Thomas Reinke
Contributing Editor

An elderly man with cancer waited two hours for a scheduled outpatient cystoscopy. When the nurse finally called him in, he asked if the clinic had a patient information sheet that explained the procedure. “Of course we do—I’ll get you one,” she replied, only to return five minutes later saying she couldn’t find one. The man asked if the clinic had a quality assurance committee, and the nurse said yes, but no one paid attention to it.

“Tell the committee Donabedian said they have a problem,” he replied.

The man that health care delivery system was failing was Avedis Donabedian, MD, a University of Michigan professor whose seminal 1966 paper, “Evaluating the Quality of Medical Care,” in The Milbank Foundation Quarterly (today it’s The Milbank Quarterly) had helped launch the field of health care quality measurement. He became known as “Mr. Structure-Process-Outcome” because he had identified those three facets as critical in assessing care.

The father of quality measurement

Avedis Donabedian, MD

Avedis Donabedian, MD, came up with the process-outcome-structure triad that remains the framework for quality measurement in American health care today. Born in Armenia in 1919, he earned his medical degree from American University in Beirut and a master’s degree in public health from Harvard in 1955. He spent most of his career at the University of Michigan. When he died in 2000, he was eulogized as a giant of public health.

Donabedian’s famous 1966 paper (which Milbank Quarterly reprinted in 2005) was based on work commissioned by the U.S. Public Health Service, which asked him to review and summarize the scholarship on quality improvement. The article noted the then-current focus on evaluating outcomes as the quality indicator, then explained in detail that structure and process of care were equally important dimensions that needed to be considered.

Donabedian told that story in a Health Affairs interview a month before his death in 2000. Asked about his experience as a patient, his report was “generally positive” but he had complaints. At one point, he said, his urologist and his nephrologist disagreed on the nature of his malady and the best treatment, so they simply left it up to him. He found the hospital floor “a disaster…[with] so many part-time nurses working variable hours.” In part he blamed “poor training and education,” adding that system management doesn’t get taught in medical and nursing schools, and that well-meaning clinicians suffered from “myopia mixed with ignorance.”

“People have a big problem understanding the relationship between quality and systems,” said Donabedian, arguing that “things won’t improve until something is done about the design of the system.” Were this pioneer to see health care 16 years after his death, some experts believe, it wouldn’t cheer him.

The measures most often used today to assess care quality are process measures. Actual outcomes, of course, are harder to measure than whether a certain action has been taken—checking the feet of a patient with diabetes, for example. But many experts don’t think process measures get at the heart of quality. By themselves they can even be an incentive to overtreat. Donabedian might add that even true outcome measures, prized as the best indicators of quality care, don’t tell the whole story.

The focus on process and outcomes overlooks Donabedian’s insight that the health care system is like any other system. Activities are enabled (and constrained) by the system’s structure and functional capabilities. That means the starting point for improving quality and outcomes should be the health care system’s structure.

“The path to better value depends upon the systems and processes we build to deliver care,” says John Toussaint, MD, of Catalysis.

John Toussaint, MD, founder and CEO of Catalysis, an education company for health care leaders in Appleton, Wis., preaches the Donabedian gospel. He sees a need for fundamental change in the structure of the health care system as a prerequisite for better outcomes and cost control. “The path to better value depends upon the systems and processes we build to deliver care,” he says. “Better value and patient outcomes require a transformation [in the health care delivery system] across all sectors.”

CMS and others have launched an armada of payment reforms, but the way American health care is paid for—a claim is generated by the provider, then paid by the payer—is deeply rooted. “The structure of the delivery system is largely tied to the fee-for-service payment model,” says Toussaint. “As long as that mechanism is in place, the fundamental incentive is to admit more patients or do more tests.”

ACOs might make a difference, but not the present versions, Toussaint believes. CMS payments in all the current models remain, fundamentally, fee for service. One answer, he says, is for CMS to move more rapidly to global payment in the ACO program that is adjusted for risk and geography. Shared savings is just not potent enough, he says, suggesting that global payment could lead to more complete integration of providers—hospitals, physicians, pharmacies, nursing facilities, and others. That integration, he thinks, can dramatically change financial incentives.

Global payment is part of CMS’s Next Generation ACO program. The program’s predecessor, the Pioneer ACO program, saw 19 of its 32 members drop out, including the Dartmouth-Hitchcock Medical Center in New Hampshire, where Elliot Fisher, MD, who dreamed up the ACO idea, is located. Perhaps the Next Generation ACOs will be a different story because of global payment.

Toussaint is talking about structural changes that involve aligning the major building blocks of American health care. But structural changes that generate value can also happen at lower levels.

Judge by teamwork

“A major focus currently is on inter-professional health care teams,” says Don Goldmann, MD, chief science officer at the Institute for Healthcare Improvement (IHI) in Cambridge, Mass., which is credited with coining the phrase Triple Aim. It stresses (1) enhancing patients’ experience, (2) improving population health, and (3) reducing per capita cost. “If you are going to improve quality or reduce cost it has to be a team effort,” he says.

Teams are the focus because of today’s increased emphasis on coordinating care, managing the health of populations, reducing gaps in care, and improving patient engagement. But team-based care has been overlooked in some of CMS’s value-based payment reforms, says Goldmann. He notes, for example, that MACRA’s Quality Payment Program for physicians has no measures of team-based care.

“You cannot parse patients into isolated diagnoses; they must be managed comprehensively,” says Don Goldmann, MD, chief science officer at the Institute for Healthcare Improvement.

Moreover, most measures in the program do not promote a holistic view of patients nor address their individual needs, cultural context, and living conditions, including social determinants of health. Many patients, especially seniors, have multiple health problems. Goldmann says managing multiple conditions sometimes requires setting priorities and making tradeoffs: “You cannot parse patients into isolated diagnoses; they must be managed comprehensively.” The measures in the Quality Payment Program do not accommodate such situations, but rather target specific elements of individual conditions.

Donabedian preached the gospel of system design as the foundation of quality. But he also saw the limits of systems. They may enable clinicians to do their jobs, but whether they actually deliver high-quality care depends on the “ethical dimensions” of the human beings involved. “Doctors and nurses are stewards of something precious,” he said in the Health Affairs interview, contending that “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.”