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Entre autonomia e controle do cuidado médico: uma compreensão histórico-crítica da noção de qualidade na Avaliação em Saúde

Between autonomy and control of medical care: a historical-critical understanding of the notion of quality in Health Assessment

Entre la autonomía y el controle de la atención médica: una comprensión histórico-crítica de la noción de calidad en la Evaluación en Salud

Max Felipe Vianna Gasparini
Escola Nacional de Saúde Pública Sergio Arouca, ENSP
Fundação Oswaldo Cruz, FIOCRUZ
maxgasparini89@gmail.com
https://orcid.org/0000-0002-5574-9719

Wagner Yoshizaki Oda
Universidade Federal de São Paulo, UNIFESP
wagner.oda@gmail.com
https://orcid.org/0000-0002-3043-6396

Fábio Ramos Barbosa Filho
Universidade Federal do Rio Grande do Sul, UFRGS
fabioramosbf@gmail.com
https://orcid.org/0000-0002-0966-4669

Juarez Pereira Furtado
Universidade Federal de São Paulo, UNIFESP
juarezpfurtado@gmail.com
https://orcid.org/0000-0001-6605-1925

RESUMO
A Avaliação em Saúde no Brasil no âmbito da Saúde Coletiva tem se constituído enquanto uma prática plural, desde suas escolhas metodológicas até seus enfoques e objetos. No entanto, há cânones que determinam as formas de pensar e praticar a Avaliação em Saúde no país, e cuja influência é produtora de sentidos dominantes na área, sendo o mais reconhecido entre eles o médico Avedis Donabedian. Partindo de uma inquietação teórica acerca do lugar reservado à concepção de qualidade do autor, empreendemos uma análise de seu texto seminal, publicado em 1966, à luz dos aportes teóricos da Epistemologia Histórica e da Filosofia e Análise de Discurso materialista. Como resultado, pudemos compreender esta produção a partir das determinações históricas de seu tempo e espaço, cujos sentidos expressam disputas entre a autonomia médica e a exigência do controle de qualidade exercido pelas instituições de saúde no contexto estadunidense. Tal compreensão implica em uma concepção de qualidade que reflete contradições e disputas de poder, o que nos permite interpretar a formulação de qualidade de Donabedian a partir de uma formação discursiva específica. Com este artigo defendemos um gesto de leitura crítica para os conceitos mobilizados pela Avaliação em Saúde a partir do funcionamento ideológico de seu discurso, que naturaliza e descontextualiza conceitos historicamente determinados.
Palavras chaves: Avaliação em Saúde; Qualidade; Saúde Coletiva; Epistemologia; Discurso.

ABSTRACT

Health assessment in Brazil in public health has constituted itself as a plural practice from its methodological choices to its approaches and objects. However, canons determine the ways of thinking and practicing health assessment in the country, the most recognized of which being that of physician Avedis Donabedian. Starting from a theoretical concern about the place reserved for the author’s conception of quality, we analyzed his seminal text from 1966 considering the theoretical contributions of historical epistemology and philosophy and analysis of materialist discourse. Thus, we were able to understand this production based on the historical determinations of its time and space, the meanings of which express disputes between medical autonomy and the demand for quality control exercised by health institutions in the United States. This understanding implies a concept of quality that reflects contradictions and power struggles, which enables us to interpret Donabedian’s formulation of quality from a specific discursive formation. This study defends a gesture of critical reading for the concepts mobilized by health assessment based on the ideological functioning of its discourse, which naturalizes and decontextualizes historically determined concepts.
Keywords: Health Assessment; Quality; Collective Health; Epistemology; Discourse.

RESUMEN
La Evaluación en Salud en Brasil en la Salud Pública se ha consolidado como una práctica plural, desde sus elecciones metodológicas hasta sus enfoques y objetos. Sin embargo, existen cánones que determinan las formas de pensar y practicar la Evaluación en Salud en el país, siendo el más reconocido entre ellos el médico Avedis Donabedian. Partiendo de una preocupación teórica sobre el lugar reservado a la concepción de calidad del autor, emprendemos un análisis de su texto seminal, publicado en 1966, a la luz de los aportes teóricos de la Epistemología Histórica, la Filosofía Materialista y el Análisis del Discurso. Como resultado, pudimos comprender esta producción a partir de las determinaciones históricas de su tiempo y espacio, cuyos significados expresan disputas entre la autonomía médica y la exigencia de control de calidad ejercida por las instituciones de salud en el contexto estadounidense. Esta comprensión implica una concepción de la calidad que refleja contradicciones y luchas de poder, lo que nos permite interpretar la formulación de la calidad de Donabedian desde una formación discursiva específica. Con este artículo defendemos un gesto de lectura crítica de los conceptos movilizados por la Evaluación en Salud a partir del funcionamiento ideológico de su discurso, que naturaliza y descontextualiza conceptos históricamente determinados.
Palabras clave: Evaluación de salud; Calidad; Salud colectiva; Epistemología; Discurso.

Introduction
Health assessment practices and formulations in Brazil is known for its several approaches, methods, focuses, and criteria 1, 2. Since its structuring and recognition as a social subspace of collective health with a relative planning autonomy in the relationship between the academic, bureaucratic, and political fields3, the plural practice of health assessment refers to its types of evaluated interventions (most often policies, programs, services, and technologies)4. Despite such eclecticism, the practice suffers the strong influence from Avedis Donabedian’s quality assessment model.
Donabedian’s influence, based on his published seminal article from 19665 emerges in a publication from 1990, in which Reis et al.6 state that most studies at the time cited or were based on Donabedian’s model. Portela7 points to that article as a “milestone” for the development of the area, whereas, for Silva and Formigli8, the author’s classification of possible approaches to health assessment constituted the most successful production on the subject in the period.
To Vuori9, Donabedian was a pioneer in dividing the care process according to the dimensions of structure, process, and results. Carnuti and Narvai10 state that the author’s model stands as the most popular methodology to evaluate health services. Furtado et al.11 also highlight the author’s importance for the consolidation of Brazilian collective health assessments.
Starting from a theoretical concern about the discourse that constitutes the concepts mobilized by health assessment in Brazil12 and the prominence of Donabedian’s model of the practices and formulations in such assessments, this study aims to analyze the notion of quality in Donabedian’s seminal 1966 study—a materialistic reading gesture12 toward Donabedian’s notion of quality based on the discursive context in which it was written13,14.
This study analyzes the concept of quality in health assessment based on Donabedian’s evident statements (replicated in the literature on evaluation) or on its transparency of meaning toward a theoretical understanding of its meaning15.
Theoretical approach
We assume that the effect of transparency of the discourse about the concept of quality in the technical-scientific formulation of assessments occurs based on the ideological functioning of discourse15. This study understands ideology based on the work of the French-Algerian philosopher Louis Althusser (1918-1990), who deems it as the symbolic-imaginary mediation between individuals interpellated as subjects16. The imaginary reality fails to correspond to objective material reality or the real as the former constitutes a repository of meanings lived and experienced by subjects as if they were the real. Thus, subjects “forget” that they result from a process, conceiving themselves as an original cause, a source of themselves and the senses. In Althusser, the concept of ideology is no longer associated with a negative form of concealment of the real as a mechanism of alienation that mechanically separates true essence from false appearance, constituting such concept as that which produces the subjects and the senses, an imaginary way of relating to the real16.
Althusser17 divides the theoretical discourse that seeks to produce knowledge about an object into two modalities: that which addresses real-concrete objects and those referring to formal-abstract objects. The former is oriented toward tangible and circumscribed objects, such as the analysis of a given historical context; whereas the theoretical discourse on abstract formal objects analyzes principles, theories, and concepts17. Without slipping into the traps of empiricism, which only accepts real-concrete objects; theoretical analysis crosses and uses these two types of objects in a dialectic that presupposes their interrelation.
Based on the contribution of a materialist epistemology toward the ideological functioning of the technical-scientific statements and understanding the theoretical component of our investigation, we analyzed concepts to build theoretical knowledge about the discourse of health assessment.
Concept analysis
Historical epistemology18 differs from the reasoning of traditional epistemology19, which deems the history of science as a linear succession of discoveries. This assumption contributed to basing most analyses of the history of science on scientific chronicles that privilege rational justifications for ideological theses proposed and defended by the tradition of idealist philosophy19,20.
In turn, historical epistemology guides us to approach scientific statements from the concepts that sustain their practices and that link universal statements (theories) and the historical materiality that enables scientists to constitute the objects that make up reality18. Based on this framework, the history of a given scientific discipline, such as health assessment, is based on understanding the conceptual context and the objectives around it that make up its effects of meaning. We consider evaluation as a scientific discipline because it is recognized as such within the legitimate knowledge production practices of endorsing institutions (which differs from admitting that it actually produces knowledge).
Articulating the notion taken as a concept of quality in Donabedian’s health assessment (deeming it, from the outset, as an abstract-formal object) enables us to work on more objects, including other evaluated concepts and real-concrete objects from a theoretical contribution. Using these approaches to analyze our object is based on the recognition that every concept is correlated to a problem that gives rise to it and stems from a specific section of the power relations of a society that, when approached theoretically, enables us to know its mechanism of production of meanings16,20. We will seek to understand the relations of meaning constituted around the notion of quality in health assessment in Avedis Donabedian’s seminal text.
Analysis
Placing interpellated subjects in their historical conjuncture
Donabedian’s vast work (eight books and over 50 articles) includes his 1966 seminal text5 “Evaluating the quality of medical care,” in which he establishes what has been declared to be the “dominant paradigm” to evaluate health care quality21.
This article is based on a literature review of methodological approaches to evaluate medical care quality at the level of the doctor-patient relationship. The author’s analysis included neither “community-level” medical care5 nor “administrative aspects of quality control”5 (p. 166). Donabedian emphasizes this circumscription to its object, the quality of medical care, remaining, as he says, “[…] familiar territory of care provided by physicians”5. (p.166).
This excerpt inscribes the author in a medical discursive training on the evaluation of clinical care quality, situating it in the “professional model” 22, an approach that proposes ways to address the control, responsibility, production, and financing of care. In this model, medical professionals exercise quality control, organizing and controlling their work based on standardized peer evaluation22.
Boaden et al.23 call this discursive formation centered on the medical profession an “artisanal approach,” in which quality control exclusively depends on the “craftsman” skills of physicians in controlling and applying the best techniques of the profession. This association between medicine and art gives this discursive formation a sense of autonomy to determine the criteria for adequate medical care. Schraiber24 categorizes this discourse as liberal medicine, which was strengthened throughout the 19th century, marked by the practice of small private producers in the private practice space. For this author, liberal medicine constitutes the practice that implies the full exercise of subjectivity, which, from a technical perspective, results in a social and political-ideological position that gives physicians exclusive authority over health and the process of illness in scientific and moral terms24.
By distancing himself from the “community” level of medical care and the “administrative” aspects of quality control, Donabedian joins a very influential tradition in quality issues (those arising from the positions of the medical corporation, which emerged in the USA in the 1910s)22,23. The Flexner report, published in this period25, greatly influenced medical education. This famous report evaluated 155 medical schools in the US and Canada, consolidated an evaluation model focused on medical specialists’ experience, and associated quality of care with the good training from educational institutions that regulated good practices, determining the “distribution of the workforce, the performance of health services, and eventually the state of people’s health”26 (p.495). In a discursive training liberal medicine in practice and in teaching and the absence of state regulations on the profession, private agencies and institutions (philanthropic or otherwise) took the role of regulating and standardizing medical practice and its quality in the USA together with medical corporation representatives. The Flexner report pioneered the standardization practices of medical education in this period and of quality of care based on the trust of influential specialists following the discourse of the professional model of quality control. The agency that promoted and funded Flexner’s study (the Carnegie Foundation, founded in 1906) emerged as a philanthropic and liberal institution that sought to standardize and define standards for the educational sector at the elementary, secondary, and higher levels in the USA. It enjoyed a wide capacity to interfere in reforms in these sectors, as proven by the reach of the Flexner report over the following decades in subsidizing broad and deep reforms in medical education within and outside the USA26.
This historical context of the rise of the professional model to standardize medical care quality—strongly influenced by initiatives of medical corporations in the USA—developed the “final result system for hospital standardization” (proposed by surgeon Ernest Amory Codman in 1913 on the foundation of the American College of Surgeons)27. Based on the American College of Surgeons accreditation performance and its standardization norms (the first of which dates to 1919), the Joint Commission on Accreditation of Hospitals is founded in 1951 (later called the Joint Commission on Accreditation of Healthcare Organizations Hospitals, given the increased scope of its action)6. The USA later endorsed the initiatives of these foundations and representatives of medical corporations as accreditors of the quality and standardization of hospitals so they can act in public health care programs (such as Medicare and Medicad) from 1965 onward28. In the 1970s, the Joint Commission on Accreditation of Hospitals accreditation became mandatory to certify hospitals that wanted to participate in state programs22.
Thus, such initiatives were decisive to define the quality criteria the US State apparatus (responsible for quality control and hospital standardization and, thus, of medical care) began to use. In other words, we can take such initiatives as events13 since its effects take shape to the extent that they can be understood by their relationship with liberal medical discursive education.
If we have been able up to this moment to understand the production conditions of the support for liberal medical discursive training for quality assessment practices, it is necessary to dialectically consider that the discursive context in which Donabedian writes his seminal article included rapid changes in the organization of hospital medical services in the USA, which affected his concept of quality. This period included the emergence of new medical technologies, the expansion and variety of services, and the entry of other healthcare providers, which constitute the bureaucratic model for medical care organization from the 1960s to 1970s22. Such model, inscribed in a specific discursive formation, changed the professional model of quality control. According to Grahan22, this process implied important modifications in the medical care provision logic, as per the change in lexicon, such as the disuse of the word “patients” for “beneficiaries” and from “doctors” to “providers” or “vendors.” Grahan22 also states that the bureaucratic model to organize the supply and control of the quality of health care generated criticism and resistance from medical corporations, which alleged loss of professional autonomy due to bureaucratic institution evaluations. Such statement follows Schraiber’s argument24 about the transition from liberal to technological medicine.
Thus, in a context in which the discourse about the quality of medical care is intertwined with hospital accreditation practices amidst changes in health institutions and in the tension between the professional and bureaucratic models, Donabedian positions himself based on his professional insertion as a physician. Such positioning—which places the interests of the medical profession and its ideals of freedom in a contradictory (tense but conciliatory) relationship, on the one hand, and the effects of the new institutional arrangements stemming from the reorganization of medical work within hospitals in a bureaucratic model, on the other—configures a technical-political struggle to preserve autonomy; retaining the control of the norms that standardize and regulate practices despite no longer having full control of the work given the regulatory institutional arrangements of the health service supply market, hierarchies, and the incorporation of technologies.
(Un)certainty of the notion of quality
Donabedian states that the value judgment of medical care process components determine quality and that such elements stem from the goals and values in force in an institutional context of medical care and in society5. The choices about which criteria and dimensions will be judged to define the quality of medical care are decisive to choose the evaluation method to be used, defining the properties of the concept of quality. Donabedian concludes that it is impossible to understand quality in isolation, which is only feasible based on the relationship between criteria, values, judgments, and context.
Although the topic of his article refers to the definition of quality, the author offers no explicit definition. Some attempts at conceptual elaboration in his article produce a sense of vagueness, complexity, and variability, even indicating a confusion about the way the author understands quality, sometimes as a concept, sometimes as a “notion”: “[…] quality of care is a remarkably difficult notion to define”5 (p. 167). At the same time, he offers an exhaustive explanation, including the strong expression “are nothing more than,” which defines quality for the properties of medical care rather than for its own sake, which in turn serve as quality criteria.
[…] These “articles” convey vividly the impression that the criteria of quality are nothing more than value judgments that are applied to several aspects, properties, ingredients or dimensions of a process called medical care. (Donabedian, p. 167, emphasis added)

The excerpt above sees quality criteria as synonymous with value judgments applied to properties of the medical care process, associating the act of evaluating (value judgments) with quality criteria, so that the criteria themselves would already configure pre-defined value judgments, which equates criteria to established norms already endowed with previous value. However, Donabedian starts by observing the limits of investigations regarding the dimensions and values that define quality based on the variation of moments and scenarios, as in the excerpt below:
Few empirical studies delve into what the relevant dimensions and values are at any given time in a given setting (Ibid., p. 167).

He proceeds to elaborate his notion of quality by pointing out its diversity in terms of criteria, finding no possibility of determining a single parameter to measure quality (again directly associating quality with evaluation):
[…] it seems likely that there will never be a single comprehensive criterion by which to measure the quality of patient care (Ibid., pp. 167, emphasis added)

Thus, rather than a definition, an indication that quality rather depends on a set of values and norms that precede it and that delimit the properties of the medical care process (and on other external factors). The author’s elaboration that concludes the brief topic on the definition of quality expresses a relationship of dependence between the concept of quality and selected dimensions and criteria, which, in turn, will determine the method to evaluate medical care:
Which of a multitude of possible dimensions and criteria are selected to define quality will, of course, have profound influence on the approaches and methods one employs in the assessment of medical care. (Ibid., p. 167, emphasis added).

In other words, Donabedian’s concept of quality, taken in its transparency of meaning, depends on criteria chosen from infinite possibilities that, in turn, will define the methodological approach to evaluation. This introduction of the methodological aspect attempts to define the concept of quality, which points to the author’s concern to associate the notion of quality with possible methods for its measurement. Here we have, in a first analysis, a concept that is neither closed in on itself nor has its own properties, depending on the type of normativity that regulates and defines adequate medical care.
In Donabedian’s first effort to focus on the concept of quality, what we read is precisely the inexistence of a concept itself, that is, no system of invariable operative norms to understand it; on the contrary, what we read is close to what Canguilhem defines as an “etiquette” since it is stretched almost indefinitely, unlike the concept18. Quality emerges as a general notion that encompasses and, in some way, gathers a construct of the properties of the medical care process, that is, a construction of which the meaning stems not from itself but from its particles. The function and meaning that the author seeks to determine for his notion of quality is not evident, no matter how much it is described as such; rather, it is dependent and variable in relation what the author calls dimensions and properties, even in a descriptive perspective of medical practice and the criteria, thus taking an evaluative perspective as the criteria in themselves constitute parts of the act of judgment or assessment.
We could reconstruct Donabedian’s conceptualization of quality in his seminal article as a cycle of definitions that, rather than defining a tautology, emphasizes its complex, variable, and rhetorical nature since he states, albeit provocatively, that “quality may be almost anything anyone wishes it to be”5 (p. 167).
So far, Donabedian’s statements describe a hermetic cycle of, rather than definitions, approximations with the problematic way in which quality has been treated until then. To illustrate such a cycle we call definitions that do not define and the return to a true circular semantic platitude, we have the following:
Figure 1

In his attempt to broadly conceptualize quality based on its complexity, the redundancy of statements, rather than conceptualizing quality, points out precisely the difficulty in doing so. However, when we observe that quality consists of the sum of criteria to assess medical care and that such criteria are seen as synonymous with evaluation, the definition of quality emanates from an instance prior to the assessment or to the very notion of quality. Quality would comprise what medical standardization defines as criteria of adequate conduct, that is, it precedes quality and the evaluation itself, the value criteria of which the medical technical knowledge had predominantly determined. What we have stated about the tension between the struggle for autonomy and adequacy for its preservation seems to find a safe place in the definition of the criteria to assess medical care quality.
Donabedian’s seminal text critiques the contemporary use of the notion of quality, which the author seeks to revise an explanation of its limits. This first digression, in his article, about the lack of a precise conceptualization of quality stems from the recomposition of a very mobilized but little conceptualized or empirically tested term, that is, a definite problem precedes the concept that, in turn, produces the possibility conditions for the concept. Hence a relationship of effects of meaning and event13: the effort to conceptualize quality (effect) precedes the retrieval of the larger problem (event) that seems to mobilize the author in that discursive formation. It consists of defining assessment criteria for the self-regulation of the medical profession as a strategy to preserve its autonomy in the face of the demands of a context that imposes the standardization of the quality of medical services in market institutions based on external pressures.
The notion of quality in a synonymous relationship with efficacy
Donabedian5 offers possible ways to evaluate medical care in the topic called: “Approaches to Assessment: What to Assess” (p. 167). The relationship the author establishes between quality and results of medical care is the first to produce meaning for the concept of quality; in it, quality medical care would equate to patients’ best results, such as their recovery, restoration of healthy states, and survival.
Starting from a position that denounces the insufficiency of the relationship between quality and results (especially by arguing about the complexity of establishing causality between the provision of medical care in complex contexts and of defining precise indicators of results), Donabedian establishes a first relationship of meaning that enables us to better understand his conception (in its transparency of meanings) about quality: “[…] although outcomes might indicate good or bad care in the aggregate, they do not give an insight into the nature and location of the deficiencies or strengths to which the outcome might be attributed.”5 (p. 169, emphasis added).
In this excerpt, Donabedian opposes the conceptualization of quality as only positive results, that is, quality cannot be conceptualized only from the achievement of the results of medical care, such as what is defended in the first quality control proposals proposed by Codman27 and its model of “end result system of hospital standardization.”
The author starts by denying the contemporary sense of quality (in association with better results) to establish his understanding, contradictorily building a direct relationship between quality of medical care, results, and efficacy: “Outcomes, by and large, remain the ultimate validators of the effectiveness and quality of medical care.”5 (p. 169, emphasis added). His argument begins by criticizing how the result dimension fails to signify the concept of quality and measure it and ends by validating this logic (that is, the one that would determine effectiveness). We emphasize the term “ultimate validators” (meaning superior or ultimately more appropriate validators) in the passage above. We are faced with a relationship of contradictory signification since it starts from a criticism to then reinforce such a statement.
The dimension Donabedian calls process of care (an approach to evaluate quality) also stands out as a way of constituting the meaning of his notion of quality. The process-centered approach consists of an analysis of the adequacy of the application of available medical knowledge for care during service. Based on this perspective, the criteria to judge the value of medical care quality would involve the good application of techniques and methods from medical science (such as the most effective means to collect information on clinical history, requests for exams, technical competence in diagnoses and therapeutic procedures) and other aspects that would characterize an adequate care process. The adequacy of the medical care process is linked to normative criteria that delimit what is considered most appropriate to medical conduct, which is why the author emphasizes that this “approach requires that a great deal of attention be given to specifying the relevant dimensions, values and standards to be used in assessment.”5 (p. 169).
In a development that better characterizes the origin, nature, and intentionality of these dimensions, values, and standards (which the beginning of his article fails to evidence), Donabedian explains the source for the normativity that “fulfills” the notion of quality and that constitute technical references with “legitimate” competence and knowledge accepted in the context of dominant health care systems:
Normative standards derive, in principle, from the sources that legitimately set the standards of knowledge and practice in the dominant medical care system. In practice, they are set by standard textbooks or publications, panels of physicians, highly qualified practitioners who serve as judges26 or a research staff in consultation with qualified practitioners. (Ibid., pp. 177, emphasis added)

We could elaborate the following paraphrases for the underlined passage: (1) “There exist sources that legitimately establish the standards of knowledge”; (1.1) “Knowledge standards are legitimately established by sources”; (2) “There exist sources that legitimately establish the standards of practice in the dominant health care system”; (2.1) “Standards of practice are legitimately established by sources.” Since such paraphrases are possible, it would be feasible to ask: what “establishes” the “sources?”
The sources that define the normative standards that make up the quality construct cited by Donabedian fail to differ from those in the professional and bureaucratic model, which include specialized physicians (such as Flexner, its best known exponent), their corporations (such as the American College of Surgeons), panels of experts, and research teams (which include accreditation boards such as the Joint Commission on Accreditation of Hospitals). In an excerpt in which he defends the relationship between the approach of results and processes, considered by Donabedian as “more correct,” the author defends medical care as “[…] an unbroken chain of antecedent means followed by intermediate ends which are themselves the means to still further ends.”5 (p. 169) in an effort to rationalize the process of medical care by dividing it into interconnected instances that includes an end that endows them with specific intentionality. Thus, medical care and the reasoning necessary to assess its quality are not limited to the dimension of the results, but also constitute a dimension of processes, which in turn is based on the adequacy of pertinent techniques and available procedures. The notion of process for Donabedian appears associated with the most appropriate application of techniques from medical science in the doctor-patient relationship, reinforcing the use of the technical-scientific rationality of his proposal in at least two dimensions: first, the need to attribute causality, that is, the application of an experimental reason (which fails to mean experimental method) to the relationship between the provision of care and results and, second, the emphasis on technical and scientific medicine by the application of the best available procedures in the care process.
Such emphasis on the scientific dimension by the adequate use of the best techniques and causal reasoning indicate that the meaning of the dimension of the process is to constitute a “scientific-causal” link that subsidizes the analysis of the results, which, in turn, remains as the final validator of quality.
Care effectiveness, as it has been asserted, to achieve or produce health and satisfaction, as defined for its individual members by a particular society or subculture, remain the ultimate validators of (…) quality of care (Ibid., p. 186, emphasis added).

Donabedian emphasizes the prominence of efficacy by pointing out the achievement of health and patient satisfaction as a conditioning factor for other quality indicators. These elements can be considered as the results intended by medical care.
The validity of all other phenomena as indicators of quality depends, ultimately, on the relationship between these phenomena and the achievement of health and satisfaction. (Ibid., pp. 186, emphasis added)

That is, any element or phenomena of the medical care process must be associated with the expected outcome or efficacy. Thus, on the one hand, no paradigm shift occurs regarding the sources of standardization and, on the other hand, efficacy remains preponderant as a value to measure quality in Donabedian. His reflection gives rise to the importance of the adequate use of technical procedures to determine the causality of the results that are sought to be evaluated, that is, the use of traditional scientific logic. Silva and Formigli8 noticed this emphasis on the outcome dimension when they stated in the early 1990s that Donabedian believes that the quality of the technical dimension of care should be judged by its effectiveness.
At this point, we can update our semantic flow of the components that determine the notion of quality to Donabedian5 as follows:
Figure 2

Donabedian also describes a third approach to evaluate medical care that focuses on the analysis of what the author calls “settings” and “instrumentalities” (understood as the scenario and the set of instruments that enable medical care to occur) rather than of the care process or its results. The author designates this approach as structure evaluation, which would encompass factors such as adequacy of facilities and equipment, the training and organization of medical teams, the administrative structure, and the operations of programs and institutions that provide care5 (p. 170).
Although structure-centered evaluations were included in his review, Donabedian neither deeply develops the characteristics and methods for this type of approach nor delves into the relationship between structure and the dimensions of process and results. His text mentions this type of evaluation and its importance, citing some works and dialoguing with their authors but mainly pointing out the fragile relationship established between the structure, the processes, and the results.
Final considerations
This study may arrive at a destination point—rather than an end point—toward understanding Donabedian’s subsequent texts based on the effects of meaning of the discursive formation of the period in which he wrote his seminal text on his conception of quality. The transparency effect of the discourse required rendering its meanings opaque to seek to read it based on what is not said but which still is. Thus, we identify in the author’s position the permanence of a medical-liberal discursive formation under the sign of artisanal work as a constituent part of his defense of the standardization of practice based on the technical-scientific knowledge of medicine, but not only that; as such, it is up to medical scientists to develop (and their peers to validate and assess) the cohesion between such normativity and their professional practice.
Regarding his elaboration around the concept of quality, Donabedian, although developing and offering a proposal that considers the dimensions of structure and process, makes his greatest effort to contribute to the result dimension. In the elaboration that we have been analyzing, the structure and the process are necessary qualifications to rationally understand the results; Thus, our interpretation finds a reification of the result dimension based on an appeal to the causal and normative logic that unites the dimensions of structure, process, and result in an abstraction (although empirically accessible by instrumental reason): the medical care process.
Thus, we sought to show that the previous determinations that make up the discursive formation (the effects of meaning of which we apprehend in our gesture of reading) require addressal and the mapping of their field of memories to try to resignify (and thus to tension) a discursivity that permeates us with its force of evidence.

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