Healthcare quality improvement: It's time to update the Donabedian approach with a complex systems perspective

There is broad consensus that healthcare systems are complex systems, which as a result, face complex problems. From this perspective, quality of care can be conceptualised as an emergent outcome of the healthcare system, that is more than the sum of individual components of care (in terms of inputs and processes), and quality improvement as a complex systems problem. However, traditional approaches, such as Donabedian's structure/process/outcome framework, are rooted in a linear, reductionist perspective, that fails to recognise that quality of care is created in the context of complex healthcare systems, and the many interactions and uncertainties at play that shape quality of care and health outcomes. A paradigm shift is needed from a reductionist to a systems thinking approach if we are to better understand and improve quality of care. Such a shift begins with asking different research questions, situated within the system context, that focus on identifying how interventions may contribute to system improvement, as opposed to seeking to directly link interventions with quality of care outcomes. In contrast to traditional healthcare quality measures focusing on single components of the system in isolation, research needs to explicitly consider quality of care as an emergent system outcome and identify new indicators and methods of assessment that provide insight into how the healthcare system functions as an interconnected whole. It is an opportune moment to harness the energy of the international healthcare quality movement to drive the innovation needed in research and practice to adopt a systems thinking approach.