Prof. Avedis Donabedian, M.D.

最近上「健康方案評估」的課程，讀到及討論到許多醫療品質的議題。在談醫療品質時，有一位學者的見解是一定會被一再提到的，這位學者是Avedis Donabedian。

Avedis Donabedian教授曾是密西根大學公衛學院醫務行政研究所的終生職榮譽教授，在台灣可能他的名字不是很讓大家熟悉，可是醫界受他的影響卻是很深遠的，現在我們將醫療品質的衡量分成結構面、過程面與結果面這三類指標的概念，就是由他在1966年首先提出來的，美國及台灣的醫院評鑑也都依照這樣的架構在發展與改進。

我第一次聽到Donabedian，是從門諾醫院醫療副院長陳清義醫師的一次有關醫療品質的演講，他引用Donabedian教授的話：「我相信品質的奧秘就是愛心，去熱愛我們的專業，關愛別人以及敬愛上帝。」這段話當時給我很大的震憾，心想為什麼有人可以用這麼簡潔的話，將品質的真諦表達得如此貼切、深入與崇高？他是怎樣的一個人？這個問題一直到我四年前到密西根大學進修時才獲得解答。

進修時有一門課老師用Donabedian一本著作”Aspects of Medical Care Administration”的一章，討論醫療行政的社會價值觀，我才知道原來Donabedian教授曾在我們系上任教，可是他已經在2000年底過世，享年81歲。Donabedian教授是亞美尼亞人(位於歐亞交界山區，是全世界第一個基督教國家，曾經被土耳其及蘇聯統治，1991年從蘇聯獨立成為一個共和國)，在黎巴嫩出生，完成醫學院教育，成為醫生，並曾擔任黎巴嫩美國大學的教職，後來移民美國，在哈佛取得公共衛生碩士學位，之後分別在哈佛大學及密西根大學任教，並曾獲選為IOM的院士。他的著作很豐富，前面所提的”Aspects of Medical Care Administration”於1973年出版，是一本醫務行政的古典著作，內容紮實。後來他一直專研醫療品質的研究、教學與發表，應該可以說是第一位有系統且深入探討及介紹醫療品質的概念與實務的學者，因此他的想法廣被引用，奠定後來相關領域發展的基礎。

在Donabedian教授罹患癌症的末期，他的學生及好友希望他再完成一本著作，因此他在癌症末期完成最後一本書”An Introduction to Quality Assurance in Health Care”，做為他留給世人的最後贈禮，這本書也可以說是他畢生對醫療品質的體認與投入成果的總結。在這本提獻給他的苦難的同胞亞美尼亞人的書中，可以感受到他對醫療品質的熱愛與對後輩的期許。陳副院長所引用的那一句話，就在本書的結語(Some Concluding Remarks[1])中，這段代表Donabedian教授的告別詞很讓人感動，他一再與讀者分享，在運用書中所介紹的種種有關醫療品質的想法與方法之前，我們先要具有對醫療品質的承諾(commitment)，同時在改善醫療服務系統與流程以提升醫療品質時，我們的決心(will)是來自於盼望，相信只要我們願意，任何醫療品質的阻礙都可以被克服。對醫療品質的承諾與決心，他曾經認為是來自專業的自我期許與成就感或社會責任的道德要求，但是在他生命即將結束之前，他體認到對醫療品質的承諾與決心是來自宗教信仰當中的愛心。我覺得這段話有很深的涵義，我自己非常喜歡，因此把它抄錄下來，與大家分享：

Some Concluding Remarks

Performance monitoring and readjustment, the subject upon which I have lavished so much attention in this work, does not in and of itself create a commitment to quality; it only serves that commitment. A genuine, persistent, unshakable resolve to advance quality must come first. If that is present, almost any reasonable method for advancing quality will succeed. If the commitment to quality is absent, even the most sophisticated methods will fail.

Some, acutely aware of the ineradicable presence of human fallibility, have put their faith in redesigning the processes of care in ways that substitute technology for human decisions and actions. It is a worthy and useful approach. But to design and implement such modifications requires the prior commitment to quality that I have already emphasized. Besides, there is a limit to how far this process of “mechanization” can be taken.

Another approach to improving the quality of care is to redesign the system of care itself in ways that channel patients, depending on what they suffer from, to the most appropriate and most highly qualified source of care in a regional system of institutions. This, too, is useful and, in some cases, necessary. But even in the most specialized institutions, the need for monitoring and readjustment will remain.

That the pursuit of quality depends ultimately on human will has been, for me, a source of hope rather despair. It is exhilarating, even ennobling, to believe that every obstacle to good care can be removed or circumvented if only we were ardently to wish it.

I have looked in many places for the source of the commitment that would bring about such dedication to quality. I have seen it in professional values and traditions. It is implicit in the contract between the professions and society—a contract that confers privileges on the former in return for responsibilities toward the latter. I have wished to see it in each practitioner’s need for the respect of colleagues and the gratitude of patients; in the quest for acceptance, for success, for the joy in virtuosity. Often I have cast the commitment to quality in moral terms, preferring to see it as the ethical imperative that must govern the conduct of all caregivers.

More recently, as I contemplate the imminent end of my every activity, a religious, a transcendent element has crept into my thinking. The secret of quality, I wish to believe, is love: love of one’s profession, love of one’s fellow man, and love of God.

I cannot, of course, impose any of my own feelings and beliefs upon the reader. I can only hope that each reader of these pages will extract from them what seems most pertinent and useful and, perhaps, go away strengthened and inspired.

And now, farewell.

[1] In Avedis Donabedian, 2003, An Introduction to Quality Assurance in Health Care (Ed. Rashid Bashshur), Oxford University Press: New York, pp.137-138.