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Assignment Prompt & Instructions

– 2 years ago

**files (5)**

– ## Home-JosieKingFoundation.pdf

– ## Competencies_QSEN.pdf

– ## Donabedian.pdf

– NursesHealthStudy_.pdf
– ArticleonArtificialintelligency.pdf

**## Home-JosieKingFoundation.pdf**

About Josie King Foundation
On February 22, 2001, eighteen-month-old Josie King died from medical errors.

More than 250,000 people die every year from medical errors, making it the third leading cause of

death in the United States.

The Josie King Foundation’s mission is to prevent patients from dying or being harmed by medical

errors. By uniting healthcare providers and consumers, and funding innovative safety programs, we

hope to create a culture of patient safety, together.

U aa

[https://josieking.org/home/](https://josieking.org/home/)

[https://josieking.org/home/](https://josieking.org/home/)

[https://josieking.org/home/](https://josieking.org/home/)

JKF News & Events
Josie King Hero Award: fifth limited edition is here

Thanks to so many amazing Josie King heroes in hospitals around the country, the first through

fourth limited editions of the Josie King Hero Award artwork have sold out. We are pleased to
announce the launch of the fifth limited edition of the Josie King Hero Award. We decided to use the

foundation’s colors of brown, green, and white in this new layout. These colors symbolize safety,

health, security, protection, and support which represent some of our core messages. Like previous

editions, each giclee watercolor print is set in a simple clear block frame. Abstract copy flows across

the washed background – and a thank you message from the Josie King Foundation to the hero
recipient is beautifully printed on the back.

To learn more click here

[https://josieking.org/jkf-tools/josie-king-hero-award](https://josieking.org/jkf-tools/josie-king-hero-award)

Patient Safety 24 years since Josie King died: How far have we come?

Opportunities and challenges were recognized 24 years ago at Hopkins when Josie died. No Room

for Error, an article just released in a special patient safety issue of Dome, a Johns Hopkins
publication marks the fifteen-year anniversary of Josie’s death and the progress and growth in

patient safety ever since.

To read the article, click here.

[https://www.hopkinsmedicine.org/news/articles/no-room-for-error](https://www.hopkinsmedicine.org/news/articles/no-room-for-error)

[https://www.hopkinsmedicine.org/news/articles/no-room-for-error](https://www.hopkinsmedicine.org/news/articles/no-room-for-error)

15 years later

MedStar Health created a new Community HeRO Award. Sorrel was recognized at the MedStar

Health Annual HeRO Luncheon.

To read more click here

Upcoming Speaking Engagements

February 27 – 2025 Virginia Patient Safety Summit – Keynote Speaker – Virtual

[https://educatetheyoung.wordpress.com/2016/02/29/sorrel-king-recognized-at-medstar-health-hero-luncheon/](https://educatetheyoung.wordpress.com/2016/02/29/sorrel-king-recognized-at-medstar-health-hero-luncheon/)

Josie King Foundation creating a culture of patient safety, together | info@josieking.org

 

Josie’s Story, written by Sorrel King, is used as an educational tool in the healthcare industry.

A memoir about Josie, the medical errors that led to her death, the family’s struggles to deal with

their grief, Sorrel’s foray into the health care industry as a patient safety advocate, and the safety
improvements that have come about in Josie’s memory.

More about Josie’s Story

JKF is so happy that Josie’s Story has reached Japan. Thank you to our friends at Eiji Press, Inc. for

doing such a great job in helping us bring her message to Japan and its healthcare industry.

Purchase Japanese copy of Josie’s Story

[mailto:info@josieking.org](mailto:info@josieking.org)

[https://www.facebook.com/JosieKingFoundation/](https://www.facebook.com/JosieKingFoundation/)

[https://twitter.com/JKFfoundation](https://twitter.com/JKFfoundation)

[https://josieking.org/josies-story-the-book](https://josieking.org/josies-story-the-book)

[https://josieking.org/josies-story-the-book](https://josieking.org/josies-story-the-book)

[http://eijipress.co.jp/sp/josie/](http://eijipress.co.jp/sp/josie/)

**## Competencies_QSEN.pdf**

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)

[https://www.qsen.org/](https://www.qsen.org/)

[https://www.qsen.org/](https://www.qsen.org/)

[https://www.qsen.org/about-qsen](https://www.qsen.org/about-qsen)

[https://www.qsen.org/academia](https://www.qsen.org/academia)

[https://www.qsen.org/post/practice](https://www.qsen.org/post/practice)

[https://www.qsen.org/post/resources](https://www.qsen.org/post/resources)

[https://www.qsen.org/publications](https://www.qsen.org/publications)

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

[https://qsen.org/wp-content/uploads/2012/07/QSEN-competencies-compacted-Spanish-I.pdf](https://qsen.org/wp-content/uploads/2012/07/QSEN-competencies-compacted-Spanish-I.pdf)

[https://qsen.org/wp-content/uploads/2012/07/QSEN-competencies-compacted-Spanish-I.pdf](https://qsen.org/wp-content/uploads/2012/07/QSEN-competencies-compacted-Spanish-I.pdf)

[https://www.qsen.org/_files/ugd/c8a414_fb2f549ac45b4cb7a6733861f3b59f6c.pdf](https://www.qsen.org/_files/ugd/c8a414_fb2f549ac45b4cb7a6733861f3b59f6c.pdf)

[https://www.qsen.org/_files/ugd/c8a414_33c685fbcb3745c09a90ef6bb4a6816c.pdf](https://www.qsen.org/_files/ugd/c8a414_33c685fbcb3745c09a90ef6bb4a6816c.pdf)

[https://www.qsen.org/_files/ugd/c8a414_39fe75b1260845a6b05ac4bf57faf93c.pdf](https://www.qsen.org/_files/ugd/c8a414_39fe75b1260845a6b05ac4bf57faf93c.pdf)

[https://www.qsen.org/_files/ugd/c8a414_288e2029ea514b6899d42999e2fa80a0.pdf](https://www.qsen.org/_files/ugd/c8a414_288e2029ea514b6899d42999e2fa80a0.pdf)

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**## Donabedian.pdf**

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.

**NursesHealthStudy_.pdf**

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**ArticleonArtificialintelligency.pdf**

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**ArticleonArtificialintelligency.pdf**

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**## Home-JosieKingFoundation.pdf**

About Josie King Foundation
On February 22, 2001, eighteen-month-old Josie King died from medical errors.

More than 250,000 people die every year from medical errors, making it the third leading cause of

death in the United States.

The Josie King Foundation’s mission is to prevent patients from dying or being harmed by medical

errors. By uniting healthcare providers and consumers, and funding innovative safety programs, we

hope to create a culture of patient safety, together.

U aa

[https://josieking.org/home/](https://josieking.org/home/)

[https://josieking.org/home/](https://josieking.org/home/)

[https://josieking.org/home/](https://josieking.org/home/)

JKF News & Events
Josie King Hero Award: fifth limited edition is here

Thanks to so many amazing Josie King heroes in hospitals around the country, the first through

fourth limited editions of the Josie King Hero Award artwork have sold out. We are pleased to
announce the launch of the fifth limited edition of the Josie King Hero Award. We decided to use the

foundation’s colors of brown, green, and white in this new layout. These colors symbolize safety,

health, security, protection, and support which represent some of our core messages. Like previous

editions, each giclee watercolor print is set in a simple clear block frame. Abstract copy flows across

the washed background – and a thank you message from the Josie King Foundation to the hero
recipient is beautifully printed on the back.

To learn more click here

[https://josieking.org/jkf-tools/josie-king-hero-award](https://josieking.org/jkf-tools/josie-king-hero-award)

Patient Safety 24 years since Josie King died: How far have we come?

Opportunities and challenges were recognized 24 years ago at Hopkins when Josie died. No Room

for Error, an article just released in a special patient safety issue of Dome, a Johns Hopkins
publication marks the fifteen-year anniversary of Josie’s death and the progress and growth in

patient safety ever since.

To read the article, click here.

[https://www.hopkinsmedicine.org/news/articles/no-room-for-error](https://www.hopkinsmedicine.org/news/articles/no-room-for-error)

[https://www.hopkinsmedicine.org/news/articles/no-room-for-error](https://www.hopkinsmedicine.org/news/articles/no-room-for-error)

15 years later

MedStar Health created a new Community HeRO Award. Sorrel was recognized at the MedStar

Health Annual HeRO Luncheon.

To read more click here

Upcoming Speaking Engagements

February 27 – 2025 Virginia Patient Safety Summit – Keynote Speaker – Virtual

[https://educatetheyoung.wordpress.com/2016/02/29/sorrel-king-recognized-at-medstar-health-hero-luncheon/](https://educatetheyoung.wordpress.com/2016/02/29/sorrel-king-recognized-at-medstar-health-hero-luncheon/)

Josie King Foundation creating a culture of patient safety, together | info@josieking.org

 

Josie’s Story, written by Sorrel King, is used as an educational tool in the healthcare industry.

A memoir about Josie, the medical errors that led to her death, the family’s struggles to deal with

their grief, Sorrel’s foray into the health care industry as a patient safety advocate, and the safety
improvements that have come about in Josie’s memory.

More about Josie’s Story

JKF is so happy that Josie’s Story has reached Japan. Thank you to our friends at Eiji Press, Inc. for

doing such a great job in helping us bring her message to Japan and its healthcare industry.

Purchase Japanese copy of Josie’s Story

[mailto:info@josieking.org](mailto:info@josieking.org)

[https://www.facebook.com/JosieKingFoundation/](https://www.facebook.com/JosieKingFoundation/)

[https://twitter.com/JKFfoundation](https://twitter.com/JKFfoundation)

[https://josieking.org/josies-story-the-book](https://josieking.org/josies-story-the-book)

[https://josieking.org/josies-story-the-book](https://josieking.org/josies-story-the-book)

[http://eijipress.co.jp/sp/josie/](http://eijipress.co.jp/sp/josie/)

**## Competencies_QSEN.pdf**

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)

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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

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**## Donabedian.pdf**

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.

**NursesHealthStudy_.pdf**

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**ArticleonArtificialintelligency.pdf**

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**## Home-JosieKingFoundation.pdf**

About Josie King Foundation
On February 22, 2001, eighteen-month-old Josie King died from medical errors.

More than 250,000 people die every year from medical errors, making it the third leading cause of

death in the United States.

The Josie King Foundation’s mission is to prevent patients from dying or being harmed by medical

errors. By uniting healthcare providers and consumers, and funding innovative safety programs, we

hope to create a culture of patient safety, together.

U aa

[https://josieking.org/home/](https://josieking.org/home/)

[https://josieking.org/home/](https://josieking.org/home/)

[https://josieking.org/home/](https://josieking.org/home/)

JKF News & Events
Josie King Hero Award: fifth limited edition is here

Thanks to so many amazing Josie King heroes in hospitals around the country, the first through

fourth limited editions of the Josie King Hero Award artwork have sold out. We are pleased to
announce the launch of the fifth limited edition of the Josie King Hero Award. We decided to use the

foundation’s colors of brown, green, and white in this new layout. These colors symbolize safety,

health, security, protection, and support which represent some of our core messages. Like previous

editions, each giclee watercolor print is set in a simple clear block frame. Abstract copy flows across

the washed background – and a thank you message from the Josie King Foundation to the hero
recipient is beautifully printed on the back.

To learn more click here

[https://josieking.org/jkf-tools/josie-king-hero-award](https://josieking.org/jkf-tools/josie-king-hero-award)

Patient Safety 24 years since Josie King died: How far have we come?

Opportunities and challenges were recognized 24 years ago at Hopkins when Josie died. No Room

for Error, an article just released in a special patient safety issue of Dome, a Johns Hopkins
publication marks the fifteen-year anniversary of Josie’s death and the progress and growth in

patient safety ever since.

To read the article, click here.

[https://www.hopkinsmedicine.org/news/articles/no-room-for-error](https://www.hopkinsmedicine.org/news/articles/no-room-for-error)

[https://www.hopkinsmedicine.org/news/articles/no-room-for-error](https://www.hopkinsmedicine.org/news/articles/no-room-for-error)

15 years later

MedStar Health created a new Community HeRO Award. Sorrel was recognized at the MedStar

Health Annual HeRO Luncheon.

To read more click here

Upcoming Speaking Engagements

February 27 – 2025 Virginia Patient Safety Summit – Keynote Speaker – Virtual

[https://educatetheyoung.wordpress.com/2016/02/29/sorrel-king-recognized-at-medstar-health-hero-luncheon/](https://educatetheyoung.wordpress.com/2016/02/29/sorrel-king-recognized-at-medstar-health-hero-luncheon/)

Josie King Foundation creating a culture of patient safety, together | info@josieking.org

 

Josie’s Story, written by Sorrel King, is used as an educational tool in the healthcare industry.

A memoir about Josie, the medical errors that led to her death, the family’s struggles to deal with

their grief, Sorrel’s foray into the health care industry as a patient safety advocate, and the safety
improvements that have come about in Josie’s memory.

More about Josie’s Story

JKF is so happy that Josie’s Story has reached Japan. Thank you to our friends at Eiji Press, Inc. for

doing such a great job in helping us bring her message to Japan and its healthcare industry.

Purchase Japanese copy of Josie’s Story

[mailto:info@josieking.org](mailto:info@josieking.org)

[https://www.facebook.com/JosieKingFoundation/](https://www.facebook.com/JosieKingFoundation/)

[https://twitter.com/JKFfoundation](https://twitter.com/JKFfoundation)

[https://josieking.org/josies-story-the-book](https://josieking.org/josies-story-the-book)

[https://josieking.org/josies-story-the-book](https://josieking.org/josies-story-the-book)

[http://eijipress.co.jp/sp/josie/](http://eijipress.co.jp/sp/josie/)

**## Competencies_QSEN.pdf**

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)

[https://www.qsen.org/](https://www.qsen.org/)

[https://www.qsen.org/](https://www.qsen.org/)

[https://www.qsen.org/about-qsen](https://www.qsen.org/about-qsen)

[https://www.qsen.org/academia](https://www.qsen.org/academia)

[https://www.qsen.org/post/practice](https://www.qsen.org/post/practice)

[https://www.qsen.org/post/resources](https://www.qsen.org/post/resources)

[https://www.qsen.org/publications](https://www.qsen.org/publications)

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

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**## Donabedian.pdf**

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.

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