It’s been nearly 20 years since the death of Avedis Donabedian, MD, MPH, the general practitioner and public health scholar who has been referred to as the father of quality measurement in health care,1 but the impact of his work has perhaps never been more keenly felt by physicians. Donabedian’s conceptual framework for assessing the quality of health care delivery in terms of structure, process, and outcome, his seven pillars of health care quality, and his understanding of the connection between quality and systems of care are foundational to the quality initiatives that pervade today’s medical practice.2 Yet, at the end of his life, just prior to his death from prostate cancer, Donabedian expressed that improving quality takes more than just systems thinking: “Ultimately, the secret of quality is love. You have to love your patients, you have to love your profession, you have to love your god.”3
Remembering Donabedian’s quote on Valentine’s Day, when I started writing this piece, it seemed particularly meaningful in connection with several of this issue’s articles. Providing Medicare wellness visits can help close care gaps and facilitate quality reporting and may also pay off in terms of relative value units and payment (see our cover story), but of course not all services do. For example, screening for adverse childhood experiences (ACEs) such as abuse or neglect may result in higher-quality care (see our article on ACEs), but it will not improve the bottom line of your practice.
In fact, like the growing number of screenings that family physicians are encouraged to provide, screening for ACEs is hard work. It requires sensitive, careful communication with patients; a systematic, efficient approach to collecting, documenting, and remembering patients’ histories; and appropriate referrals and follow-up. Choosing to screen for ACEs requires tapping into the altruism that may have attracted you to patient care in the first place. Cultivating this sense of purpose is vital because, as Donabedian knew and as our article on intrinsic motivation reminds us, external motivators have their limits.