Reframing Donabedian's Model as an Operational Maturity Framework: Evidence from the Romanian Public and Private Healthcare

The relationship between operations management practices and healthcare quality is well-established in the literature, yet the conditions under which these practices can be successfully transferred across organisational contexts remain poorly understood. This paper proposes a reinterpretation of Donabedian's classic structures-processes-outcomes model as a hierarchical operational maturity framework for healthcare organisations, in which progress on higher-order dimensions is conditioned on sufficient maturity at lower-order dimensions. The framework is applied to the Romanian healthcare context, where a sharp and well-documented asymmetry between the public and private sectors provides an instructive analytical setting. Drawing on documentary analysis of public sources including ANMCS accreditation reports, Eurostat and OECD data, peer-reviewed governance assessments, and private network annual reports, the paper identifies a structural maturity gap as the primary constraint on the transferability of operational excellence tools (TQM, Lean, Six Sigma) to Romanian public hospitals. Four theoretical propositions are advanced, with implications for healthcare management practice and future empirical research.