The document discusses the Donabedian model for evaluating healthcare quality, which consists of structure, process, and outcomes. The author argues that the process domain is the most significant because it directly relates to how patients are treated and cared for. Processes like diagnosis, treatment and education have a large impact on patient recovery, satisfaction and outcomes. While all three domains are important, the processes of care delivery are most crucial for ensuring quality. The document also notes that composite measures are now commonly used in addition to the three traditional domains to evaluate overall quality of care.

1. Student Response #1
The domain that I believe to be the most significant of the three
would be the process. This reasoning is being is that process
entails the collection of all actions that encompass healthcare.
In fact according to Donabedian (1982), the measurement taken
on the process domain is almost equivalent to the measurement
of the quality of care. This suggests strongly that the process
domain is the most accurate reflection of the quality of
healthcare that is being provided to the recipients. Receiving
quality care is synonymous with receiving the correct care as
well as efficient care; this is further evidence that the process
stage is the most significant of the three. It could also be argued
that the process domain is inclusive of the individual activities
required for the purpose of healthcare delivery.
The activities that are carried out in within the process domain
include treatments, preventive care, diagnosis, and patient/
family education (McLaughlin & Kaluzny, 2006). These
activities are performed in order to promote recovery, restore
function, increase survival, and increase the patient’s level of
satisfaction (Ranji, Shetty, Posley, Lewis, Sundaram, Galvin, &
Winston, 2007). Although I have identified the process domain
as the most significant it is important to consider that processes
rely on the structures for resources as well as the mechanisms
used by the providers to care for patients. If the activities are
carried out that results in a positive outcome then it can be
determined that the structure in place is the correct one. The
correct structure should result in the processes being carried out
efficiently and effectively as a result of the dependent nature
between the process and structure domain.
The process domain can be further classified into separate
functions be represented by the interpersonal classification as
well as the technical processes. The interpersonal processes can
be described as the manner in which healthcare is delivered to

2. the patient from the healthcare provider. The focus within this
sub-process is the interpersonal interaction between patient and
provider and the building of a strong relationship. This requires
the establishment of trust through showing empathy, listening,
and working in a collaborative fashion. Donabedian (1982)
established that the technical domain was the application of
medicine and health care science. This domain would include
the equipment and the different systems and methods used in the
delivery of healthcare to the people. The equipment and systems
would then be compared against previously established criteria
relating to technical, professional, and ethical standards. Data
collected during interviews with patients and providers, as well
as medical records or direct observations during healthcare
visits, can be valuable sources of information about the process
domain.
In my opinion, the least significant domain is the structure
domain because it has the least effect with regard to outcome.
There are many instances in which structure is changed many
times to improve efficiency, while theoretically not affecting
quality. The better argument would be that this domain is not
any less significant but changes within this domain have less of
an effect on positive outcomes than do the other domains. This
is possible because the structure domain consists of elements
such as medical equipment, staff training, payment methods,
physical facilities, and human resources. These factors all
contribute to the ability to deliver efficient and effective health
care to the patient, but inherently allow for the widest range of
variation between factors within the process. It could also be
argued that the structure domain is the easiest to recognize and
measure. This often allows for adjustments to be made quickly
because problems within this domain are often also observed
and measured first (Nelson, & Staggers, 2014).
Quality measures are quickly becoming increasingly
sophisticated and other categories are beginning to supplement
the existing domains of structure, process, and outcome. One of
the most popular additions is the composite measure domain.

3. Often the overall quality cannot be judged accurately as a sum
of its combined parts. The composite measures domain allows
the combining of multiple measures into a single unified score.
This better allows patients, healthcare organizations, and
researchers to get a better picture of the overall range of patient
care. Composite measures are now widely being used by
insurance companies as well as for promotion of high scoring
facilities and providers (Dimick, 2010).
References
Donabedian, A., Wheeler, J. R., & Wyszewianski, L. (1982).
Quality, cost, and health: an integrative model.Medical care,
975-992. Retrieved from
http://www.jstor.org/stable/3764709?seq=1#page_scan_tab_cont
ents
Dimick, Chris. Quality Check: An Overview of Quality
Measures and Their Uses. Journal of AHIMA 81, no.9
(September 2010): 34-38. Retrieved from
http://bok.ahima.org/doc?oid=101998#.WNDQVhiZNsY
McLaughlin, C. P., & Kaluzny, A. D. Continuous quality
improvement in health care: theory, implementation and
applications. 2006. Gaithersburg, Md: Aspen Publishers
Inc, 3. Retrieved from
https://books.google.com/books?hl=en&lr=&id=6pOyV0SDZ8M
C&o
Nelson, R. & Staggers, N. (2014). Health informatics: an
interprofessional approach. St. Louis, Mo.: Elsevier Mosby.
Retrieved from http://www.worldcat.org/libraries/10142
Ranji, S. R., Shetty, K., Posley, K. A., Lewis, R., Sundaram, V.,
Galvin, C. M.,
& Winston, L. G. (2007). Closing the Quality Gap: A
Critical Analysis of Quality
Improvement Strategies (Vol. 6: Prevention of
Healthcare–Associated Infections).

4. Student Response #2
Learning from defects is a huge campaign that many hospitals
are participating in including the one I work in. One
motivational factor for these educational programs is that
approximately 300 people die per day from avoidable medical
errors in US hospitals (Vanteddu & McAllister, 2014).
Improving patient outcomes is the goal of these initiatives.
Measuring the quality of the product a healthcare institution
produces is difficult due to multiple contributing factors. One
example is the overall living standards of a population that
surrounds a healthcare institution. Evaluating specific entities
in how a health care system operates is a great place to start.
An article written by Avedis Donabedian published in July of
1966 titled “Evaluating the Quality of Medical Care” outlines
the quality of a healthcare system as a product of its structure,
process, and outcome (Ayanian & Markel, 2016). This article
presents information on how and what to assess when
attempting to determine the quality of a health care
organization.
The structure is described by Donabedian as what resources the
organization has to operate. One example mentioned in his
article is the training and qualifications of physicians and how
it is directly related to the quality of care they provide
(Donabedian, 1966). Hospital accreditation and dedication to
investments in quality equipment are other indicators that
define the strength of the organizational structure. The idea
behind structure as a foundation for quality is because without
resources, the processes that are delivered within an institution
cannot be carried out. Procedures cannot be performed without
adequate equipment. Funding to meet accreditation criteria is
an indication of administration’s dedication to quality. To
become accredited and organization must demonstrate that it

5. requires licensure of its staff and/or prove it meets specific
service levels. Criteria is dependent on what type of
accreditation the organization is attempting to secure. The
question I always ask myself is do I want a good surgeon
performing a procedure on me or do I want a great surgeon
performing the procedure. Working in a health care facility
provides me with the opportunity to understand which physician
I prefer for a particular procedure as a direct result of observed
outcomes. The general non-medical population does not have
this inside information. This is reason why health care
organizations must focus on their structure to provide the
fundamental best possible services. Structure is the foundation
for the other domains noted in the model which is why its level
of quality is imperative.
The process is the second most important domain because it
defines the how the delivery of health care occurs in an
organization. The process cannot occur without proper
structure, but it is an extremely important piece when
evaluating an organization. Complicated processes can set even
the best health care provider up for failure. There are two sides
to the process aspect regarding delivery technical and
interpersonal (Shi & Singh, 2015). The manner in which a
patient is treated is extremely important because compliant
patients are patients that believe they have been treated well by
their provider. Trust is won with care and compassion and
when a patient believes in their health care provider they will
follow instructions. Cancellation of surgical procedures is a
huge issue in hospitals. Surgical cancellations occur for many
reasons and is mentally harmful for patients that are anxiously
awaiting for a procedure. Waiting times and accuracy of
prescription delivery are all included in process improvements
at many facilities. Patient satisfaction surveys are one method
of determining where process issues are most prevalent at an
institution.

6. Structure and process directly affect outcomes. Outcomes are a
metric that can be measured easier than the process and
structure. Readmission rates are one measurement that
hospitals utilize to indicate issues with structure and process.
Poor patient outcomes are studied immensely to determine
where contributing factors occurred in the structure or process.
Unfortunately this is a backwards way of doing things, but it is
a process utilized to get data for improving structure and
processes. My facility utilizes a system that requests all staff to
report process or care issues. Our administration requests that
we encourage staff to use this system with all issues to give us a
good way to measure quality issues. It is a great system as long
as the staff truly is using it. Our system was improved for ease
of use last year and it has become a much more widely accepted
reporting method.
References
Ayanian, J. Z., & Markel, H. (2016). Donabedian's lasting
framework for health care quality. The
New England Journal of Medicine, 375(3), 205-207. Retrieved
fromhttp://search.proquest.com.proxy.davenport.edu/docview/1
806105238?accountid=40195
Donabedian, A. (2005). Evaluating the Quality of Medical
Care. The Milbank Quarterly, 83(4),
691–729. http://doi.org/10.1111/j.1468-0009.2005.00397.x

7. Shi, L., & Singh, D. A. (2015). Delivering Health Care in
America A Systems Approach (Sixth
ed., pp. 494 - 495). Burlington, MA: Jones & Bartlett Learning.
Vanteddu, G., & McAllister, C.,D. (2014). An integrated
approach for prioritized process
improvement. International Journal of Health Care Quality
Assurance, 27(6), 493-504. Retrieved from
http://search.proquest.com.proxy.davenport.edu/docview/16606
89036?accountid=40195
Student Response #3
Introduction
The donabedian model is represented by the structure, process,
and outcome. It represents three types of information that is
needed to draw conclusions about the quality of care in a given
system. The improvement of the health care quality is the
expected end result of the implementation. The model consists
of Structure, process, and outcome (Models of health care
quality, 2017). Structure is physical and the organizational
chacterstics, process is the focus on the care delivered to
patients, and outcome is effect of health care on the status of
patients and population (Models of health care quality, 2017)
Discussion
A study was done and showed that the Donabedian
model can really help with the health care system. A
questionnaire was developed and sent to a random sample of
600 hospitals in Sweden. The results found that the model with
relationships between structure, process and outcome was found

8. to be reasonable to represent the quality systems within hospital
departments and the model could be used to describe and
evaluate and compare various systems and help to improve the
quality ( Kunkel, S & Rosenqvist, U & Westerling, R, 2007).
This was just an example to show that the model really does
have benefits to it if we use it properly.
I think from the 3 domain, the process is the most significant.
Because the better the patients are treated, the better the overall
health care results will be. That’s the most important goal that
affects everything. I think sometimes administration forgets that
and all they care about is money and the net coming in. If the
patients don’t get the right treatment, that money will go
downhill really fast and no time to recover. Honestly, there’s no
domain that that is really least significant. I find all of them
pretty critical for the system to work. That’s why I really don’t
think any other domain needs to be added to make it better. I
think the overall set up is very well.
Conclusion
In general, I think the donabedian model is set up pretty
well to determine how good our health care system is. It
consists of structure, process, and outcome. I believe all 3 are
very important to determine the success of the quality system
and using it the right way can give out really good results for
the future.
References:
Models of Healthcare quality. “International centre for Allied
Health Evidence”. 2017. Retrieved
fromhttp://implementationcentral.com/ebponline/?page_id=340
Kunkel S, Rosenqvist U, Westerling R. The structure of quality
systems is important to the process and outcome, an empirical
study of 386 hospital departments in Sweden. BMC Health
Services Research. 2007;7:104. doi:10.1186/1472-6963-7-104.
Student Response #4

9. Healthcare system in United States is deviating their quality of
care based on the cost spend by the patient or patient
insurances. The contribution of the healthcare system to the
GDP of United States is exponentially higher, as the GDP
contribution is higher is harder to change the healthcare system.
For example, “United States uses a larger percentage of
economic resources on health care 2009, 17.4% of GDP was
spent on health care $7,960 per capita 2015, 20% of GDP
projected to be spent on health care”(Shi 2015). As it has shown
the healthcare contribution to the GDP of the nation, and how
much it has been increase in last six years. According to the
Donabedian Quality Improvement Framework model is based on
the evaluating the certain factors that can influences the cost
and quality of care in healthcare system. This model deals from
structure to the service in healthcare industry.
The main goal of this model is provide the good care with least
expensive or innovative way to patients, where cost should be
not related to the quality of care. According to study, “This
study demonstrated that the Donabedian framework of
Structure, Process and Outcome evaluation is a valuable and
validated approach to examine the safety and quality of a
service innovation. Furthermore, in this study, specific
Structure elements were shown to influence the quality of
service processes further validating the framework and the
interdependence of the Structure, Process and Outcome
components”(Gardner 2013). It shows how the Donabedian
framework works with quality of care along with the cost of the
care. It does include certain factors to ensure the quality of care
is not comprised with cost of care. Having these models in
healthcare will provides checks and balances in healthcare
system. Knowing these checks and balances in healthcare
industry by healthcare professionals’ will ensure the quality of
care to the patients.
Additionally just having these models will show the transition
in healthcare from traditional methods to modern methods, with
the help of research and many more factors. These models also

10. allows healthcare professional to predict the results
of biopsychosocial outcome of the patients regarding their care
and physicians professionalism while dealing with the patients.
For instances, “Existing conceptual models do not sufficiently
address the significant interrelationships amongst variables to
explain, predict and/or control AEA-SHCN's biopsychosocial
HCT outcomes. This article provides a description of a health
care transition theoretical model developed by the international
and interdisciplinary Health Care Transition Research
Consortium (HCTRC) that can be applied for testing in research
and serve as a framework for clinical practice and
policymaking”(Cecily 2014). Above quotes shows how these
models have changed the disciplinary in the healthcare system
in United States. Knowing these models in theory and
implementing them in practically is tough task. However these
models provide the base for healthcare system should be while
treating patients.
Finally, any model in healthcare system including Donabedian
Quality Improvement Framework model is to provide the best
quality of care to patients. Quality of care should not be
comprised or equated to the cost of care for patients. However
due to the huge contribution by healthcare towards GDP of
United States, it is getting harder not to include the cost of
healthcare system while quality of care towards patients is
questionable. It is every healthcare professional responsibility
to provide the good quality of care to their patients, while
providing good of care to their patients and proving it to the
healthcare system might eventually shift the gears form cost of
care to the quality of care for patients. This was the main aspect
of Donabedian Quality Improvement Framework model in
healthcare system.
References
Cecily Q. (2014, December 11). The health care transition
research consortium health care transition model: A framework

11. for research and practice. Retrieved March 28, 2017,
from http://content.iospress.org/articles/journal-of-pediatric-
rehabilitation-medicine/prm00277
Gardner G. (2013, July 3). Using the Donabedian framework to
examine the quality and safety of nursing service innovation.
Retrieved March 28, 2017,
from http://onlinelibrary.wiley.org/doi/10.1111/jocn.12146/full
Shi. L. (2015). Delivering Healthcare in America in systematic
approach. 6th ed Retrieved March 28,
2017,https://docs.google.com/presentation/d/1uUFd6_qloo7Baf
WYz7iAsQfGP8O4we149X0ZES4ToWw/edit#slide=id.p4
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ACM. How to Classify Works Using ACM’s Computing
Classification System. 2014. Retrieved August 22, 2014 from
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Ronald E. Anderson. 1992. Social impacts of computing: Codes
of professional ethics. Soc Sci Comput Rev 10, 2: 453-469.
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Writing Guide. Retrieved August 22, 2014 from
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18. Morton L. Heilig. 1962. Sensorama Simulator, U.S. Patent
3,050,870, Filed January 10, 1961, issued August 28, 1962.
Jofish Kaye and Paul Dourish. 2014. Special issue on science
fiction and ubiquitous computing. Personal Ubiquitous Comput.
18, 4 (April 2014), 765-766. http://dx.doi.org/10.1007/s00779-
014-0773-4
Scott R. Klemmer, Michael Thomsen, Ethan Phelps-Goodman,
Robert Lee, and James A. Landay. 2002. Where do web sites
come from?: capturing and interacting with design history. In
Proceedings of the SIGCHI Conference on Human Factors in
Computing Systems (CHI '02), 1-8.
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Psy. 2012. Gangnam Style. Video. (15 July 2012.). Retrieved
August 22, 2014 from
https://www.youtube.com/watch?v=9bZkp7q19f0
Marilyn Schwartz. 1995. Guidelines for Bias-Free Writing.
Indiana University Press.
Ivan E. Sutherland. 1963. Sketchpad, a Man-Machine Graphical
Communication System. Ph.D Dissertation. Massachusetts
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Langdon Winner. 1999. Do artifacts have politics? In The
Social Shaping of Technology (2nd. ed.), Donald MacKenzie
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UK, 28-40.
For this writing assignment, you will explore how video games
are being used by the medical community.
Video games (both online and apps) are a source of
entertainment for individuals and groups of people. They are
also big business for the gaming industry. However, video
games are not just being used for entertainment. Health
professionals and researchers are designing games to help with
medical conditions, for example, for recovering stroke patients
and patients rehabilitating after accidents.

19. In this assignment, you will explore and report on four areas:
1. You will research the different types of health conditions that
are using video games and what these games are designed to
help.
2. You need to report on the different input and output
techniques that have been shown to be appropriate to help such
conditions. For example, using gestures for input has shown to
help with mobility issues for some senior citizens. Give
concrete examples from the research.
3. You will report on the effectiveness of these therapeutic
approaches. Which approaches have been found to be
successful, which ones need improvement, etc. and why?
4. Finally, you will report on the future of gaming for medical
and health conditions and provide some insight into new and
innovated approaches or technologies that may not have been
evaluated yet, but that researchers believe hold promise.
The ACM library and the IEEE library will be great sources for
the paper and you may want to look at some medical journals
For this assignment, you need to use peer reviewed sources to
research this topic (such as papers from the ACM Library and
IEEE library). The IEEE has a database that you can search just
like the ACM library. You should have 5-6 peer reviewed
references for this assignment.
You will use the ACM SIGCHI paper format available as a
Word template (attached). This is the same one you used for
Assignments 1 and 2.
You will use the IEEE citation format. Your paper is to be 2.5-3
pages, properly formatted, including references.