The document outlines three types of quality measurement: structure, process, and outcome. Structure measures relate to characteristics of the healthcare setting. Process measures evaluate appropriate actions and care delivery. Outcome measures capture changes in patient health status. Examples show how each type of measure could be applied to prenatal care and personal protective equipment compliance.
2. Presentation Outline
Jade will discuss
constructing a
measurement
Astrid will discuss
interpreting quality
measurement
Alex will discuss how
compliance is being
measured in the real
world setting
3. Donabedian’s Model of Measures
Structure
Physical equipment and
facilities
Process
How the system works
Outcome
The final product, results
4. Structure Measures
Relate to characteristics
associated with a health
care setting
Broad list of variables
reflecting the setting or
system in which care is
delivered
5. Structure Measures
Advantages Disadvantages
Strongly related to Focuses on a small
outcomes number of variables
Can be assessed easily Most structural
and inexpensively measures can only be
assessed in
observational studies
Many structural
measures are not
readily actionable
6. Process Measures
Evaluate if appropriate
actions were taken for
an intended outcome
and how well these
actions were performed
to achieve a given
outcome
Describe the care that
patients actually receive
and are routinely used
as quality indicators
7. Process Measures
Advantages Disadvantages
High level of evidence Must be able to
supporting their accurately identify
effectiveness eligible patient
Reflect the care that Ensuring the right
patients actually receive denominator implies the
Generally actionable need for clinical data
and link directly to and may be labor
quality improvement intensive
activities
8. Outcome Measures
Seek to capture
changes in the health
status of patients
following the provision
of a set of health care
processes
Describe the patient’s
condition, behavior and
response
Provide an indirect
measure of the overall
quality of an
organisation
9. Outcome Measures
Advantages Disadvantages
Most consider patient Relates to sample size
outcomes the “bottom
line”
Measurement alone
may improve outcomes
10. Summary of Measures
Historically, quality
measurement has
focused primarily on
outcomes
Now, structure and
process measures are
important to improve
outcomes
11. Example
If you were concerned about reducing prenatal mortality, you might look at:
Type of Example
Measure
Structure •Availability of physicians and/or midwives providing
obstetrical care.
Process •Percent of mothers receiving prenatal care prior to 12
weeks gestation
•Percent of mothers taking prenatal vitamins
•Percent of smoking mothers counseled to quit
Outcome •Neonatal mortality rate
•Pre-maturity rate
12. PPE Example
If you were concerned about PPE compliance, you might look at:
Type of Example
Measure
Structure •Availability of staff
•Availability of PPE equipment
Process •Percent of staff receiving PPE training
•Percent of staff complying with PPE
Outcome •What is the hospital acquired infection rate
StructurePhysical equipment and facilitiesProcessHow the system worksOutcomeThe final product, resultsVarkey, P. (Ed.). (2010). Medical quality management: Theoryandpractice. Sudbury, MA: Jonesand Bartlett Publishers.Measurement: Process and Outcome Indicators. (2005). Retrieved January 11, 2012, from http://patientsafetyed.duhs.duke.edu/module_a/measurement/measurement.htmlImage sourced from:http://www.blog.republicofmath.com/wp-content/uploads/2010/12/tape_measure.jpg
Relate to characteristics associated with a health care setting, including its policies and proceduresStructural measures include a broad list of variables reflecting the setting or system in which care is deliveredVarkey, P. (Ed.). (2010). Medical quality management: Theoryandpractice. Sudbury, MA: Jonesand Bartlett Publishers.Birkmeyer, J., Dimick, J., & Birkmeyer, N. (2005). Measuring the Quality of Surgical Care, Structure, Process, or Outcomes. Retrieved January 11, 2012, from http://www.surgicalcomplication.info/PDF/2004BJD.pdfImage sourced from:http://www.engineersinc.co.uk/pics/structural-analysis2.jpg
AdvantagesMany of these variables are strongly related to outcomesStructural variables can be assessed easily and inexpensively, often with administrative dataDisadvantagesFocuses on a small number of variables and outcomes measuresMost structural measures can only be assessed in observational studiesIn contrast to process measures, many structural measures are not readily actionable, which limit their ultimate effectiveness as a means toward quality improvementVarkey, P. (Ed.). (2010). Medical quality management: Theoryandpractice. Sudbury, MA: Jonesand Bartlett Publishers.Birkmeyer, J., Dimick, J., & Birkmeyer, N. (2005). Measuring the Quality of Surgical Care, Structure, Process, or Outcomes. Retrieved January 11, 2012, from http://www.surgicalcomplication.info/PDF/2004BJD.pdf
Evaluate if appropriate actions were taken for an intended outcome and how well these actions were performed to achieve a given outcomeProcess variables describe the care that patients actually receive and are routinely used as quality indicatorsVarkey, P. (Ed.). (2010). Medical quality management: Theoryandpractice. Sudbury, MA: Jonesand Bartlett Publishers.Birkmeyer, J., Dimick, J., & Birkmeyer, N. (2005). Measuring the Quality of Surgical Care, Structure, Process, or Outcomes. Retrieved January 11, 2012, from http://www.surgicalcomplication.info/PDF/2004BJD.pdfImage sourced from:http://3forward.com/wp-content/uploads/2011/04/process.jpg
AdvantagesHigh level of evidence supporting their effectiveness (often randomised clinical trials), some process measures have very large potential benefitsReflect the care that patients actually receive and may be perceived by providers as “fairer” measures of quality than structural measuresGenerally actionable and link directly to quality improvement activitiesDisadvantagesMust be able to accurately identify eligible patient Ensuring the right denominator implies the need for clinical data and may be labor intensive, a practical limitation of process measurementVarkey, P. (Ed.). (2010). Medical quality management: Theoryandpractice. Sudbury, MA: Jonesand Bartlett Publishers.Birkmeyer, J., Dimick, J., & Birkmeyer, N. (2005). Measuring the Quality of Surgical Care, Structure, Process, or Outcomes. Retrieved January 11, 2012, from http://www.surgicalcomplication.info/PDF/2004BJD.pdf
Seek to capture changes in the health status of patients following the provision of a set of health care processes and include the costs of delivering the processesShould describe the patient’s condition, behavior and responseProvide an indirect measure of the overall quality of an organisationVarkey, P. (Ed.). (2010). Medical quality management: Theoryandpractice. Sudbury, MA: Jonesand Bartlett Publishers.Birkmeyer, J., Dimick, J., & Birkmeyer, N. (2005). Measuring the Quality of Surgical Care, Structure, Process, or Outcomes. Retrieved January 11, 2012, from http://www.surgicalcomplication.info/PDF/2004BJD.pdfImage sourced from:http://tennisassist.com/wp-content/uploads/iStock_000004996421XSmall.jpg
AdvantagesMost consider patient outcomes the “bottom line” Measurement alone may improve outcomesDisadvantagesRelates to sample sizeBirkmeyer, J., Dimick, J., & Birkmeyer, N. (2005). Measuring the Quality of Surgical Care, Structure, Process, or Outcomes. Retrieved January 11, 2012, from http://www.surgicalcomplication.info/PDF/2004BJD.pdf
Historically, quality measurement has focused primarily on outcomes. Today, structure and process measures provide important insights, illuminating which areas to address in order to improve outcomes. Structure and process provide direct measures of quality and thus yield more sensitive measures of quality, which can direct clinicians to the most effective ways to improve patient care. Varkey, P. (Ed.). (2010). Medical quality management: Theoryandpractice. Sudbury, MA: Jonesand Bartlett Publishers.
Measurement: Process and Outcome Indicators. (2005). Retrieved January 11, 2012, from http://patientsafetyed.duhs.duke.edu/module_a/measurement/measurement.html
Adapted from:Measurement: Process and Outcome Indicators. (2005). Retrieved January 11, 2012, from http://patientsafetyed.duhs.duke.edu/module_a/measurement/measurement.html