Revisiting structure, process, and outcome

Abstract

Nearly 4 decades after first describing the structure-process-outcome framework for assessing quality in health care, Dr. Avedis Donabedian outlined some of the shortfalls in his own care during an interview published in Health Affairs. 1,2 Treated earlier in his life for prostate cancer, Donabedian was diagnosed with bladder cancer years later after worsening urinary symptoms and episodes of urinary obstruction, infections, and renal failure led to the detection of a tumor in his bladder. Urine cytology, commonly used to evaluate a patient for bladder cancer, was performed at some point before the diagnosis but went unchecked for months (James Montie, MD, oral communication). The results were abnormal. Donabedian ultimately had his bladder removed, and he lived the remaining few years of his life with "lots of permanent tubes and pouches." 2 He died on November 9, 2000 of metastatic cancer. 3 In the 14 years since Donabedian's death, the quality landscape has changed markedly and has moved from a more general awareness of quality chasms in health care to broader policy efforts designed to proactively assess quality and improve care. [4][5][6][7][8] Central to these efforts, the best way to measure quality is as pertinent a question today as it was in 2000. Resoundingly, however, structure, process, and outcome measures that evaluate the context and setting of care, the way in which care is delivered, and the effects of that care have become the main linchpins in quality assessment and improvement programs. To date, the National Quality Forum has vetted and endorsed more than 460 quality indicators, 9 many of which underpin high-profile quality improvement programs such as the Physician Quality Reporting System and the Hospital Inpatient Quality Reporting Program of the Centers for Medicare & Medicaid Services. 10,11 Within the realm of urology, National Quality Forum-endorsed quality measures have been limited mainly to urinary incontinence and prostate cancer thus far. 9 Bladder cancer quality indicators have been proposed by some groups, but they have not yet been adopted or implemented into actionable measures at a national level. 12,13 In this issue of Cancer, Chamie et al 14 further probe quality gaps in the management of bladder cancer. Leveraging the Los Angeles Surveillance, Epidemiology, and End Results cancer registry and supporting information abstracted from operative and pathology reports, they critically evaluate and link a meaningful and probably inarguable measure of quality-the presence of muscle on endoscopic biopsy/resection-to outcome, in this case, mortality, on a relatively large scale. Adequate muscle sampling at the time of transurethral bladder tumor resection has been examined in a number of prior studies and linked to an increased risk of understaging and higher rates of disease recurrence. 15,16 As a result, ensuring adequate muscle sampling during bladder tumor resection has become a standard principle across bladder cancer guidelines, particularly in the setting of invasive high-gr...

Developing Strategic Health Care Key Performance Indicators: A Case Study on a Tertiary Care Hospital

“…According to Donabedian conceptual model, which provides a framework for evaluating healthcare services and quality of care, key performance indicators can be classified differently by being related to the three components of the healthcare system; structures, processes and outcomes. Structure describes the context in which healthcare is delivered, including hospital buildings, staff, financing, and equipment, while processes include all transactions between patients and providers throughout the delivery of healthcare, and outcomes refer to the effects of healthcare on the health status of patients and populations 6 . And finally, according to studies in the science of healthcare performance measurement and improvement, and according to the Institute of Medicine definition of goals for high quality healthcare delivery systems that we mentioned above, performance indicators can also be classified according to the different dimensions of measurement into the main six elements defined; safety, effectiveness, efficiency, timeliness, patient centeredness and equity 7,8 .…”

Opportunities of digital health technologies for rheumatology: from clinics to quality and research

“…The main advantage of digital health technologies should be the facilitation of fast and specific documentation of routine clinical work, thus empowering clinicians and cooperating healthcare workers to improve the quality of care for individual patients. In recent years, Donabedian's approach to quality assessment has become widely accepted for defining and evaluating quality in medical care [8]. According to Donabedian's conceptual model, key performance indicators are classified differently by referring to the structure, which describes the context in which health care is delivered, the processes, including all transactions between patients and providers throughout the healthcare continuum and outcomes referring to the impact of health care on the health status of patients [9].…”

Economics and Mathematical Modeling in Health-Related Research

“…The performance dimensions of healthcare functioning necessary for evaluation on the basis of indicators are: patient health safety, clinical effectiveness of treatment, resource efficiency, appropriate time to carry out the treatment process, focus on patient centeredness understood as improving health status and patient satisfaction, as well as equal access for all patients and all types of benefits. In addition, KPIs should assess three components of the treatment process, that is, firstly, a structure representing treatment determinants (e.g., hospital, staff, equipment, financing); secondly, processes that reflect all relationships between healthcare providers and patients during treatment; and thirdly, treatment outcome revealing its impact on the health of the individual and society (Gilbert, 2015).…”