There is no shortfall of heroes these days in healthcare. COVID has pulled the curtain back, exposing the frontlines of hospitals, urgent care centers and clinics giving us an incredibly small glimpse into the harrowing daily work lives of those dedicated to getting us back on track. Even while being overwhelmed with a pandemic, it’s irrefutable that the U.S. has the highest quality of healthcare. While cost and value are debatable, quality is a firmly cemented cornerstone. We have all become so accustomed to hearing about quality measures in healthcare. Centers of excellence and medical treatment destinations have all used quality measures and resulting data to attain their superlatives. If you’ve sat in a meeting with hospital clinicians, and someone says, “We’ve looked at the data,” they were talking about quality measures. Having high quality healthcare is by design, and there’s one hero we can thank: Dr. Avedis Donabedian. 

Donabedian’s “Evaluating the Quality of Medical Care,” published in 1966, became one of the most cited papers of the 20th century. In it, Donabedian lays out three categories from which the quality of care can be measured –simple by design, scalable to any practice or facility:

  • Structure describes the context in which care is delivered, including hospital buildings, staff, financing, and equipment.
  • Process denotes the transactions between patients and providers throughout the delivery of healthcare.
  • Finally, outcomes refer to the effects of healthcare on the health status of patients and populations.[1]

As an aside, go on and take note of the publishing year in the footnote. Twenty-two years after publishing a paper that berthed the practice of analyzing and improving modern medicine, Donabedian was still in pursuit of quality’s ultimate stake: assessing it. The dedication is admirable, but the design of the model is even more so in that there is no implied definition of “Quality of Care.”  This supports the model’s application across large, systemic problems, as well as nuanced, particular challenges.  Donabedian was able to create a model for measuring quality that could adapt and evolve, just as the patient population does. It’s fluidity is its permanence, which is pretty wild if you like to geek out on healthcare.

Heroic? Undoubtedly. Donabedian forewent being a present father and husband to his children and wife for the sake of improving the quality of healthcare. Anytime outcomes improve, Donabedian’s paradigm has played a role in the design of the research and work behind it. Literally, billions of people will benefit greatly from his work without ever having known it. He spent his life doing research and presenting it across the world. He didn’t create quality, but he established the best way to think about improving it. 

However, there’s a bit more to the man than his work. After all of the research, the panel participations, the publications, the speaking engagements and consultations with healthcare leaders around the world, what did Donabedian think was the secret of quality? Love. Ironically, Donabedian throws the data out the window with a nod to one of our most unexplainable, unquantifiable emotions when it comes to delivering quality care. In the end, it’s rarely the patient’s clinical outcome but rather the sum of their emotional experience during their care that dictates how they feel about their outcome. 

If you truly love the patient and delivering his or her care, only the best quality of care will be delivered.  He acknowledged that what mattered most could not be measured by the research he had done, but chose to disclose his thoughts on what matters in medicine fully. 

That’s a hero. 

Today, we see it more than ever in our hospitals – nurses, doctors, and technicians braving the ER in the name of love for humanity. That deserves a cape and X-Ray vision.  


[1] Donabedian, A. (1988). “The quality of care: How can it be assessed?”. JAMA. 260 (12): 1743–8. doi:10.1001/jama.1988.03410120089033PMID 3045356.