Evaluating the Quality of Medical Care
Version of Record online: 9 NOV 2005
The Milbank Quarterly
Volume 83, Issue 4, pages 691–729, December 2005
How to Cite
DONABEDIAN, A. (2005), Evaluating the Quality of Medical Care. Milbank Quarterly, 83: 691–729. doi: 10.1111/j.1468-0009.2005.00397.x
- Issue online: 9 NOV 2005
- Version of Record online: 9 NOV 2005
- 1September, 1955 . Approaches to the Quality of Hospital Care . Public Health Reports 70 : 877 – 886 . This paper represents an unusually successful crystallization of thinking concerning the evaluation of quality. It contains brief but remarkably complete discussions of the purposes of evaluation, problems of definition, criteria and standards, various approaches to measurement, the reliability of qualitative judgments and indices of quality. The bibliography is excellent .
- 3January, 1964 . The Teamster Study and the Quality of Medical Care . Inquiry 1 : 69 – 80 . The major value of this paper is that it raises questions concerning methods of assessment including the sampling of populations and diagnostic categories, the use of records and the need for supplementation by interview, the value of detailed standards, the need for understanding the auditing process, the definition of terms and concepts (of “unnecessary admission,” for example), and the problems of defining the relevant episode of care ., and .
- 41933 . The Fundamentals of Good Medical Care . Chicago : University of Chicago Press ., and .
- 61955 . Perinatal Mortality in New York City: Responsible Factors . Cambridge : Harvard University Press . This study, sponsored by the New York Academy of Medicine, was an examination by an expert committee of records pertaining to a representative sample of perinatal deaths in New York City. Preventable deaths were recognized and “responsibility factors” identified, including errors in medical judgment and technique. The incidence of both of these was further related to type of hospital service, type of professional service and type of hospital, indicating relationships between structure and outcome as modified by the characteristics of the population served .
- 10October 13, 1956 . Medical Auditing by Scientific Methods . Journal of the American Medical Association 162 : 646 – 655 . ( Appendices A and B supplied by the author. ) This is perhaps the single best paper that describes the underlying concepts as well as the methods of the highly structured approach developed by Lembcke to audit hospital records. Also included is an example of the remarkable effect that an “external audit” of this kind can have on surgical practice in a hospital.
- 11April, 1962 . Problems in Measurement and Evaluation of Rehabilitation . Archives of Physical Medicine and Rehabilitation 43 : 172 – 181 ., and .
- 131961 . Administrative Behavior , 62 – 66 . New York : The Macmillan Company .
- 151960 . Evaluation of Public Health , 7 – 17 . Report of the Second National Conference on Evaluation in Public Health . Ann Arbor : The University of Michigan, School of Public Health .
- 171954 . The Quality of Medical Care Provided at the Labor Health Institute, St. Louis, Missouri . St. Louis : The Labor Health Institute . This is a good example of an approach to evaluation based on structural characteristics. In this instance, these included the layout and equipment of physical facilities, the competence and stability of medical staff, provisions made for continuity of service centering around a family physician, the scheduling and duration of clinic visits, the content of the initial examination, the degree of emphasis on preventive medicine and the adequacy of the medical records ., and .
- 18December, 1956 . An Analytical Study of North Carolina General Practice: 1953–1954 . The Journal of Medical Education 31 : 1 – 165 , Part 2 . Already a classic, this study is distinguished by more than ordinary attention to methods and rather exhaustive exploration of the relationship between quality ratings and characteristics of physicians, including education training and methods of practice. The findings of this study, and others that have used the same method, raise basic questions about traditional general practice in this and other countries, et al.
- 191963 . The General Practitioner: A Study of Medical Education and Practice in Ontario and Nova Scotia . Toronto : University of Toronto Press , chapters 1, 2, 16, 17 and 18 . Since this study uses the method developed by Peterson, et al., it offers an excellent opportunity to examine the generality of relationships between physician characteristics and quality ratings. In addition, the reader of this elegantly written volume gets a richly detailed view of general practice in the two areas studied .
- 20August 2, 1965 . The Office Practice of Internists, I. The Feasibility of Evaluating Quality of Care . The Journal of the American Medical Association 193 : 371 – 376 . This is the first of a series of papers based on a study of the practice of members of the New York Society of Internal Medicine. This paper reports findings concerning the completeness of office records, their suitability for judging quality and the degree of agreement between abstracts of records prepared by physicians and by highly trained non-physicians. Judgments concerning the quality of care provided are not given. Other papers in this series currently appearing in the Journal of the American Medical Association concern patient load (August 23), characteristics of patients (September 13), professional activities other than care of private patients (October 11), and background and form of practice (November 1) ., et al.
- 22July, 1957 . Quality of Medical Care in Hospitals . American Journal of Public Health 47 : 856 – 865 . This carefully designed comparative study of the quality of care in four hospitals addresses itself to the problems of methods in the assessment of quality. Here one finds important information about the use of normative and empirical standards, reliability and bias in judgments based on chart review, the correlation between defects in recording and defects in practice and homogeneity in quality ratings within and between diagnostic categories .
- 23July, 1951 . The Quality of Medical Care: Methodological Survey of the Medical Groups Associated with the Health Insurance Plan of New York . American Journal of Public Health 41 : 824 – 832 . This is possibly the first published report concerning an administratively instituted, but research oriented, program of studies of the quality of care in medical groups contracting with the Health Insurance Plan of Greater New York. Unfortunately much of this work remains unpublished. A particular feature of this paper is that it describes, and presents the findings of simultaneous evaluation of structure (policies, organization, administration, finances and professional activities) and process (evaluation of a sample of clinical records) .
- 251962 . Character and Effectiveness of Hospital Use in Hospital and Medical Economics , edited by W.J. Mc Nerney , et al. , 495 – 509 . Chicago : Hospital Research and Educational Trust, American Hospital Association ., , and .
- 261964 . A Study of the Quality of Hospital Care Secured by a Sample of Teamster Family Members in New York City . New York : Columbia University, School of Public Health and Administrative Medicine . This study and its companion28 perform a very important social and administrative function by documenting how frequently the care received by members of a union through traditional sources proves to be inadequate. These studies also make a major contribution to understanding the relationships between hospital and physician characteristics and the quality of care they provide. Considered are physician classifications by specialty status and admission privileges, as well as hospital classifications by ownership, medical school affiliation, approval for residency training and accreditation status. The interactional effects of some of these variables are also explored. In addition, the second of the two studies pays considerable attention to questions of method, including representative versus judgmental sampling of hospital admissions and the reliability of record evaluations by different judges ., et al.
- 281962 . The Quantity, Quality and Costs of Medical and Hospital Care Secured by a Sample of Teamster Families in the New York Area . New York : Columbia University, School of Public Health and Administrative Medicine ., , and .
- 29November, 1960 . Physicians Choose Medical Care: A Sociometric Approach to Quality Appraisal . American Journal of Public Health 50 : 1678 – 1686 . This study represents an ingenious approach to evaluation through the use of “peer judgments” in what is believed to be a particularly revealing situation: choice of care for the physician or members of his own family. Some of the characteristics of the physicians and surgeons selected included long-standing personal and professional relationships, recognized specialist status, and medical school affiliation. An incidental pearl of information is that although nine out of ten physicians said everyone should have a personal physician, four out of ten said they had someone whom they considered their personal physician, and only two out of ten had seen their personal physician in the past year!, , and .
- 301962 . The Community General Hospital . New York : The Macmillan Company . The study of quality reported in several chapters of this book is based on the thesis that if one wishes to find out about the quality of care provided, all one might need to do is to ask the persons directly or indirectly involved in the provision of such care. Although physicians may find this notion rather naive, the stability and internal consistency of the findings reported in this study indicate that this approach deserves further careful evaluation. A second study of a nationwide sample of general hospitals will attempt to confirm the validity of respondent opinions by comparing them to selected indices of professional activities in each hospital. The findings will be awaited with great interest ., and .
- 31One of the author's students, Mr. Arnold D. Kaluzny, helped the author to coin this word .
- 341962 . The Test of Diagnostic Skills . Loyola Psychometric Laboratory Publication Number 25 . Chicago : Loyola University Press . This study is of interest because it uses a controlled test situation to study the performance of medical students and physicians. Even more intriguing is the attempt to approach the question of the value or utility of diagnostic actions in a systematic and rigorous manner. While this particular study does not appear to contribute greatly to understanding the quality of care, this general approach appears to be worth pursuing ., , and .
- 35February, 1965 . Assessing Clinical Judgment . Journal of Medical Education 40 : 180 – 187 . This is another example of the assessment of clinical performance using an artificial test situation. The noteworthy aspect of the work is the attachment of certain values (“helpful” or “harmful”) to a set of diagnostic and therapeutic actions and the development of measures of “efficiency,”“proficiency” and “competence” based on which actions are selected by the subject in managing the test case. Differences of performance between individual physicians were detected using this method. An unexpected finding was the absence of systematic differences by age, training or type of practice in groups tested so far .
- 36January, 1956 . Can the Practice of Internal Medicine Be Evaluated? Annals of Internal Medicine 44 : 144 – 161 . The authors discuss the use of indices from which inferences might be drawn concerning the quality of surgical and medical management. The indices described include tissue pathology reports in appendectomies, diabetes patients without blood sugar determinations and without chest x-rays, and pneumonia without chest x-rays. A striking finding reported in this paper, and others based on the same approach, is the tremendous variation by physician and hospital in the occurrence of such indices of “professional activity.”, , and .
- 38October 711, 1963 . An Application of Logic to a Study of Quality of Surgical Care . Paper read at the Fifth IBM Medical Symposium , Endicott , New York . This paper and its companion39 present a fairly complete description of the “logic tree” approach to the evaluation of quality. Examples are given of the logic systems for the Stein-Leventhal Syndrome and uterine fibromyoma. No data are given on empirical findings using this method ., and .
- 39April, 1964 . Diagnostic Performance . In The Diagnostic Process , edited by J.A. Jacquez , 347 – 362 . Ann Arbor : The University of Michigan Press ., and .
- 401963 . A Medical Audit Report . Los Angeles : University of California, School of Public Health ( Mimeographed ). This is an extension of Lembcke's method of medical audit to medical diagnostic categories as well as a large number of surgical operations. Although this volume is a compendium of fairly raw data, careful study can provide insights and limitations of the method used by the author ., and .
- 42The dimensionality of the set of variables incorporating these standards remains to be determined .
- 43December, 1961 . The Quality of Medical Care: Techniques and Investigation in the Outpatient Clinic . Journal of Chronic Diseases 14 : 630 – 642 . This study provides an example of the application of a routine chart review procedure as a check on the quality of management in the outpatient department of a teaching hospital. Fairly often routine procedures were not carried out and abnormalities that were found were not followed up. A revised chart review procedure seemed to make a significant reduction in the percent of abnormalities not followed up ., et al. ,
- 4414 – 15 ., et al. , loc. cit., attempted to get some confirmation of weightings through the procedure of factor analysis. The mathematically sophisticated are referred to their footnote on pp .
- 45August 24, 1964 . Calibration of the Human Instrument . Notes from a Laboratory of Medical Statistics , Number 81 ( Mimeographed ).,
- 46Joint Committee of the Royal College of Obstetricians and Gynecologists and the Population Investigation Committee . 1948 . Maternity in Great Britain . London : Oxford University Press .
- 49Commission on Professional and Hospital Activities . October, 1957 . Medical Audit Study Report 5: Primary Appendectomies . Ann Arbor : The Commission on Professional and Hospital Activities .
- 55October 5, 1964 . Research in Evaluation in Public Health Practices . Paper presented at the 92nd Annual Meeting, American Public Health Association , New York ., et al. ,
- 56Assuming the direct evaluation of process to be the criterion, the issue becomes one of the implications of reliability measures for validity .
- 57January 27, 1950 . Statistics on Clinical Services to New Patients in Medical Groups . Public Health Reports 65 : 99 – 115 . This is an early application to group practice of the analysis of “professional activities” now generally associated with the evaluation of hospital care. The indices used included the recording of diagnosis and treatment, the performance of rectal and vaginal examinations, the performance of certain laboratory examinations and the use of sedatives, stimulants and other medications subject to abuse. As is true of hospitals, the groups varied a great deal with respect to these indicators ., , and .
- 58July, 1954 . Hospital Statistics Don't Tell the Truth . Modern Hospital 83 : 53 – 54 .
- 59Even for hospital care the appropriate unit may include care before and after admission, as well as several hospital admissions.3
- 63February, 1964 . Experimental Studies of Problem Solving . Journal of Medical Education 39 : 212 – 225 .,
- 641957 . Contributions to the Study of the Problem Solving Process , Psychological Monographs 71 .
- 661954 . Some Statistical Relationships between Selected Response Dimensions and Problem-Solving Proficiency . Psychological Monographs 68 ., , and .
- 691964 . Conceptual Models of Diagnosis . In The Diagnostic Process , edited by J.A. Jacquez , 157 – 174 . Ann Arbor : The University of Michigan Press ., and .
- 701965 . Emerging Technologies for Making Decisions . In New Directions in Psychology, II , edited by T.M. Newcomb , 261 – 325 . New York : Holt, Rinchart & Winston, Inc ., , and .