writing

Search...

Quality and Safety Education for Nurses

QSEN HOME ABOUT QSEN ACADEMIA PRACTICE RESOURCES PUBLICATIONS

Competencies Using the Institute of Medicine (2003) competencies for nursing, QSEN faculty have defined pre-licensure and graduate quality and safety competencies for nursing and proposed targets for the knowledge, skills, and attitudes to be developed in nursing pre-licensure programs for each competency.  

Patient-Centered Care Teamwork & Collaboration Evidence-Based Practice Quality Improvement Safety Informatics

  Led by a national advisory board and distinguished faculty, QSEN pursues strategies to build will and develop effective teaching approaches to assure that future graduates develop competencies in patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics.

Acknowledgments   The QSEN Institute gratefully acknowledges the following QSEN faculty and Advisory Board members for their contributions to the development of the competency definitions and KSAs:  

Paul Batalden, MD, (Dartmouth) Geraldine Bednash, PhD, RN, FAAN, (American Association of Colleges of Nursing) Jean Blackwell, MLS (UNC-Chapel Hill) Linda Cronenwett, PhD, RN, FAAN (UNC Chapel Hill) Lisa Day, PhD, RN (UC-San Francisco) Karen Drenkard, PhD, RN, CNAA, (Inova Health System) Carol Durham, EdD(c), MSN, RN, (UNC-Chapel Hill) Leslie Hall, MD (U Missouri-Columbia) Pamela Ironside, PhD, RN, FAAN, (Indiana University) Jean Johnson, PhD, RN, FAAN (George Washington University) Mary (Polly) Johnson, MSN, RN, FAAN (NC Board of Nursing) Maryjoan Ladden, PhD, RN, (Harvard) Shirley Moore, PhD, RN, FAAN, (Case Western Reserve University) Audrey Nelson, PhD, RN, FAAN (Veterans Administration-Tampa) Gwen Sherwood, PhD, RN, FAAN (UNC Chapel Hill) Elaine Smith, EdD(c), MBA, MSN, RN, CNAA (UNC-Chapel Hill) M. Elaine Tagliareni, EdD, RN (Community College of Philadelphia)

The QSEN Institute gratefully acknowledges the following for their contributions to the Spanish translation of the competency definitions: Nilda Peragallo-Montano, Dean, School of Nursing (UNC-Chapel Hill) Claudia Giraldo, Bilingual Executive Assistant to the Dean, School of Nursing (UNC-Chapel Hill)

QSEN Competencies translated in Spanish   QSEN Competencias de Pre- Licenciatura, Perspectiva de Enfermería, mayo-junio de 2007 y

Translation provided by Claudia S. Lizcano Giraldo, Translator, UNC Chapel Hill School of Nursing

Read More

QSEN Competencies translated in Portuguese   Competências para o ensino sobre qualidade e segurança em enfermagem (Competências QSEN)

Translation provided by Juliana Santana de Freitas Read More

QSEN SES translated in Portuguese

Instrumento de avaliação do estudante quanto ao ensino sobre qualidade e segurança em enfermagem (QSEN SES BR)

Translation provided by Juliana Santana de Freitas

Read More

The QSEN Institute gratefully acknowledges the following for their contributions to the Turkish translation of the competency definitions: Dr. Öğr. Üye. Merve TARHAN, Sağlık Bilimleri Fakültesi, Hemşirelik Bölümü Merve TARHAN, Asst. Prof., Health Sciences Faculty, Department of Nursing

QSEN Competencies translated in Turkish

Translation provided by Dr. Öğr. Üye. Merve TARHAN Sağlık Bilimleri Fakültesi, Hemşirelik Bölümü Merve TARHAN, Asst. Prof. Health Sciences Faculty, Department of Nursing

Read More

Follow Us QSEN Institutional A�liation

[email protected]

© 2022 qsen.org

Privacy Policy | Cookies Policy  | Accessibility   

Created by iPanda Designs

PERSPECTIVE

205

donabedian’s lasting framework for health care quality

n engl j med 375;3 nejm.org July 21, 2016

HISTORY 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.

Though 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).

As an immigrant and a non- practicing physician, Donabedian could assess the quality of U.S. health care from a distinctive perspective. As he would note in 1998, “I’m a double outsider in terms of seeing the value founda- tions of the health care system. I’m an outsider and, therefore, I can see how these ‘natives’ think.”3 Donabedian was born in 1919 in Beirut, Lebanon, to Armenian par- ents who had been exiled from Ottoman Turkey during the Arme- nian genocide. Raised in Ramal- lah, Palestine, he followed in his father’s path and studied medi- cine. As a young physician, he directed the faculty and student health service of the American University in Beirut.

This experience spawned his

lifelong interest in the ways in which medical care is delivered, in organizations ranging from small clinics to large health care systems. In 1953, Donabedian was granted a scholarship to study epidemiology and health services administration at the Harvard School of Public Health, where he forged lasting relationships with leaders in studying health care, and in 1961 he was recruit- ed to the University of Michigan. For the rest of his career, he worked to define and develop methods to measure the quality of health care, assessing how clinical decision making affects quality and analyzing the man- agement and governance of health care systems and resources.

In his landmark 1966 article,

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.

Notable Publications on the Quality of Health Care by Avedis Donabedian.

PERSPECTIVE

206

donabedian’s lasting framework for health care quality

n engl j med 375;3 nejm.org July 21, 2016

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

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,

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

PERSPECTIVE

207

Donabedian’s Lasting Framework for Health Care Quality

n engl j med 375;3 nejm.org July 21, 2016

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:/ / www .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

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.