, Oxford University Press Inc, 1933;.
17 +
Kohl SG: Perinatal Mortality in New York City: Responsible Factors . Cambridge, Mass, Harvard University Press, 1955;.
18 +
Rutstein DB, Berenberg W, Chalmers TC, et al:  Measuring quality of medical care: A clinical method . N Engl J Med 1976;;294:582-588.
19 +
Mushlin AI, Appel FA:  Testing an outcomebased quality assurance strategy in primary care . Med Care 1980;;18:1-100.
20 +
Donabedian A: The Criteria and Standards of Quality, vol 2: Explorations in Quality Assessment and Monitoring . Ann Arbor, Mich, Health Administration Press, 1982;.
21 +
Donabedian A:  Criteria and standards for quality assessment and monitoring . Quality Rev Bull 1986;;12:99-108.
22 +
Greenfield S, Lewis CE, Kaplan SH, et al:  Peer review by criteria mapping: Criteria for diabetes mellitus: The use of decision-making in chart audit . Ann Intern Med 1975;;83:761-770.
23 +
Greenfield S, Cretin S, Worthman L, et al:  Comparison of a criteria map to a criteria list in quality-of-care assessment for patients with chest pain: The relation of each to outcome . Med Care 1981;;19:255-272.
24 +
Lyons TF, Payne BC:  The use of item weights in assessing physician performance with predetermined criteria indices . Med Care 1975;;13:432-439.
25 +
Stewart AL, Ware JE Jr, Brook RH:  Advances in the measurement of functional states: Construction of aggregate indexes . Med Care 1981;;19: 473-488.
26 +
Fanshel S, Bush JW:  A health status index and its application to health service outcomes . Operations Res 1970;;18:1021-1060.
27 +
Patrick DI, Bush JW, Chen MM:  Methods for measuring levels of well-being for a health status index . Health Serv Res 1973;;8:228-245.
28 +
Weinstein MC, Stason WB:  Foundations of cost-effectiveness analysis for health and medical practices . N Engl J Med 1977;;296:716-721.
29 +
Willems JS, Sanders CR, Riddiough MA, et al:  Cost-effectiveness of vaccination against pneumococcal pneumonia . N Engl J Med 1980;;303:553-559.
30 +
Peterson OL, Andrews LP, Spain RA, et al:  An analytical study of North Carolina general practice, 1953-1954 . J Med Educ 1956;;31:1-165.
31 +
What Sort of Doctor? Assessing Quality of Care in General Practice . London, Royal College of General Practitioners, 1985;.

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1 +
Donabedian A: The Definition of Quality and Approaches to Its Management, vol 1: Explorations in Quality Assessment and Monitoring . Ann Arbor, Mich, Health Administration Press, 1980;.
2 +
Eraker S, Politser P:  How decisions are reached: Physician and patient . Ann Intern Med 1982;;97:262-268.
3 +
Donabedian A:  Models for organizing the delivery of health services and criteria for evaluating them . Milbank Q 1972;;50:103-154.
4 +
McNeil BJ, Weichselbaum R, Pauker SG:  Fallacy of the five-year survival in lung cancer . N Engl J Med 1978;;299:1397-1401.
5 +
McNeil BJ, Weichselbaum R, Pauker SG:  Tradeoffs between quality and quantity of life in laryngeal cancer . N Engl J Med 1981;;305:982-987.
6 +
McNeil BJ, Pauker SG, Sox HC Jr, et al:  On the elicitation of preferences for alternative therapies . N Engl J Med 1982;;306:1259-1262.
7 +
Donabedian A, Wheeler JRC, Whszewianski L:  Quality, cost, and health; An integrative model . Med Care 1982;;20:975-992.
8 +
Torrance GW:  Measurement of health status utilities for economic appraisal: A review . J Health Econ 1986;;5:1-30.
9 +
Donabedian A:  Quality, cost, and clinical decisions . Ann Am Acad Polit Soc Sci 1983;;468:196-204.
10 +
Donabedian A:  Evaluating the quality of medical care . Milbank Q 1966;;44:166-203.
11 +
Palmer RH, Reilly MC:  Individual and institutional variables which may serve as indicators of quality of medical care . Med Care 1979;;17:693-717.
12 +
Donabedian A:  The epidemiology of quality . Inquiry 1985;;22:282-292.
13 +
Kessner DM, Kalk CE, James S:  Assessing health quality--the case for tracers . N Engl J Med 1973;;288:189-194.
14 +
Rhee KJ, Donabedian A, Burney RE:  Assessing the quality of care in a hospital emergency unit: A framework and its application . Quality Rev Bull 1987;;13:4-16.
15 +
Williamson JW:  Formulating priorities for quality assurance activity: Description of a method and its application . JAMA 1978;;239:631-637.
16 +
New York Academy of Medicine, Committee on Public Health Relations: Maternal Mortality in New York City; A Study of All Puerperal Deaths 1930-1932 . New York, Oxford University Press Inc, 1933;.
17 +
Kohl SG: Perinatal Mortality in New York City: Responsible Factors . Cambridge, Mass, Harvard University Press, 1955;.
18 +
Rutstein DB, Berenberg W, Chalmers TC, et al:  Measuring quality of medical care: A clinical method . N Engl J Med 1976;;294:582-588.
19 +
Mushlin AI, Appel FA:  Testing an outcomebased quality assurance strategy in primary care . Med Care 1980;;18:1-100.
20 +
Donabedian A: The Criteria and Standards of Quality, vol 2: Explorations in Quality Assessment and Monitoring . Ann Arbor, Mich, Health Administration Press, 1982;.
21 +
Donabedian A:  Criteria and standards for quality assessment and monitoring . Quality Rev Bull 1986;;12:99-108.
22 +
Greenfield S, Lewis CE, Kaplan SH, et al:  Peer review by criteria mapping: Criteria for diabetes mellitus: The use of decision-making in chart audit . Ann Intern Med 1975;;83:761-770.
23 +
Greenfield S, Cretin S, Worthman L, et al:  Comparison of a criteria map to a criteria list in quality-of-care assessment for patients with chest pain: The relation of each to outcome . Med Care 1981;;19:255-272.
24 +
Lyons TF, Payne BC:  The use of item weights in assessing physician performance with predetermined criteria indices . Med Care 1975;;13:432-439.
25 +
Stewart AL, Ware JE Jr, Brook RH:  Advances in the measurement of functional states: Construction of aggregate indexes . Med Care 1981;;19: 473-488.
26 +
Fanshel S, Bush JW:  A health status index and its application to health service outcomes . Operations Res 1970;;18:1021-1060.
27 +
Patrick DI, Bush JW, Chen MM:  Methods for measuring levels of well-being for a health status index . Health Serv Res 1973;;8:228-245.
28 +
Weinstein MC, Stason WB:  Foundations of cost-effectiveness analysis for health and medical practices . N Engl J Med 1977;;296:716-721.
29 +
Willems JS, Sanders CR, Riddiough MA, et al:  Cost-effectiveness of vaccination against pneumococcal pneumonia . N Engl J Med 1980;;303:553-559.
30 +
Peterson OL, Andrews LP, Spain RA, et al:  An analytical study of North Carolina general practice, 1953-1954 . J Med Educ 1956;;31:1-165.
31 +
What Sort of Doctor? Assessing Quality of Care in General Practice . London, Royal College of General Practitioners, 1985;.

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