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International Journal for Quality in Health Care, VoL 8, No. 4, pp. 401-407,1996
Copyright 1996 Avtdii Donabediui, Published by Eljevier Science Ltd. All righti reserved
Printed in Great Britain
1353-4505/96 $15.00+0.00
AVEDIS DONABEDIAN
Presented on May 30th, 1996, at the Closing Ceremony of the 13th International Conference of the IntcrnationaJ Society for
Quality in Health Care, Jerusalem. The author reserves copyright.
401
ance act continuously throughout this progression. It is also likely that at each stage some
factors are more influential than others, and that
at some points new factors emerge to become
critical. For example, early in the progression,
the nature of the intervention and the receptivity
to it are dominant factors. At the transition from
behaviors to outcomes, the ability to harness
most effectively the technology of health care is
the more critical variable. Yet, what comes
before prefigures what is to come later; and
anticipation of what is to come influences what
happens at preceding steps.
A similar pattern of modulation and reverberation runs through the many layers of the
health care system. At the most general level,
there are the societal factors that surround,
shape, and profoundly influence the functioning
of the health care enterprise. That enterprise is
itself differentiated into layers and segments:
layers such as the institution, the department,
the work group, and the individual, and segments such as the professional and administrative. At each of these levels and in each of these
segments, distinctive forces may influence
whether or not quahty assurance will be
adopted, the form it will take, and how effectively it will be implemented.
The large number of quality assurance interventions, separately and in combination, add
another set of complexities to the task at hand.
So does the imperfect state of our knowledge
about the effects of these interventions. True
enough, there is an extensive literature to draw
upon. But much of it is anecdotal; it merely
describes what was done, and what seemed to
have been accomplished, only in specific locations, during short periods of time. There are
very few controlled studies. For example, of the
more than 6,000 reports on continuing education gathered by Davis and associates, only 99
402
A. Donabcdian
403
404
A. Donabedian
405
406
tofia, ftec
A. Donabedian
REFERENCES
1. Donabedian A, A guide to medical care administration, Volume 11, Medical care Appraisal.
American Public Health Association, 1969. See
pages 116-121 on "Implementation", and pages
122-151 on "Effectiveness".
2. Donabedian A, The effectiveness of quality
assurance. Part II, pages 59-128 in R H Palmer,
A Donabedian and G J Povar, Striving for
quality in health care: an inquiry into policy and
practice, Ann Arbor: Health Administration
Press, 1991.
3. Davis D A, Thomson M A, Oxman A D and
Haynes B, Changing physician performance: a
systematic review of the effect of continuing
medical education strategies. Journal of the American Medical Association 1995; 274: 700-705.
4. Mittman B S, Tonesk X and Jacobson P D,
Implementing clinical guidelines: social influence
strategies and practitioner behavior change.
Quality Review Bulletin 1992: 18: 413-422.
5. Batalden P and Stoltz P K, A framework for
' continued improvement of health care: building
and applying professional and improvement
knowledge to test changes in daily work. Joint
Commission Journal of Quality Improvement
1995; 19: 424-^52.
6. Robertson N, Baker R and Hearnshaw H,
407
Pergamon
ERRATA
B. Ottosson, I. R. HaDberg, K. Axebson and L. Loven: Patients Satisfaction with Surgical Care Impaired by Cuts in
Expenditure and After Interventions to Improve Nursing Care at a Surgical Clinic. Int J Qual Health Care 9:43-53.
It is regretted that errors were made in Table 3 of the- above article. The corrected table is as follows:
Often
1993
1994
Seldom
1993
1994
Not at all
1993
1994
p-value
10.2
10.3
15.0
22.2 '
29.1
32.5
45.7
35.0
0.1
1.6
0.9
11.2
11.3
87.2
86.1
0.8
1.7
1.6
1.7
0.8
2.5
4.7
5.9
92.9
89.8
0.4
0.8
0.9
2.4
3.4
18.1
23.9
78.7
71.8
0.2
60.9
54.3
25.2
29.3
12.2
12.9
1.6
3.5
0.3
41.6
38.1
17.6
17.7
3.2
6.2
4.0
3.5
0.9
Experience of embarrassment
Quite often
1993
1994
311
TABLE 3. Respondents' experience of tbelr personal contact with nursing staff. Comparisons between 1993 (n -131) and
1994 (n -128) as measured by the Mum-Whitney U-test (%)
312
Errata
ERRATUM
A. Donabedian: The Effectiveness of Quality Assurance. Int J Qual Health Care 8:401-407.
It is regretted that in publishing the above article, a passage of text was inadvertently printed upsidedown. The publishers would Uke to apologise for any embarrassment this error may have caused to
Professor Donabedian, and for any inconvenience to readers of the Journal. The correct version of the
text is given below: