la eficacia de la garantía de calidad

8/19/2019 La Eficacia de La Garantía de Calidad

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Pergamon

International Journal for Quality in Health Care

VoL 8 , No. 4 , pp . 401-40 7,1996

Copyright © 1996 Av tdii D ona bedi ui, Published by Eljevier Science Ltd. All righti reserved

Printed in Great Britain

1353-4505/96 15 .00+0.00

The Effectiveness of Quality Assurance

AVEDIS DONABEDIAN

The organizers of this conference intended,

from the very first, to adopt as its theme: "The

Impact of Quality Interventions in Health Ca re"

and, indeed, we have heard the strains of this

theme in its many variations, like the enticing

notes of a magic flute, all these many d ays.

What more appropriate ending to the con-

ference I thought, when asked to be your fare-

well speaker, than a few parting words about

"The Effectiveness of Quahty Assuran ce". W hat

easier, I went on to th ink, since this is a subject I

have studied and written about during the more

than thirty years of my professional life

[1,2].

How hasty I was How reckless How foolish

Soon you shall see why.

As the enormity of my task sank in, I stripped

it to its bare essentials. I shall speak, I decided,

only about one form of quality assurance: that

which consists of obtaining information about

performance and, based on an analysis of

performance in any given situation, leads to

modification in behavior: directly, through edu-

cational and motivational activities, and indir-

ectly, through adjustments in system design.

Furthermore, I would have in mind, I decided,

only clinical care, lopping off all othe r aspects of

organizational performance less central to the

patient-practitioner transaction.

But even when so restricted, the subject

presents some serious difficulties: in definition,

in conceptualization, in documentation, and in

presentation.

"Effectiveness"

is

itself no simple

concept.

It is

to be visualized as a process in a series of steps:

introduction; implantation; implementation;

modification in behavior; and finally, conse-

quent progress toward health and health-related

objectives. It is likely that many of the factors

that influence the effectiveness of quahty assur-

ance act continuously throughout this progres-

sion. 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. A t 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 rever-

beration 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 seg-

ments such as the professional and administra-

tive. 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 effec-

tively it will be implem ented.

The large number of quality assurance inter-

ventions, 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 loca-

tions, during short periods of time. There are

very few controlled studies. For example, of the

more than

6 000

reports on continuing educa-

tion gathered by Davis and associates, only 99

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


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4

A. Donabcdian

were deemed worthy of further analysis. Of

these, only two thirds reported a change in

behavior, and even fewer spoke of changes in

outcomes. Furthermore, the changes observed

were often limited to a few of the process and

outcome variables studied, they were small,

difficult to quantify, and of indeterminate clin-

ical significance [3].

Even rare r t han well-designed studies of single

interventions are assessments of variants of such

methods. Rarer still, to the point of non-

existence, are studies that set out to test compet-

ing, theory-based strategies of quality assurance.

To present this empirical material, even after

rigorous pru ning, w ould be impossible in a talk

such as this and if presented, it would lead to the

almost foregone conclusion that: every reason-

ably established method in the armamentarium

of quality assurance has been shown to work in

some situations. Precertification and second-

opinions work. Reminders, feedback, profiling,

benchm arking, guidelines, protocols, indicators,

detailing, continuing education in its various

forms—they all work. Quality circles, quality

improvement teams and similar group efforts

work. Financial incentives work; professional

incentives too. So do regulatory interventions,

administrative controls and professional inter-

ventions. They all work. Yet no one method is

demonstrably superior in every situation, or in

most.

One response to this uncertainty is to use a

combination of methods, hoping that a cumu-

lative effect, or even a synergy, may emerge.

Fortunately, the methods at hand do fall into

reasonable constellations or sequences that

promise mutual reinforcement. Guidelines,

feedback, professional persuasion and continu-

ing education form one such sequence. There

could also be an interaction between external

regulatory requirements and internal adminis-

trative or professional initiatives—an interac-

tion that is mutually supportive rather than

antagonistic.

Another response to the current uncertainty

in choosing what method is best is to postulate

that effectiveness depends not on the method

alone, but on an interaction between the

method and the situation in which it is to be

implemented. One looks, therefore, for a kind

of fit between method and situation. The study

of effectiveness becomes, then, a study of

contexts, and the interventions appropriate to

each of these.

In such a study a theory of effectiveness would

help, but I know of no such theory. There are,

rather, many theories and many competing

perspectives. The health care enterprise may be

seen as

a

culture, or a set of cultures, to which the

quality assurance effort must adapt, or which

may have to

be

modified if quality assurance

is

to

flourish. Or the health care enterprise may be

seen, in a somewhat related fash ion, as a system

of social interactions in which the example,

approval and support of significant others

govern behavior. Therefore, it is to this network

of social exchanges that quality assurance must

be linked [4]. Alternatively, the health care

enterprise is endowed with a considerable

degree of rationality, so that information and

knowledge rule and it is through these that

quality assurance must act [5]. Or, perhaps,

behavior in the health care system is rational in

still another w ay, tha t of self-seeking calc ulation,

the advantages sought being econom ic, social, or

professional. Quality assurance must, therefore,

aim to contribute to these interests or, at least,

not to harm them. Contrariwise, behavior in the

health care system may not be as rational as one

would like to believe. R ather , it may be governed

in part by a variety of psychological and

emotional needs, aspirations, and fears [6]. Or,

possibly, the health care system is a network of

communications, vertical and horizontal; or it is

a system of power relationships, or superordina-

tion and subordination; or it is all of the

aforementioned and other things besides.

In the absence of

a

unifying theory, one takes

refuge in eclectic formulations that draw on

several perspectives. The most dominant of

these formulations today goes under the name

of "total quality management" or some variant

of it.

I have before me two reports. One is of an

effort to reduce mortality from coronary artery

bypass surgery in several States in Northern

New England. It flies the banner of "TQM",

uses its concepts and methods, speaks its

language—and it succeeds. In this case, as in

many others, TQM w orks [7].

The second enterprise, this one in not too-far-

away New York State, has the same objectives,

but it is conceived and operated by a govern-

mental agency with awsome powers of retribu-


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The effectiveness of quality as surance

4 3

tion, held in check, but unmistakable. It is

traditional, pragmatic. TQM is beyond its ken.

Yet, it also works—at least as well, perhaps

better

[8].

Can one make sense of all this? Do you see,

now, the problem I have faced?

Fortunately, despite all the uncertainties I

have portrayed, there are certain themes that

run constantly throughout the literature on

"effectiveness", themes partly founded on

empirical evidence, partly on theory-based

expectations, and partly on informed specula-

tion. It is to these themes that I now turn.

To introduce a t least a semblance of order into

my presentation, I shall divide these themes,

rather arbitrarily, into "Contextual" and

"Operational".

The context subsumes the general properties

of the situation into which quality assurance is

to be introduced and in which it is to operate.

These properties may support or handicap

quality assurance, or they may only support it

in some forms, under restricted conditions.

Among the contextual factors, one encounters

at the onset, the notion of "culture", which

includes what one believes and values, how

reality is seen and interpreted, how one is to

behave and how things are to be done. All

these are manifested in how important quality

is regarded to be, how it is defined, who is to

be responsible for it, and through what

mechanisms. The role of government is critical

to these matters, as is the role of the health

professions, of the organizations that finance

and provide care and of consumers, in associa-

tion or individually.

In a step down from the more general to the

more particular, one often speaks of the culture

within an organization—the microcosm where

the issues I have just mentioned come into play.

It is often said that some forms of quality

assurance amount to a "thought revolution",

one that requires a corresponding cultural

change. Some features of that change appear in

the clear assum ption of responsibility for quality

in the highest reaches of an organization, the

diffusion of that responsibility throu gho ut all its

parts and layers, a corresponding empowerment

of personnel and a less authoritarian form of

governance. Furthermore, organizations are

distinguished into some that resist change and

others that seek to learn, are ready to strike out

in new directions, willing to take justifiable

risks

[9].

What is not clear is how the appropriate

cultural change is to be achieved. Perhaps it

occurs, partly, through the play of external

forces: such as governmental pressure, profes-

sional aspirations, consumer demand, the play

of market forces, and so on. All these imply a

manifest or subtle threat to the organization; it

must a dapt o r possibly perish.

Perhaps the factor most often mentioned as a

feature of

a

culture, as well as a m odifier of

it

is

leadership: leadership in every sphere of a society

and every level of an organization. The chief

executive is a leader; so is the head of a clinical

unit; so is a manager; so m ust be som eone in the

quality improvement team.

Leadership is often associated with positions

of authority; the ability to exercise authority, to

influence careers, to reward or censure, is an

important adjunct to it, even if kept in the

background. Power relationships are a factor

not to be ignored in the adoption and c onduct of

quality assurance. But other attributes of leader-

ship matter equally, if not more: the ability to

persuade, to motivate, to inspire trust, to set a

personal example of commitment to and perso-

nal participation in the quality assurance enter-

prise. Furtherm ore, mo st clinicians would like to

see in charge of the quality assurance a pparatu s

one of their own; a clinician senior

in

rank and of

unquestioned competence.

In part, this preference is related to still

another contextual factor, that of sponsorship.

In clinical practice, sponsorship by the relevant

professional association (of physicians, nurses,

and so on) confers legitimacy on the quality

assurance effort as a whole, and more so on the

particular guidelines and criteria that pertain to

the details of clinical work. It is a resource

assiduously to be sought.

Both leadership and sponsorship imply an

underlying structure of socially organized rela-

tionships. In addition to these, formal organiza-

tion of the health care enterprise is an almost

necessary requirement for the institution and

operation of quality assurance activities. Formal

organizations provide the arena within which

cultural change takes place and where leadership

is exercised. They have the m eans to set the goals

of performance, to investigate success or failure,

to identify causative factors and to take appro-


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4 4

A. Donabedian

priate action. Within organizations, the

networks of informal communication and inter-

personal influence are concentrated and poten-

tiated, offering thereby a ready vehicle for the

processes of quality assurance. When the orga-

nizational nexus is underdeveloped, or virtually

absent, as in the private practice of ambulatory

care, some new organizational structure, formal

or informal, is usually needed to allow physi-

cians to recruit resources, develop expertise, and

offer mutual support in the effort to improve

performance [10].

Let me now turn to my second category:

namely, the "ope rati ona l" factors that influence

effectiveness. To help me present these in some

order, I shall assume, guided by more general

models of health behavior, a rather crude

progress ion of steps, as follows [11].

(1) There is a demonstrable, consequential,

legitimate need.

(2) Something can be done to meet the need.

(3) Tha t w hich will be done, or is done, is the

right thing, done in the right way.

(4) There are demonstrable, useful results,

free of unforeseen, harmful consequences.

I shall go through these steps in order.

1. There

is a

demonstrable, consequential

legitimate need

The awareness of need may derive, as I have

already im plied, from the play of external forces,

or it may be self-generated, or the two may

interact. But, no ma tter how prom pted, the need

must be regarded as important and clinically

relevant. Often, a reasonable first step is an

organized effort, through group discussion, to

identify needs, and set them in an agreed-upon

order of priority. In general, trivialization is

deadly, but sometimes one must seize upon

something relatively unim portant that a clinical

unit wishes to have done, hoping in that way to

demonstrate the potential of the quality assur-

ance enterprise to help and to succeed.

In order to be demonstrable and credible,

what

is

needful m ust be documented w ith data—

data of unimpeachable provenance and quality.

Moreover, the inference to be drawn from the

data must, themselves, be persuasive and com-

pelling. Compariso ns m ay be made with norma-

tive standards of acceptable legitimacy, either

professionally approved or self-generated. Parti-

cipation in the formulation of such guidelines

and standards is said to enhance compliance. It

is said, moreover, that comparison with the

actual performance of peers or of similar

institutions tends to be more compelling, and

some believe that setting precise, measurable

goals in advance, especially concerning out-

comes of care, is powerfully motivating, if the

goals fail to be achieved [12,13].

The manner of presenting data is also im por-

tant. More effective than written transmittal is

the opportunity to explain and discuss the

findings and their interpretation, and even more

so if individual performance is discussed in

private with a trusted and respected senior

colleague [14].

A genuine conviction that performance needs

to be improved is the indispensable first step in

the process of quality assurance.

2.

Something can be done to meet the need

What should follow upon a conviction that

something needs to be improved is at least a

reasonable expectation tha t improvement can be

made. Loosely, this falls under the now pop ular,

even alluring, rubric of "e mpo werm ent".

Empowerment applies at all levels in an

organization: executive, managerial and opera-

tional. It applies, in particular, to the quality

assurance directorate. This is empowered by the

appointment of a chief of considerable stature

and authority, who belongs in the highest

reaches of an organization, where one can

participate in and influence, all decisions that

significantly impinge on quality. The directorate

is also empowered by having at its disposal the

necessary resources: human and material. These

include the requisite varieties and levels of

expertise. They also include time. Nothing

vitiates a quality assurance enterprise, revealing

its marginality in an organization, m ore than its

being delegated to persons of relatively little

authority, or conducted as an add-on to existing

responsibilities, in one's own free time.

These observations apply, as well, to groups

or teams that undertake, or are asked to under-

take, quality improvement tasks. Quality

flourishes if everyone is alert to op portunities to

improve it, can communicate these, can suggest

how improvements are to be made, and can

expect serious consideration, leading to action,


5/9

The

effectiveness of quality assurance

405

where appropriate. T hus, one fosters a sense of

optimism, even of adventure,

in an

organization.

If

not

one can expect cynicism

at

first,

and

later

an apathetic resignation

in

those

who

remain,

while the best depart.

The necessary next step, therefore,

is

that

action

be

taken

but not any

action, only actions

that

are

reasonable

and

approved.

3.

That which will be done,

or is

done,

is the

right

thing, done

in the

right

way

Expectations of what interventions, what

disturbances

in the

accustomed life

of an

organization, quality assurance

is

likely

to

make,

are

perhaps

the

major determinant

of

how warmly

it is

likely

to be

received when

proposed,

or how

obstinately opposed. Later,

the very first actions taken can justify what

was

hoped for or either confirm or begin to allay the

fears that almost

any

change

in the

established

order

is

certain

to

arouse.

At

every step, there-

after, with each

new

undertaking,

the

need

to

gain approval recurs, except that past events,

one hopes, have gradually built

up

trust,

and

fostered

an

inclination

to

cooperate.

Much of what makes qu ality assurance inter-

ventions acceptable can be m ade to fall under the

rubric of "congruence" , which

is

the degree

of fit

between the interventions envisaged, and what I

earlier called "culture":

the

culture

of the

organization

as a

whole

or of the

subcultures

of its parts—amon g

the

latter, that of the health

care professions being the m ost compelling.

At

the

very least, one aim s

for a

compatibility

with professional ideals, or better still, a

reinforcem ent of these.

A

clear commitment

to

quality,

as

professionals understand

the

term,

rather than cost-saving mainly,

is a

necessary

bond. So is the resolve to advance the welfare of

patients,

to

reinforce professional responsibility,

and

to

serve

the

need

for

professionals

to

know,

and continue to learn. It helps if what is

proposed

is

familiar

in

rationale

and

method.

It

is less disturbing

if the

concepts

and

methods

of

quality assurance

are

seen

to

resemble those

of

the scientific method, which professionals

respect, or

of

clinical problem -solving,

in

which

they

are

daily engaged. If could

be

disturbing

to

ask professionals to adopt concepts and meth-

ods ostensibly borrowed from

the

industrial

sector.

And it is

unnecessary

to do so

since

service

to

patients

is a

compelling professional

goal, the model of governance proposed is an

established feature

of

professional life,

and the

methods

to

be em ployed

are

largely ep idem iolo-

gical, with some compatible extensions [15].

In most cases,

it is

best,

it

seems

to me to

emphasize continuities rathe r than disjunctions,

where possible extending quality assurance

activities already present

in

many health care

institutions.

But

that principle does

not

hold

if

what already exists is, itself externally imposed,

discordant, discredited,

and

demonstrably

inef-

fective. It

is

better, then,

to

offer

as

a replacement

not another unfamiliar incursion, but rather, a

return

to the

purer, more authentic traditions

of

the health care professions.

Much of what seems new

in

quality assurance

is,

in fact, eminently traditional. Professionals

wish

to

monitor their

own

work,

led by one of

their

own

whom they trust

and

respect. They

prefer

to

study patterns

of

performance rather

than to search for individual miscreants. They

would much rather look

for

causes

of

failure

in

underlying processes

and

structure, than

in

professional malfeasance. If

there

are failures in

knowledge, judgme nt,

or

skill, they would want

these

to be

corrected

by

education

and

retrain-

ing,

not

punishment. Furthermore, education

would be more effective if specifically directed at

discrete, verified needs, cond ucted

in

person

by

respected colleagues,

and

reinforced, where

possible, by individual consultation and advice.

All this is persuant to congruence with

professional norms.

But it

also serves

a

second

principle, that

of

"ownership". Professional

sponsorship and leadership are one prerequisite

to ownership. And so

is

personal participation in

the quality assurance enterprise:

in

setting

its

goals, in

constructing

its

criteria

and

standards,

in carrying out its processes and, w here possible,

implementing

the

changes that

it

prescribes.

Through "ownership", two other related

principles

are

also served. These are "relev ance"

and " utility". The purposes and consequences

of

quality assurance m ust be

relevant o

the life

and

work of those who engage in it or are to be

consumers,

so to

speak,

of its

findings

and

consequences.

It

operates

in the

domains these

consumers recognize as their own where they

work, where they exercise responsibility, where

they can bring about change. Ideally,

the

quality

assurance enterprise will

do

what

its

consumers


6/9

406

A. Donabedian

would want to see done in the first place,

generate information they would like to have,

aim for effects they would want to

see realized.

In

short, it is useful.

Sometimes, quality assurance is useful in

solving discrete problems that have troubled a

clinical unit. At other times, it serves individual

aspirations, for example by revealing and

rewarding meritorious performance, otherwise

unnoticed. Sometimes, an entire profession,

nursing for example, is offered new opportu-

nities for person al self-expression and g rowth, as

well as an avenue to professional recognition—

even power. Whenever such utilities are man-

ifest, participation in quality assurance is not

only welcomed, it is avidly sought.

To summarize, the quality assurance enter-

prise, if it is to flourish, should conform to the

cultural imperatives of those it wishes to

influence. But quality assurance is also a force

capable, of itself to bring about a gradual

change in that c ulture, so that, in time, a greater

congruence can emerge. Therefore, the quality

assurance enterprise must

be

in for the long haul.

It must be persistent, consistent, meticulously

fair, and it must show results.

4. There are

demonstrable,

u seful results, free o f

unforeseen, harmful consequences

The credibility of the quality assurance enter-

prise hinges on one thing above all else; that

something is done as a consequence of its

activities, and tha t this something is demonstra-

bly useful. L et me call this, somew hat fancifully,

the principle of "fruition".

What could be more persuasive than to

experience, first hand, the benefits of quality

assurance? What could more demonstrably

confirm an organization's commitment to it?

On the contra ry, wh at could be more destructive

to the entire effort than to observe that quality

assurance is a tissue of ostentatious pronounce-

ments, or merely busy-work: onerous, boring,

unrewarding and useless.

Even worse, would be to experience the

undesirable consequences that one has feared

from the start, among them: dilution of profes-

sional responsibility, distortion of professional

judgment, stereotyping of practice, discourage-

ment of innovation, legal hazard and an ambi-

ence of fearfulness that leads to resistance,

evasion, concealment and ultimate demoraliza-

tion.

These dire prognostications are most often, of

course, only the hobgoblins summoned forth by

the timid, or the merely manipulative, to justify

opposition to legitimate quality assurance initia-

tives. But, sad experience has also shown that,

under perverse forms of intervention, such fears

can materialize. Therefore, at every step, they

are assiduously to be guarded against.

It is now time to end, but on a more hopeful

note.

To my mind, the most important single

condition for success in quality assurance is the

determination to make it work. If we are truly

committed to quality, almost any reasonable

method will work. If we are not, the most

elegantly constructed of mechanisms will fail.

We shall leave this place, I know, determined

to hold the stewardship of quality as a sacred

trust. Once again, we dedicate ourselves to that

high calling.

It is also fitting that, as we leave this city, we

offer thanks for its hospitality, and pray earn-

estly for peace to reign within it. Permit me,

therefore, to do so now , in the words of the sweet

psalmist himself first as he spoke, and then in

translation [16]:

tofia,

ftec

Pray for the peace of Jeru-

salem they shall prosper that

love thee.

Peace be w ithin th y wa lls ,

and prosperi ty within thy

palaces.

For my bre thren and com-

panions ' sakes, I wil l now say,

Peace

be

wi thin thee .

Because of the house of the

LORD OUT God I will seek th y

good.

And now, dear friends, farewell—and God

bless u s all.


7/9

The effectiveness of quality assurance 4 7

Acknowledgements:

I wish to thank Dr. Richard

Baker who no t only helped m e locate references but,

also,

by sharing his own ideas, shaped some of my

thinking as well.

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American Public Health Association, 1969. See

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A Donabedian and G J Povar, Striving for

quality in health

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and medical audit: general practitioners' per-

ceived obstacles and requirements. British Jour-

nal of

General Practice 1995; 45: 548-552.

11.

Becker M H, Editor, The Health Belief Model

an d Personal Health

Behavior.

Health Education

Mon ograph, Volume 11: 324-508, 1974.

12. Williamson J W, Evaluating quality of patient

care:

a strategy relating outcome and process

assessment. Journal of the American Medical

ssociation 1971; 218: 564-569.

13. Grimshaw J e t al. Developing and implementing

clinical practice guidelines. Quality in Health

Care 1995; 4: 55-64.

14.

Eisenberg J M, Changing physicians' practice

patterns. Part II, pages 87-142 in Eisenberg,

Doctors Decisions a nd the Cost of Medical Care.

Ann Arbor: Health Administration Press, 1986.

15. Donabedian A, Continuity and Change in the

quest for quality. Clinical Performance and

Quality Health Care 1993; 1: 9-1 6.

16. Psalm 122, verses 6-9.


8/9

Pergamon

iHlmatiomUoumalfor Qm iXj f Htetth Cart VoL 9, No. 4, pp. 311-312,199

O 1997 Hjevfer Sconce Ltd. All

righu

naencd

Printed in Gnat Briuin

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 :43-53.

It is regretted that errors were made in Table 3 of the- above article. The corrected table is as follows:

TABLE 3. Respondents experience of tbelr personal contact with nursing staff. Comparisons between 1993 (n -131) and

1994 n - 1 2 8 ) as measured by the Mum-Whitney U-test

( )

Often Quite often Seldom No t at all p-value

99 993 993 993

994 994 994 994

Anxiety before examination/treatm.

Experience of em barrassment

Anxiety regarding professional secrecy

Needing someone to talk to without finding anyone

There is someone to talk to abo ut the examin./treatm.

There is someone to talk to about their personal

situation •

10.2

10.3

1.6

0.9

1.6

1.7

0.8

0.9

60.9

54.3

41.6

38.1

15.0

22.2 '

1.7

0.8

2.5

2.4

3.4

25.2

29.3

17.6

17.7

29.1

32.5

11.2

11.3

4.7

5.9

18.1

23.9

12.2

12.9

3.2

6.2

45.7

35.0

87.2

86.1

92.9

89.8

78.7

71.8

1.6

3.5

4.0

3.5

0.1

0.8

0.4

0.2

0.3

0.9

D not applicable

993

= 33.6%;

994

=

34.5%

Internal drop-out 1-10 respondents

11-15 respondents

311


9/9

312 Errata

ERRATUM

A. Donabedian: The Effectiveness of Quality Assurance.

Int J Qual Health are

8:401-407.

It is regretted that in publishing the above article, a passage of text was inadvertently printed upside-

down. The publishers would Uke to apologise for any embarrassment this error may have caused to

Professor D onab edian , and for any inconvenience to readers of the Journal. The correct version of the

text is given below:

The English translation is as follows:

Pray for the peace of Jeru-

salem.

:

they shall prosper that

love thee.

Peace be within thy walls ,

and prosperity within thy

For my brethren and com-

panions sakes, I will now say,

Peace be within thee.

Because of the house of the

L O R D our God I will seek th y

good.

la eficacia de la garantía de calidad

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