Quality informatics

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Defining Quality Health Care

In order for Quality Informatics to address the quality of health care, it is necessary to first define the phrase "quality health care". The father of health quality assurance, Avedis Donabedian said that high quality health care consisted of "that kind of care which is expected to maximize an inclusive measure of patient welfare, after one has taken account of the balance of expected gains and losses that attend the process of care in all its parts." (Donabedian, A. 1980)

The American Medical Association described high quality health care as that "which consistently contributes to improvement or maintenance of the quality and/or duration of life." (AMA, 1986)

Lohr and her committee were tasked by the IOM to define quality health care and their definition was "the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge." (Lohr, 1990)

The fact that multiple definitions of health care quality exist is an indication that this is a very complex subject to try to define in a few phrases. Donabedian further described attributes of quality health care, which he called the "Seven Pillars of Quality":

1. Efficacy: the ability of care, at its best, to improve health;

2. Effectiveness: the degree to which attainable health improvements are realized;

3. Efficiency: the ability to obtain the greatest health improvement at the lowest cost;

4. Optimality: the most advantageous balancing of costs and benefits;

5. Acceptability: conformity to patient preferences regarding accessibility, the patient-practitioner relation, the amenities, the effects of care, and the cost of care;

6. Legitimacy: conformity to social preferences concerning all of the above; and

7. Equity: fairness in the distribution of care and its effects on health. (Donabedian, 1990)

In a similar fashion, Maxwell defined the six dimensions of quality health care:

1. Access to services

2. Relevance to need (for the whole community)

3. Effectiveness (for individual patients)

4. Equity (fairness)

5. Social Acceptability

6. Efficiency and Economy (Maxwell, 1984)

With multiple dimensions and attributes ascribed to quality health care, it is of note that physicians themselves tend to judge the quality of care on the basis of the technical sophistication of the health care delivered, and placed an emphasis on the quality of the interaction between the physician and the patient.(Blumenthal, 1996)

What Measurements to Assess?

The many descriptions and factors involved in producing quality health care makes it difficult to determine which of these attributes or characteristics should be assessed? A seemingly natural candidate for measurement. After all, outcomes are usually not debatable when considering whether a patient lived or died, recovered, or remained impaired. Because outcomes are rarely subject to interpretation, measurement of outcomes is considered to be desirable. (Donabedian, 1966)

However, there are limitations to studying treatment outcomes. The application of medical science to a problem may or may not result in the best outcome for that patient. A patient may not receive all of the benefits that were anticipated for a treatment. In addition, measuring the patient as being among the survivors for a given condition can lead to faulty assumptions if the person survived, but otherwise severely impaired. The measurement of the outcome of survival alone would not produce reliable information. (Donabedian, 1966)

Some treatment outcomes take years to come to fruition, which may not be taken into account at the time that the quality assessments are being made. Multiple non-medical factors may also influence outcome. When assessing outcomes it is necessary to make sure that the non-medical impacts are accounted for, holding as many external variables constant as possible. (Donabedian, 1966)


1. Donabedian A. Explorations in quality assessment and monitoring. Vol. 1. The definition of quality and approaches to its assessment. Ann Arbor, Mich.: Health Administration Press, 1980.

2. American Medical Association, Council of Medical Service. Quality of care. JAMA 1986;256:1032-1034.

3. Lohr KN, ed. Medicare: a strategy for quality assurance. Washington, D.C.: National Academy Press, 1990.

4. Donabedian, A. (1990). "The seven pillars of quality." Archives of Pathology & Laboratory Medicine 114(11): 1115.

5. Maxwell, R. (1984). "Quality assessment in health." British Medical Journal 288(6428): 1470-1.

6. Donabedian, A. (1969). "Quality of care: problems of measurement. II. Some issues in evaluating the quality of nursing care." American Journal of Public Health 59(10): 1833.

7. Larson, J. S. and A. Muller (2002). Managing the Quality of Health Care. Journal of Health & Human Services Administration, Southern Public Administration Education Foundation. 25: 261-280.

8. Blumenthal, D. (1996). "Quality of Care--What is It?-Part One of Six." New England Journal of Medicine 335(12): 891.

9. Donabedian, A. (1966). "Evaluating the quality of medical care." The Milbank Memorial Fund Quarterly 44(3): 166-206.