A multidimensional quality model: an opportunity for patients, their kin, healthcare providers and professionals to coproduce health

Background: It is twenty years since the US Institute of Medicine (IOM) defined quality in healthcare, as comprising six domains: person-centredness, timeliness, efficiency, effectiveness, safety and equity. Since then, a new quality movement has emerged, with the development of numerous interventions aimed at improving quality, with a focus on accessibility, safety and effectiveness of care. Further gains in equity and timeliness have proven even more challenging. The challenge: With the emergence of “service-oriented” systems, complexity science, the challenges of climate change, the growth of social media and the internet and the new reality of COVID-19, the original domains proposed by the IOM invite reflection on their relevance and possibility for improvement. The possible solution: In this paper, we propose a revised model of quality that is built on never-ending learning and includes new domains, such as Ecology and Transparency, which reflect the changing worldview of healthcare. We also introduce the concept of person- or “kin-centred care” to emphasise the shared humanity of people involved in the interdependent work. The change of Person Centred Care to Kin Centred Care introduces a broader concept of the person and ensures that Person Centred Care is included in every domain of quality rather than as a separate domain. The concentration on the technological aspects of quality is an example of the problem in the past. This is a more expansive view of what “person-centredness” began. The delivery of health and healthcare requires people working in differing roles, with explicit attention to the lived realities of the people in the roles of professional and patient. The new model will provide a construct that may make the attainment of equity in healthcare more possible with a focus on kindness for all.


Changes made
In the abstract we have included a statement emphasising the importance of the new concept we introduce in the paper as follows: The change of Person Centred Care to Kin Centred Care introduces a broader concept of the person and ensures that Person Centred Care is included in every domain of quality rather than as a separate domain. The concentration on the technological aspects of quality is an example of the problem in the past.
In the main text, we have added this statement to strengthen the argument for a new framework.
To ensure that Person Centred Care is at the core of all that we do, care givers must accept that people centredness is the primary aim and concern of healthcare and is essential for the realisation of health. Only when this has been attained can our advances in biomedical knowledge and skills serve the patient as a person. Patients and healthcare providers are humans first and patients. If we lose our humanity, then the people involved, the patient and the healthcare provider are diminished in their unique interaction.

Any further responses from the reviewers can be found at the end of the article The rationale for change
Over the past twenty years, since the defining of quality in healthcare by the Institute of Medicine (IOM) 1 , an industry has developed in the field of quality improvement and patient safety. This has included the academic study of the theory and methodology and the actual implementation of the studied theory. The result has been some improvement, but not to the extent that would allow a claim of success 2, 3 . It has been said that there is insufficient evidence for the impact of quality improvement and more research is required 4 . One may ask why we need to redefine what is meant by quality in healthcare. A recent review by the National Quality Task Force in the USA stated that "Despite impressive gains, notable shortcomings persist in normalizing consistent, high-value, person-centered care. What is primarily missing is not progress in measurement, but progress in results. Changes in culture, investment, leadership, and even the distribution of power are even more important than measurement alone" 5 . They identified four stages of quality improvement -defining the problem, measuring to improve, reporting and transparency and paying for value. None of them have produced person centred care. In this paper, we take the opportunity to revise the basic quality framework and to redefine quality with the advantage of the experience gained over the past 20 years. The aim is to allow us to address the deficiencies that have been identified by the task force and redefine what it will take to make a difference.
The actual work of healthcare service today struggles to meet the needs of people for better health. Previously, the work has been designed to address failures in disease management, rather than in working with people to maintain or improve health. It seems easier to focus on "standard work" and the "actions" in disease management, rather than on a more integrated view of the "relationships" that are required to maintain health. Furthermore, more advances in health have come from preventive measures in public health, such as immunisation, clean water, sanitation and housing 6,7 . In addition, the methods of assessing the impact of quality improvement have not lent themselves well to the standard way of assessing interventions in healthcare, nor have they addressed the change in disease management to better health 8 .
Current healthcare service improvement has adopted many theories, methodologies and interventions from other industries, which have demonstrated important gains in quality, cost and safety. During the last century, one can discern two approaches on the creation, assessment, and improvement of the quality of healthcare delivery (see Table 1). Each approach has made important contributions to our abilities to make a better healthcare service and each has worked around a relatively common question. For convenience, we have named the first approach, Quality 1.0, "Q 1.0". This began in the second decade of the 20th century in the USA, when the American College of Surgeons began their program of hospital standards. Three decades later, other national organizations of hospitals and professionals joined to form the "Joint Commission" for the Accreditation of Hospitals 9 . With the passage of the Medicare With the advent of post-World War II improvement in systems thinking and system improvement methods, system-or enterprisewide efforts to address quality emerged in many economic sectors. Initially, these improvement initiatives occurred outside of healthcare service, but increasingly from the mid-1980's, enterprise-wide improvement interventions spread to healthcare services. This new approach is termed Quality 2.0, "Q 2.0". In this process the ideas of quality were defined by Donabedian as being system-and process-driven to produce the desired outcomes 10 . The early interventions to make quality a system or enterprise-wide endeavour were promoted with the introduction of the theories and methods of W. Edwards Deming, Joseph M. Juran and others [11][12][13][14] .
The IOM provided an important stimulus for the current focus on quality in healthcare with its reviews of the safety and quality of health care services 1,15 . The IOM defined six domains of quality, which have become the standard within the growing development of the science of improvement in healthcare: safe, efficient, effective, timely, equitable and patient-centred 1 .
The theories and methodologies that had been successful in other economic sectors have been thought to be appropriate to the challenges of quality in health care delivery 16-18 . We have learned much, as a new language of systems, processes and outcomes has been added to the study and practice of clinical excellence, previously thought to be "quality in healthcare." Attention shifted from a minimum "threshold" of quality to the concept of a "ceiling" of quality-not, "are you good enough to qualify?" but "how good can quality become?" Examples of success have been decreases in some infection rates, perceived increased access to healthcare, changes in person-centred care and improvements in aspects of safety 19-23 . System-wide improvement has been demonstrated at some institutions 24 .
Yet, for all these achievements, the persistence and the universal nature of the problem was highlighted in three key publications in 2018, which demonstrated that more than eight million people die from poor quality care in Low-and Middle-income countries (LMIC) 25-27 . In high income countries, at least 1 out of 10 patients is adversely affected during treatment, often resulting from persistent unwarranted variations in healthcare delivery, where a considerable proportion of patients did not receive appropriate, evidence-based care 28 .
We believe that the development of technical solutions helped connect improvement efforts to the earlier focus on "professional work." These efforts allowed many gains. For example, specific safety initiatives have decreased pressure ulcers, falls in hospitals and hospital-acquired infections 29-32 . However, today we can also recognise the diminishment of attention to some very basic issues. For example, what does "quality" really mean to the person whose health it is? In our efforts to clarify desired professional roles, we may have inadvertently created a "product-dominant logic": professionals making a quality healthcare service and then trying to "sell" it to patients. We think it is time to step back and reconsider what healthcare service is. How is it made and what does quality really means to the person whose health it is?
With the Industrial Revolution came the development of the goods/product dominant logic for manufacturing. This logic separated the producer and the consumer with progressive specialization of the producer and the production of homogenous goods with progressively more efficient methods of production. This logic became a pervasive model for the operations of organized work and was transposed into the design of healthcare where the clinician held all the knowledge and skills and provide care to the person as a patient.
Today the internet connects across "separated" functions and fosters networking that obliterates the earlier separation of producer and consumer. Service-dominant logic fosters integrated resources and interactivity and collaborative work of producers and consumers for mutual value-creating work 33 . For healthcare this implies that the distinction between clinician as the holder of knowledge no longer holds and the patient is now a person who can share in finding the solution.
If one considers the study of the process of production of an outcome, the logic behind the making of products, or "goods" involves linked processes. Efforts to improve those processes often uses "standardization" of the processes and their linkages. The output of the processes is usually tangible. The logic behind the making of a "service" usually involves interactive steps of professionals and beneficiary users working in dyads or networks that are needed to solve a problem, on an individual or group basis 34,35 . Therefore the service will require interaction between all parties involved (see Table 2).
The approach has changed more recently, and the focusing question seems to have become something of the following nature: "How might we improve the value of the contribution that healthcare service makes to health?" 36 . This invites attention to who actually owns a person's health: the healthcare provider or the individual receiving healthcare? In addition, we postulate that the concept of kinship extends to include both the care giver and the care provider, as they regularly work together to make and improve services in support of an individual's or a community's health. The work of design, execution, assessment and improvement involves the integration of multiple systems of knowledge and skill.
Early observers of "service" work noted that because more than one person was involved, it might be named, "Co-productive work" 37 It also invites and enables new models of value creation with attention to the basic architecture of those systems. Because these are different to those in the approach of "Q 2.0," we have named this approach Quality 3.0, "Q 3.0". Each of these approaches to quality offer important insights into the complex work involved in healthcare service. We think of each approach as adding to our capability to make better health, rather than "substituting" or "replacing" for the earlier approaches. The approaches are summarised in Table 1.
In this paper, we propose a new construct for defining quality of healthcare, where the aim is to meet the needs of the patient as a person, rather than meeting the needs of the healthcare system, which is as complex industry selling a product of disease management 38 . The construct builds on an often overlooked emphasis in the original IOM concept, namely that person centredness is central to quality 1 . Some authors have focused on the need for compassion and person centredness to have a greater position in a quality framework and have noted the shortcomings of many initiatives 39-42 . In the person centred care literature the lack of kindness and respect has been raised as failing in our healthcare systems [43][44][45][46][47][48] . Despite the focus on the need for person centred care to be a central part of the quality system there has not been the traction required to make a difference. We believe that this is because person centred care is seen as a separate domain rather than one that is a precondition in every domain of quality. To ensure that Person Centred Care is at the core of all that we do, care givers must accept that people centredness is the primary aim and concern of healthcare and is essential for the realisation of health. Only when this has been attained can our advances in biomedical knowledge and skills serve the patient as a person. Patients and healthcare providers are humans first and patients. If we lose our humanity, then the people involved, the patient and the healthcare provider are diminished in their unique interaction.
In proposing a new framework, it is tempting to dismiss earlier concepts. While we utilise the same dimensions, they have been reoriented with new ones added to invite a "service-dominant" logic. The new dimensions of quality will become even more relevant for the way we will facilitate health and make healthcare services in the future. This new model incorporates the key essential values that embody person centred care and incorporates a broader definition of persons and the essential relational nature by including their kin.

Why now?
Many forces are at work today that seem to invite these changes. Information access has become more open, with the growth of the internet and social media, so it is much easier for any person to explore what is known about a problem or condition. "Making" and the maker-society invite a sense of personal agency more than traditional deference to "professional experts." Healthcare professionals have been working to shed paternalistic legacies, creating a new construct, which we have named the commons, whereby all are working together towards the common good of health rather than simply managing disease and its related illness. This is evidenced in some of the interventions to address the challenge of COVID-19. Historic conventions about payment and finance have given way to significant organizational financial stresses in all societies. The challenge of explicitly recognising the contributions of patients and families, in addition to those of professionals, while maintaining a person-centred focus during and after the pandemic for people who are affected and for those who are not, has invited a new model of quality for the future.
Concurrent with the pandemic, the issue of the structural inequalities in society have become more prominent. A new model is required to address the way we, as healthcare providers, address issues in society that impact the health of the people. These include structural racism 49 and the social determinants of health 50 , including food insecurity 51 , gender inequality 52 and inherent violence 53,54 within many societies. COVID-19 has unmasked these 55 , and we think the new model is a response to the past failures of society to address these issues. Some may say that this is politicisation of health. Rather we see it as making the quality model socially relevant to our times and to the people who are most marginalised.
One of the early developers of modern Health Services Research, Kerr White, noted that the public's health was not well served by the schism that developed during the last century between "medicine" (personal health) and "public health" 56 . He suggested that this separation was not serving the public's health well and that the study of epidemiology might help. Today, the challenge of the COVID-19 pandemic has given us another clear view of the ways that this separation has had real consequences in unnecessary death and continues to serve us poorly. We believe that an appreciation of the common humanity-kin-amongst the people who act in the personal and in the public sectors, in addition to the study and contribution of epidemiology, can help. This focus on the relationships helps energise a bridge across the divide of the two sectors. By an Table 2. Difference between Health Products and Health Service.

Health-related Goods/Products Health-related Service
• usually tangible-can hold it, measure its physical dimensions • usually made without direct active involvement in the manufacturing process by the user • usually made with standardized linked processes • dichotomized maker and user, seller, and purchaser • e.g., "unit of blood," IV solution, on-the-film Xray image, a lab test-such as a CBC • usually intangible-usually does not have material physical dimensions • usually made with direct and active involvement in its "construction" by the professional and the user • usually made to solve a problem for individuals or at scale, for a community • because the two parties work together to create a service, some of the dichotomizations of the roles seen in 'product-making' do not fit perfectly well • e.g., "a medical history", "a physical exam", "advice" for exercise, well-child assessment explicit focus on the concept of kin, we can see a person as an individual and as a member of a population. This shared position of people helps us appreciate that kin-shipness or "kindness" can serve as a core value and the 'glue' of cooperation required for progress and for the benefit of most people 57 . It has helped us recognise the importance of kin, our fellow human beings, in our daily lives and that the absence of attention to these relationships-kin-, is a painful limitation to how we pursue health, not only in COVID-19, but also in numerous other ways, including in the end of life, for example. By kin we refer to the wider social construct around the people involved in receiving and providing care. Moreover, there is a need to develop a new way of thinking as one faces the challenges of measuring wellness, equity and good health 58 . The COVID-19 pandemic has exposed the failure of linear thinking to produce results when responding to a crisis. This has demonstrated that we need to see quality as part of a complex adaptive system with many competing linkages. Healthcare has many components, both within the formal structures of health service delivery and more importantly within the community and in other sectors. To produce health, these components need to interact in a way that benefits the people receiving care 59,60 .
In short, we can now see clearly that not only is it very difficult to outsource one's health to someone else-the truth is that we have no real option but to work in new ways to coproduce a healthcare service that is capable of a greater contribution to better health. We believe that the impact of COVID-19 opens an opportunity not to return to the "old normal" or develop a "new normal" based on the old, but rather to conceptually redefine what we mean by quality in healthcare, how we define each other's roles and how we define person-centred care for individuals and communities.

Assumptions underlying a new quality movement
Underlying our thinking has been a recognition of the benefits of understanding systems as complex adaptive phenomena, of recognising that at some level all healthcare service is coproduced by persons we sometimes call professionals and persons we sometimes call patients. They are "kin" to each other in this interdependent work 57 .
The failure to link up the different parts of care during the pandemic, e.g. social care with healthcare, has exposed an underlying problem with the design of care. This has meant that many vulnerable people were placed at risk and potentially endured more harm. Healthcare quality and safety requires the interaction of these complex parts, continually adapting to the changing demands, each with its own complexity and each of which having to integrate at a specific time to deliver safe, good quality care. For example, the initial approach to patient safety (called Safety 1) focused on addressing adverse events and undertook linear assessments of unsafe events. These cause and effect assessments were often too simplistic to consider the complexity of causal systems at work. The progression has been to an understanding of complexity and resilience in quality and safety, with the building of resilience and constant learning, as we adapt to changing circumstances (called Safety 2). A different approach to quality is required as well 61,62 .
The quality and safety movement has been reactive to what has not been working and we believe that we now need to move to the concept of health and its coproduction. The concept of coproduction of quality in healthcare service systems is in its early phase of development 63-65 . There is a need to include people as partners and to move away from the correction of defects in disease management towards the co-creation of health. People, i.e. both the professionals and the patients interdependently involved, are not the problem, they are the key to a future quality model. While there has been a growing body of evidenced-based interventions, the problem has been one of implementation, spread and sustainability of interventions that have a firm evidence base 66 . We believe that organised efforts of quality improvement and safety, be it the practice or academic research of the practice has become too technical and people cannot relate to the challenge of fostering better health. We need a paradigm that works in today's real world. One that facilitates better health for individuals and communities, so that the goal of better health will be achieved. In an era where shared creation of services is key, human resources in healthcare will become one of the major challenges. Quality should include care for both persons as patients and as professionals.

The model
The six domains of quality in the IOM model no longer fit the requirements of a person-centred approach to the facilitation of health and the delivery of universal healthcare. We suggest a focus on the co-creation of better health -a quality system for the people who are working together to co-produce services that contribute to better health ( Figure 1).
The original model had person-centred care as one of the domains. We wish to further develop this by recognising the shared humanity of the people involved. The word "kin" is introduced to embody the social relationships and lived realities that surround the individuals involved, both those providing care and those receiving care. Healthcare service is not only about the person as patient or professional, but also about their family and wider social relationships. The dimension person/kin-centred surrounds every domain and is part of all that we do. The need for this approach has been demonstrated to be an essential component of the response to the pandemic. John Ballatt and colleagues suggest that "kindness [kinshipness] is ...not a 'nice' side issue, it is the glue of cooperation required for progress to be the most beneficial to the most people" 57 .
We place the person at the core of quality, rather than being a separate domain. At the core are the values of healthcare, based on kindness with compassion; partnership and coproduction; dignity and respect for people and each other; where people are seen from a holistic approach, in their totality and not as a disease-holder or a person with a problematic body organ. The central tenet is kindness, so the dimension of person-centred care is kin-centred as well, involving all those who are related to the person receiving and the person providing care. This approach will facilitate the coproduction of quality and safety and achievement of the other domains. This emphasis invites and expands change from "installing" technical solutions to working with people and technical solutions. Telehealth A new domain, eco-friendly, is added to reflect the growing challenges of climate change and to introduce the need to address the challenges of sustainability, not only on organisation level, but in every contact in the micro-system 69,70 . We believe that being eco-friendly with a concern for climate change is central to the concept of kinship. The principle of transparency and leadership are included to surround all the technical domains, respecting the person's right to privacy but also the right to know the data that specifically concerns themselves. Transparency is needed for providers, so that they can be open with themselves, as well as with the people to whom they deliver care. Humble leadership is needed to merge the technical domains with the core values of the model and the vision of person and kin. Humble leadership calls for "here and now" humility based on a deeper understanding of the constantly evolving complexities of interpersonal, group and intergroup relationships that require shifting our focus towards the process of group dynamics and collaboration 71 . In the multidimensional quality model we state that it is not only a collaboration among care providers but also open and trustful collaboration between care providers and patients & kin. This implies a change in the culture of care to one that can embrace the new model. Transparency and resilience, i.e. the ability to operate with psychological safety, are the basis for the pursuit of truthful data collection, analysis and interpretation. Transparency with all our "kin" begins with professionals being transparent with each other 72 .

Implication for current programmes
We believe that healthcare promotion and the delivery of healthcare must return to the core tenets of care-a form of "service"-and include the values that we have made central to the model in everything that we do. As one reflects on the Donabedian construct of "Structures and Process leading to Outcomes," neither the structures nor processes we currently have designed are able to deliver a care model that could encompass the domains of quality nor kin centred approach. Healthcare will require a considerable redesign in which power is transferred to the person rather than remaining in the system. This would entail placing the people who receive care in positions of power in deciding how care should be delivered and how services are planned. As the complexity of care has redefined the way care is delivered with several providers often being involved in the delivery of care, the concept of integrating care around the person receiving care will be required with partnership and collaboration being core. In the Table 3 we demonstrate the actions that are required to implement this new quality paradigm. Kin and person-centred care are infused in every effort to improve care, safety and effectiveness. The introduction of transparency will require a culture change in every sector of healthcare. Ecology is now a central domain, so all decisions and planning will require programmes to improve the impact on the climate and environment. Quality health services are based on what one human offers to another. These services are fundamentally a human activity, with attendant Table 3. The domains of quality and action to be taken.

Domain of quality
Patient/Kin receiving care Person providing care Organisation

Person/Kin centred
The care a person receives should be filled with kindness, dignity, and respect.
People should be seen as a whole and their care must be coproduced. Shared decision-making and selfmanagement are essential.
The person providing care should experience psychological safety, kindness, dignity and respect with a sense of belonging and meaning.
This will facilitate the resilience or coping skills required by healthcare professionals to feel physically and mentally safe.
The core value is about quality, and kin-centred care health with meaning and purpose.
Leadership is distributed to engender physical and psychological safety for all people proving care.
Meaning and purpose to the work is part of all decision making and the organisation is learning from excellence and challenges.

Safety
Care should be free from harm, where harm is defined as something one would not accept for oneself or one's Kin (physical or psychological).
Psychological safety is a central part of the culture.

Proactive management of risk and learning from incidents is standard.
Debriefing and support are provided after an incident.
Learning and understanding how the complexity of the system works, is a daily activity.
Designing for safety using human factors is central to all operations.

Effective
All care follows evidence-based guidelines and standard operating procedures (SOP) where appropriate, with deviation only as per need of the person receiving care.
Reliable care is provided following SOPs to reduce unwarranted variation.
Transparency on (non-)compliance to SOPs is evident.
Translating evidence-based guidelines into local protocols.
Benchmarks process and outcome indicators.

Efficient
Unnecessary care is not provided.

All care should have intended benefit.
Care provided is cost-effective, minimising duplication and waste.
Clinicians constantly study processes to improve.
Focus on prevention of wasteful processes.
Improvement and or management methods are used to decrease waste.
Administrative waste is decreased.
Constant attention to pricing and cost of care without decreasing quality is standard.
Health is the outcome one aims for, rather than disease management.

Accessible and Timely
There are no delays in receiving care.
Universal quality with safe access is the goal.
Working in teams to provide care.
Available 24/7/365 with respect to staff wellbeing and risk of burn-out and bore-out.
Organisation of services so that they are accessible. Manage the impact of weekendeffect or out-of-office hours demand.

Equitable
Care is of the same quality all the time, no matter who you are and where you require care.
Seven-day week service for acute care that is fully staffed for acute care.
No racism among staff.
Real interprofessional care where all professionals can contribute equally.
Active programmes to decrease institutional racism, or any discrimination based on gender, ethnicity, sexuality disability etc.
Focus on the Social Determinants of Health.

Eco-friendly
Kin and the person aim to receive care that decreases duplication, repetition and over-investigation or treatment.
Decrease unnecessary consultations.
No duplication of tests.
Electronic records where possible and use of digital health.
Decrease disposables and consumables in all processes.
Organise video-consultation to decrease need to attend clinics.
Water and energy management.
Less use of plastic.
Conversion to reusable energy.
Active programmes for heat conservation and efficient water disposal.
rights, responsibilities, and implications. To achieve this, we need to have high quality care for the professionals who deliver care and a redesign of systems, in order to facilitate true person and kin-centred care. In Table 3 the possible actions to be undertaken are suggested, these are not comprehensive and will be dynamic, changing in different contexts. These in turn can become measures of the change process.
The model can be used to define and translate your own view on quality or integrate different visions and ideas into one overall framework. The multidimensional model has been piloted recently in different types of care organizations and it helped the involved clinicians and managers to define and specify the organization specific goals for the six technical domains, the umbrella domain of person and kin centred care and how to focus on the four core values. For example, to demonstrate application of the new eco-friendly domain one could preserve energy, water, resources, improve are using digital interventions and decrease carbon footprint. We invite clinical teams to use the model to examine how they can become person centred and then publish their experience so that we can coproduce the future.

Conclusion
Over the past few years, there has been a growing realisation that the current design of the system of healthcare has resulted in decreased wellbeing for the professionals involved in healthcare, with increasing reports of burn-out and "bore-out" 73 . The impact of safety events on clinicians has been documented and a meta-analysis of wellness and burn-out demonstrates the negative impact on care givers 74,75 . The review by the National Academies of Sciences concluded that the delivery of quality person-centred care will require a workforce whose wellbeing is paramount, which implies the dehumanisation of healthcare must be reversed 76,77 .
The recent focus on health inequalities and structural racism makes a change of focus more pressing with the concept of kinship reaching to the core of what it is to be a healer. This attention to relationship-as-fundamental is not new. It is the foundation of many religions. In addition to the bridging energy for our use as we address the "schism", we also recognise that numerous cultures across the globe have realised for centuries that this universal recognition of the importance of relationship is fundamental in all human life. Perhaps this is best known in the African philosophy of Ubuntu, where "I" am because "we" are. It is our contention that the new model of quality that we propose is the first step in this direction for policy makers, leaders and healthcare providers to explore and embrace this new way of thinking and to invite a return to a recognition of our shared humanity and the importance of kindness in healthcare for people and kin.

Data availability
No data is associated with this article.

Acknowledgements
The graphic is based on one designed by Sinead McArdle at ISQua. Astrid Van Wilder proofread the paper. We thank our reviewers and international experts who commented on this paper for their suggestions which lead to this second version of the manuscript and the multidimensional model.

Dignity and Respect
All views are accepted and respected in all decision-making.
Practices shared decision-making.
Is treated with respect by other providers from own and other disciplines.
Does not see divisions of care.
Develops a culture of learning and respect.
Provides a sense of belonging.
Develops psychological safety of staff.

Holistic
Care addresses physical needs as well as spirituality and mental wellbeing in an integrated manner.
Moral compass in all activities.
Treats patients as people, not as diseases and integrates care.
Breaks down the silos between levels of care so that the person experiences integrated care.

Partnership and coproduction
Be an active partner in designing health.
Able to choose where and how to receive care.
Sees patients as equal partners to develop health.
Coproduces health with people.
Supports the involvement of patients as experts by experience.
Works across all systems in pursuit of health.
Are people focused.
Performs experience-based coproduction programmes.

Kindness with compassion
Appreciation of the human side of the person.
Patient/Kin are kind to the provider.
Appreciation of the human side of the person.
Is always kinder than necessary.
Appreciation of the human side of the person.
Kindness is quality indicator in balanced scorecard.
The historical context around eras 1 and 2 of quality links well to the cogently set-out framework for quality which includes kindness/kin and person-centred as elements which run through the whole frame. In the UK/NHS context at least (& I expect for other health systems too), this framework will be of practical use to a range of people aiming to rebuild better in light of the pandemic. The authors should be congratulated on bringing together complex issues, multiple strands and schools of evidence into a coherent, readable and likely actionable whole.

Are the conclusions drawn balanced and justified on the basis of the presented arguments? Yes
do not see it as a separate domain of quality by rather in every domain. We contend that other models have focussed more on the technical -e.g. patient safety is a good example of this problem in the past." I think it is essential that you bring this point out in a much clearer way in the abstract, and possibly also in the text. This is the central change, and a much needed change in our thinking about quality of care. People-centeredness is the primary concern, which is served by our advanced biomedical knowledge and skills. We are humans first, both the patient and the provider. If our humanity is lost, the health care transaction turns into a violation of both the patient and the provider. Most of the other arguments of the paper flow from this one point and as such deserves to be highlighted. Good luck. ○ There is no focus on "relationships" and co-production of care in the IOM model, which is necessary for patients and professionals to "work" together towards a common good.

○
The focus on general prevention is lacking. All the terms of the model are described more in detail in table 2, which shows how the authors expect each of the following "roles": Patient-kin, Health provider, Organization, to work, or act in alignment with the goals that make up the model.

Strengths:
I agree with the authors that the current IOM-model of quality of care has not brought about the expected improvements. In practice, the IOM-domains of effective and efficient, and safe care have gotten all the attention and become the primary "measures" of care quality. The softer goals of person-centered, timely, and equitable care have also received some attention, but not nearly as much as the three former.
This paper adds some genuinely new ideas in the following areas: The authors emphasize Kin-ship and how we are all first humans. It underscores even more than the many other papers on Person-centeredness in care that the foundation for success is a relationship built on trust between the person who needs care and the person who provides it. Without a robust trusting relationship, the common goal(s) of health can not be reached.
○ Also, I believe that the cross-table between roles and care goals is genuinely new. It bridges the gap from the desired outcome, e.g., safety (the row-headline), the most critical resources (column headlines), and the process (Cell value). The essential resources in every care process are those mentioned in the column headings: the patient, the provider, and the Organization.

○
The domain Eco-friendliness is not commonly highlighted in other publications on quality of care and adds a novel dimension to the complex concept of quality.

○
The strong emphasis on the well-being of the person who provides care is not entirely new 1 . Still, this paper gives it a more decisive role than most other similar publications on quality of care, and I believe this to be an essential contribution.

Comments
The authors present their quest as a novel approach: "Assumptions underlying a new quality movement." However, most of the features of Lachman's quality model, such as relationshipbased care, patient-centeredness, and transparency, were highlighted in the original IOM "Quality Chasm" report (See "Simple Rules for the 21st-Century Health Care System, p. 67"). Many other authors have also pointed out many of the same shortcomings of current care systems 2 , 3 , 4 , 5 . The terms of kindness, compassion, dignity and respect, holism, partnership, and co-production, are desired outcomes highlighted before by different authors 6 , 7 , 8 , 9 , 10 . These authors share the concern, with Lachman et al., that the current care systems are not adopting the quality chasm report's recommendations well enough, nor fast enough. It would strengthen the paper to acknowledge how this paper builds and adds to the many previous publications that have pointed this out.
The many prior authors on this topic show that practice worldwide builds on a "too technical understanding of care quality" over a long period. The bigger question then is: Even though many express the need for qualities similar to those presented in this new model, such as personcenteredness, compassion, and empathy in current care, these authors concern does not seem to make an impact on care practices. Why are these compelling publications and analyses, many with strong arguments and support from empirical data, not making a difference? I would welcome the authors' reflection upon the following question: How will this model make a difference when other publications did not? What is it with this model that makes it stand out from previous models?
The paper has a paragraph concerned with complexity and how linear solutions may not provide the answers we need. The illustrated version of the quality model reflects the complexity in the arrows that link every component to other components. I share this view. Furthermore, I support the authors' recommendation of co-production, where a plurality of voices participates in the change implementation. However, change management in complex adaptive systems rely heavily on a shared vision and iterative trial-and-error implementation efforts, where measurement/ observations of "the desired change" are central 11 . I want to challenge the authors on the consequences of making a complexity science approach to improvement: How should we identify the measurements or observations that will guide change?
Donabedian's Structure => Process => Outcome model for understanding a care process's outcomes is still relevant. In their quality model, the authors have given us several domains that should be reflected in the care process. I would like to see the authors reflect upon the following question: If this is the process we would like to see, what changes, if any, do we need in care structures that would support such an approach?
The authors strongly argue the need to honor the relationship between patient and provider. However, in many care processes, the only stable person is the patient. Only those conditions that are managed by the general practitioner (GP) have continuity in terms of "persons" present in the relationship. Even in the GP office, there are temps and health secretaries and nurses, so that personal continuity might not be ensured even there. For patients with more complex issues, the care process consists of a string of care providers, who, more often than not, are not fully aware of what happened last with the last provider they saw. I invite the authors to reflect upon the "patient-provider relationship" in a situation where many different persons share the role of "the provider." expanded to kin centred so is an overtly broader; and secondly we do not see it as a separate domain of quality by rather in every domain. We contend that other models have focussed more on the technical -e.g. patient safety is a good example of this problem in the past. How should we identify the measurements or observations (of complexity) that will guide change?
1. Table 3 provides many different possible interventions, each of which could be developed into a measure of the complexity and the changes required. This noted in the text If this is the process we would like to see, what changes, if any, do we need in care structures that would support such an approach? 1.
I invite the authors to reflect upon the "patient-provider relationship" in a situation where many different persons share the role of "the provider." 2.
In response to the above two question, We agree there needs to be some consideration of the Donabedian model and the different relationships and have amended as follows: We believe that healthcare promotion and the delivery of healthcare must return to the core tenets of care-a form of "service"-and include the values that we have made central to the model in everything that we do. As one reflects on the Donabedian construct of "Structures and Process leading to Outcomes," neither the structures nor processes we currently have designed are able to deliver a care model that could encompass the domains of quality nor kin centred approach. Healthcare will require a considerable redesign in which power is transferred to the person rather than remaining in the system. This would entail placing the people who receive care in positions of power in deciding how care should be delivered. And services be planned. As the complexity of care has redefined the way care is delivered with several providers often being involved in the delivery of care, the concept of integrating care around the person receiving care will be required with partnership and collaboration being core.
We have reflected on the need for leadership and have added a reference to this point. We believe that this will be ongoing work in process. As we see the model being adopted so we will learn about the complexity of implementation. Nonetheless, the outcome will be looking at health from the view of the person and kin rather from the current model based on disease.

Response to Ross Baker
Thank you for the valuable review. We have identified three main issues to be addressed. Distinction between product logic and service logic 1.
We accept that the explanation of the distinction between product and service logic had not been as well developed as it could have been. We have added more detail to support this part of the argument . We have added a table which can provide can easier way to distinguish between n the two We have added as follows as well as provided a table to explain the point. Changes on page 6-7 With the Industrial Revolution came the development of the goods/product dominant logic for manufacturing. This logic separated the producer and the consumer with progressive specialization of the producer and the production of homogenous goods with progressively more efficient methods of production. This logic became a pervasive model for the operations of organized work and was transposed into the design of healthcare where the clinician held all the knowledge and skills and provide care to the person as a patient.
Today the internet connects across "separated" functions and fosters networking that obliterates the earlier separation of producer and consumer. Service-dominant logic fosters integrated resources and interactivity and collaborative work of producers and consumers for mutual valuecreating work. [33] For healthcare this implies that the distinction between clinician as the holder of knowledge no longer holds and the patient is now a person who can share in finding the solution. If one considers the study of the process of production of an outcome, the logic behind the making of products, or "goods" involves linked processes. Efforts to improve those processes often uses "standardization" of the processes and their linkages. The output of the processes is usually tangible. The logic behind the making of a "service" usually involves interactive steps of professionals and beneficiary users working in dyads or networks that are needed to solve a problem, on an individual or group basis. [34,35] Therefore the service will require interaction between all parties involved. t.
Requirements of the new framework 1.
What the interventions may look like in practice especially where providers are stretched due to growing need 2.
These two points are related. A theoretical model needs to be tested and implemented. We believe the model brings together some of the current concerns regarding wellness of healthcare workers, of people who receive care and the concepts of kindness. As the model is new it has been tested in a limited way in Belgium where it has been adopted by the local policy makers as a framework. One could also look at different quality frameworks developed in other organization where elements of the framework are included in their definition of quality, e.g., in British Columbia. . https://bcpsqc.ca/what-is-quality/ We contend that the framework is being implemented in part and it brings together many of the current activities in to one construct. We have expanded on this in the text and have added more on leadership as any changes will require a leadership responsive to both people receiving care and those providing care.
The model can be used to define and translate your own view on quality or integrate different visions and ideas into one overall framework. The multidimensional model has been piloted recently in different types of care organizations and it helped the involved clinicians and managers to define and specify the organization specific goals for the six technical domains, the umbrella domain of person and kin centred care and how to focus on the four core values. For example, to demonstrate application of the new eco-friendly domain one could preserve energy, water, resources, improve are using digital interventions and decrease carbon footprint. We invite clinical teams to use the model to examine how they can become person centred and then publish their experience so that we can coproduce the future.

Comments on this article Version 2
Reader Comment 19 Jan 2021 the everyday work ethics of the individual healthcare providers and all involved in the care process. But the organisation focus could be more elaborated in the article.
-To conclude I think there is a need of 'leadership' on different levels and for the different actors, which is not adressed yet in this article. The proposed model can serve towards a common and shared mission. This mission almost cannot be defined otherwise than "to focus on the health and well-being of the client and all involved, in an athmosphere of friendly and kind relationships". And the patient himself should show some leadership by taking an active role in decisions about his health, cure and care. Clinicians should lead the patient forward, but not in a paternalistic way. They should also be leaders for their multidisciplinary colleagues and lift each other to a higher level of quality. The health care providers (institutions) should show leadership to maintain 'healthy' organisations and a healthy staff. "kind," or how do we measure "feeling respected?" I hope in the future experts will work to provide us with some possible objective ways of measuring, so that we can learn and grow. I also like the idea espoused in the article about "co-creation" of better health. I agree that it takes a team, sometimes even a village! One important factor is that the patient must have the desire and be willing to co-create. Therefore, practitioners should be skilled in the art of motivation and relationship building. Angela McCaskill, RN MSc, MA, BSN, Certified Health Coach