This Article Extract Reprint (PDF) Submit a response to this article Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services E-mail this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to My Personal Archive Download to Citation Manager Reprints & Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Mullan, F. Search for Related Content PubMed PubMed Citation Articles by Mullan, F. Related Collections Quality Of Care Related Article

Interview

A Founder of Quality Assessment Encounters A Troubled System Firsthand

INTRODUCTION:Avedis Donabedian, physician, scholar, and poet, died on 9 November 2000 at age eighty-one, a month after this conversation with Fitzhugh Mullan. Known fondly by his students as "Mr. Structure-Process-Outcome" and internationally for his "Seven Pillars of Quality," Donabedian through his research and writing created much of the conceptual underpinnings for quality assessment in health systems used today. Born in Beirut of Armenian parents who had fled persecution in central Turkey, he grew up in an Arab village north of Jerusalem, where his father worked as a general practitioner. Donabedian studied medicine at the American University in Beirut, the starting point for his academic career. In 1953 he came to the United States to study public health at Harvard and in 1961 joined the faculty of the School of Public Health at the University of Michigan, where he spent the balance of his career. His work was framed by a simple question that he asked often: "How can you tell if you have good-quality health care?" His books include the classics, Aspects of Medical Care Administration (1973), Benefits of Medical Care Programs (1976), and the three-volume Explorations in Quality Assessment and Monitoring (1980–1985). Today many of his students are leaders in health care and public health around the world. His name, Avedis, means "good news" in Armenian—a comment on his life and work with which his colleagues, students, and the public at large would surely agree.

Donabedian: My current illness began in 1972 with symptoms of urinary infection. A subsequent exam and biopsy revealed that I had cancer of the prostate that had spread a little. I had a prostatectomy and cobalt therapy and, for many years, was in pretty good shape. I actually did much of the work for which I am known after the cancer manifested itself. Then, about fifteen years ago, my PSA (prostate specific antigen) began climbing, and I was placed on various hormone therapies and had more surgery. Technically I was ill, but I generally felt well and functioned at full speed.

About three years ago, however, I developed a narrowing of the urethra, resulting in a series of complications leading to infection and renal failure. I became very, very ill and was admitted to the hospital. The problems were compounded because the urologist and the nephrologist didn’t agree on the nature of my problem or the best treatment for it. Since there was no meeting of the minds, they left it to me to decide what to do. To me! In the end, they discharged me.

At the University of Michigan, the outpatient and inpatient teams are entirely separate, and my outpatient nephrologist discovered that I had a new growth—a bladder tumor. This led to more surgery and left me without a bladder or a rectum and lots of permanent tubes and pouches. I have good support at home. I have a wonderful wife, and I’ve been able to cope. Within the last several months, the prostate cancer has spread and I have metastases everywhere. Gradually, I’m getting weaker. But I can hobble around at home, and my pain is reasonably well controlled.

Mullan: You have certainly been a patient of the system. But for many years you have also been a physician, commentator, and philosopher of the system. What stands out in your mind about medical care as you’ve experienced it?

Donabedian: Where should I begin, my friend? I would say that my view is generally positive. I have tried to choose doctors who work together reasonably well, so that there is some degree of communication and continuity. Still, there are areas where no one takes responsibility, where planning is weak, where I am left on my own. I have a primary care physician who visits me regularly, and this helps. But at a university hospital, residents from the different services control most things, and their coordination is not always good. I also know that I get a little VIP attention, which is nice. My urologist goes to a conference and someone cites Donabedian and he puts his hand up and says, "Donabedian—he’s my patient." Then he comes back and tells me. And the nursing staff is very friendly. They give me hugs and kisses.

Mullan: When I became severely ill some years ago, I found that going from being a doctor to being a patient was very difficult. I didn’t want to give up control. How has it been for you?

Donabedian: How you make this transition is partly a matter of temperament and partly a matter of circumstance. I’m not so demanding of my doctors because, heaven knows, I have made mistakes. I don’t expect perfection in my doctors. All I expect is that they be reasonably prudent and attentive and do the best they can. By the time my illness started, I had moved on from clinical practice to public health, research, and scholarship. Then I retired from that, so I’m really a layman now— just how I started. Then, too, I’m a little fatalistic because of my Middle Eastern background. I’m Armenian and was brought up in a Christian environment. I’m more willing to accept things as they happen and make do. So being a cancer patient hasn’t been too difficult for me for reasons of temperament and religious faith.

Judging Quality

Top Being A Patient Judging Quality Confidence Amid Errors Commercialization Of Care A Scholar And A... Daisies In Winter

 
Mullan: You’ve written a great deal about quality of care, for instance, your principles known as Donabedian’s Seven Pillars of Quality. How do you feel about the quality of care you’ve received?

Donabedian: The view of quality that is taken in the hospital is really limited to technical competence and, more recently, to superficial attention to the interpersonal process. Keep the patient happy, be nice to the patient, call him Mr. or Mrs., remember his name. The idea that patients should be involved in their care is not really practiced in a responsible way. Today people talk about patient autonomy, but often it gets translated into patient abandonment. The doctor has to work diligently with the patient to arrive at a solution that is ultimately acceptable to the patient but is not entirely undirected. The role of the doctor is to actively make sure that the patient arrives at a decision that is a reasonable one for him or her, without being manipulative.

Mullan: In your experience, do systems of care work the way they are supposed to?

Donabedian: People have a big problem understanding the relationship between quality and systems. Many doctors seek refuge in the allegation that they are good clinicians but the system is wrong, without realizing that they are the key aspect of the system. The system is the responsibility of the doctors and the hospital leadership. The surgery outpatient clinic is an excellent and troubling example; it’s a place I have frequently waited for extended periods. I once asked one of the nurses why the wait was so long. She responded that they had to wait until the residents on the inpatient service finished their work and came to staff the outpatient clinic. Meanwhile, the patients wait. The system is the problem. The same thing happens in the geriatric outpatient clinic where, in theory, I am cared for by the same team of nurses at every visit. It never happens. A plan exists on paper, but the system doesn’t work. I see different people every time, and we start from scratch.

Confidence Amid Errors

Top Being A Patient Judging Quality Confidence Amid Errors Commercialization Of Care A Scholar And A... Daisies In Winter

 
Mullan: As hospital care becomes increasingly complex and intensive, it is clear that the lack of a well-honed system can easily lead to errors. What was your sense of confidence in the day-to-day management of your care in the hospital?

Donabedian: I think the hospital floors are a disaster. I saw so many part-time nurses working variable hours. They come and go. Often I couldn’t tell whether I was dealing with a nurse, a technician, an attending physician, or an attendant. I saw rampant discontinuity in nursing care and many poorly oriented nurses, especially on weekends. I had a young nurse assigned to me one day who clearly did not know how to handle a colostomy. "Do you know anything about colostomy management?" I asked her. "No," she answered. "Okay, sit down. I’ll teach you." She learned and thanked me profusely, but this was an unbelievable situation. Of course, there’s tremendous difference in the competence of nurses. Some nurses make everything run like clockwork, while others are quite disengaged.

Mullan: During a recent stay in the hospital, I found myself checking to see who was going to be assigned tome the next shift. I was enormously relieved to see someone who had been there before and who knew me and my equipment.

Donabedian: What makes for clinical situations like this is failure to realize the relationship between what I have called structure, which can be called system design, and system performance. Things won’t improve until something is done about the design of the system.

Mullan: Why is this happening? The hospital leadership is not malevolent, and yet the system it has constructed is in many ways poor and occasionally dangerous.

Donabedian: I think poor training and education have a lot to do with it. System management doesn’t get taught in medical or nursing schools. Then you put doctors and nurses in charge of systems that are under constant short-term financial pressures. These pressures are real, but the purpose of good systems is to deal with them.

The problem stems from a bit of myopia mixed with ignorance. It’s easy to train people to use a certain vocabulary—for instance, calling people "customers" to whom we offer "products"—but this doesn’t really change the culture or the awareness of the clinicians. Our clinicians should be able to spot weaknesses and bring them to the attention of the people who can fix them, but that doesn’t happen. There’s lip service to quality and, goodness knows, propaganda, but real commitment is in short supply.

For example, I was scheduled for a cystoscopy as an outpatient. I arrived at the clinic and waited for two hours. I received no information about the procedure before I got there or while I was waiting. Finally, after all the other patients had left, I queried the woman at the desk about my appointment. "They’re busy. Please wait," she replied. Nobody came to talk to me. Finally, I was called in by the cystoscopy nurse. I asked her if she had some kind of patient information sheet, something to explain what was going to happen to me during the procedure and afterwards. "Well, yes," she said. "Of course we do. I’ll get you one." Five minutes later she said she was sorry but she couldn’t find any copies. I asked her if the clinic had a quality assurance committee and she told me they did but that nobody pays attention to it. "Tell the committee that Donabedian said they have a problem," I said. "He’s the father of quality assurance." She thought I was crazy.

We have all this shadow apparatus that doesn’t really work—partly because nobody’s listening and partly because the clinicians at the frontlines are either unaware or are unable to make their voices heard. When the management doesn’t pay attention, the clinicians will surely stop trying, and the apparatus will fall by the wayside.

Commercialization Of Care

Top Being A Patient Judging Quality Confidence Amid Errors Commercialization Of Care A Scholar And A... Daisies In Winter

 
Mullan: We have all experienced the rapid commercialization of health care in recent years. How do you feel about this?

Donabedian: I have never been convinced that competition by itself will improve the efficiency or the effectiveness of care or even that it will reduce the cost of care. I think that commercialization of care is a big mistake. Health care is a sacred mission. It is 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 understands everything and makes rational choices—and I include myself here. Doctors and nurses are stewards of something precious. Their work is a kind of vocation rather than simply a job; commercial values don’t really capture what they do for patients and for society as a whole.

Systems awareness and systems design are important for health professionals but are not enough. They are enabling mechanisms only. It is the ethical dimension of individuals that is essential to a system’s success. 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 monitor and improve the system. Commercialism should not be a principal force in the system. That people should make money by investing in health care without actually being providers of health care seems somewhat perverse, like a kind of racketeering.

Mullan: How do you feel about the HMO movement?

Donabedian: I have always been strongly in favor of prepaid group practice as away of providing medical care, reducing access barriers, and increasing fairness in the distribution of services. Managed care promised a more coherent, integrated, and coordinated way to provide care. Many of the structural features in today’s HMOs (health maintenance organizations) are those for which I advocated very strongly from the beginning. But there was always the proviso that HMOs would be designed with the objective of improving care, not reducing costs. There is nothing wrong with pursuing efficiency, but cost cutting alone does not produce efficiency and certainly does not improve patient care. HMOs today are good at measuring costs but pay little attention to measuring effects. This failure to look at outcomes undercuts all of the reasons that so many of us were interested in the prepaid group practice model to begin with. Even today I would be enthusiastic about HMOs if the financial pressures on doctors were removed. The challenge is to keep some control over costs with out creating a conflict of interest for physicians by tying their reimbursements to cutting patient costs. My solution would be built on the moral and scientific probity of the practitioner rather than on financial incentives and disincentives.

Mullan: As you reflect on the state of our health care system, including its commercial aspects and its huge continuing disparities in access to care, where do you see us headed?

Donabedian: I worry about my colleagues, the doctors. I’m a doctor, my son is a doctor, and my father was a doctor—a country practitioner in the villages of Arab Palestine and my model for what a good physician should be. I worry about the fate of the medical profession because physicians are babes in the woods. Over the years, doctors haven’t trusted government. They fought every proposed reform—national health insurance under Harry Truman, Medicare under Lyndon Johnson, and most recently, health care reform under Bill Clinton. Now market capitalism has taken over, and doctors are being exploited left and right by corporate enterprise. They’re gradually losing the respect of the public. I worry about the health care profession developing a kind of technician status and attracting only second-rate people. One positive aspect of the current chaos is that it is generating dissatisfaction on all sides. Sooner rather than later we are going to have to develop a national health plan. The design and implementation of such a plan will be an exciting task of the fairly near future, I believe. This country has tremendous wisdom and tremendous goodness. Eventually they will triumph in health care.

A Scholar And A Poet

Top Being A Patient Judging Quality Confidence Amid Errors Commercialization Of Care A Scholar And A... Daisies In Winter

 
Mullan: Tell me a word about your poetry. I gather it has been a lifetime avocation.

Donabedian: When I was young I wrote love poems. During middle age I wrote religious poems. In old age I started writing about old friends, ancient loves, and early experiences. Most recently my poems have turned religious again. Writing poetry is very important to me. I am Armenian but grew up in Palestine with Arab, Jewish, and Christian friends. I went to school in Lebanon but have spent most of my adult life in the United States. All of these experiences enriched my work as a physician and a scholar. But it is the poetry that tells the most about who I am.

Daisies In Winter

Top Being A Patient Judging Quality Confidence Amid Errors Commercialization Of Care A Scholar And A... Daisies In Winter

 
It is deep winter now,
And deep the snow
On winter’s desolation.
Wasteland of white
Torments my eyes, and bids
My sorrows flow.

Deep in my heart
There is your summer now,
To set my meadows greening.
Green-garlanded,
Daisies are flecks of snow,
Their hearts aglow.

Deep under snow
It is dark winter now,
But in your sun
Winter shades into summer,
All seasons one.

Avedis Donabedian
Ann Arbor, Michigan
March 1995

Editor's Notes

 
Avedis Donabedian retired from the Nathan Sinai Professorship in Public Health at the University of Michigan in 1988 but continued to lecture throughout the world until 1999. He was a charter member of the National Academy of Sciences’ Institute of Medicine. Fitzhugh Mullan, a physician, is contributing editor of Health Affairs.

                      What's this?

Related Article

• John K. Iglehart
  Will New Leadership Address The Issue Of The Uninsured?
  Health Affairs, January/February 2001; 20(1): 6-7.
  [Extract] [Full Text] [PDF]
   
  

This article has been cited by other articles:

				P. S. Douglas President's Page: Making Imaging Meaningful J. Am. Coll. Cardiol., April 4, 2006; 47(7): 1485 - 1486. [Full Text] [PDF]

				M. M. Safford, L. Russell, D.-C. Suh, S. Roman, and L. Pogach How Much Time Do Patients with Diabetes Spend on Self-Care? J Am Board Fam Med, July 1, 2005; 18(4): 262 - 270. [Abstract] [Full Text] [PDF]

				S. Satya-Murti An Introduction to Quality Assurance in Health Care JAMA, July 2, 2003; 290(1): 119 - 120. [Full Text] [PDF]