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Evaluating the Quality of Health Care

4. Types of Quality of Care Measures

Although the aims above suggest how one might measure quality, there are multiple approaches to measuring different aspects of quality.  One of the first comprehensive works that focused on quality of care was published in a series of three books by Avedis Donabedian (Donabedian, 1980, 1982, 1985).  A subsequent article (Donabedian, 1965) summarized that work.  Donabedian proposed that one could assess whether high quality care is provided by examining the structure of the setting in which care is provided, by measuring the actual process of care, and/or by assessing what the outcomes of care are.

Structure refers to the characteristics of the setting in which care takes place.  Measures of the setting used might include characteristics of:

  • Physicians and hospitals (e.g., a physician's specialty or the ownership of a hospital);
  • Personnel; and/or
  • Policies related to care delivery. 

Increasingly, we view structure as not just the way clinics and hospitals are organized and operated, but by the policies they have in place that affect care quality.  For example, processes for monitoring and promoting quality, incentives for high quality care, etc. can have an influence on how well care is delivered.  A motivation for focusing on structure is the premise that the setting can be a strong determinant of care quality and given the proper system, good care will follow.  For example, one would expect care to be of higher quality when all staff are clear about their roles and responsibilities, when there are strategies for monitoring adherence to recommended procedures, and there are systematic approaches to continuously improving care quality.
Donabedian, A. (1980). Explorations in quality assessment and monitoring. Vol. 1. The definition of quality and approaches to its assessment. Ann Arbor, Mich.: Health Administration Press.
Donabedian, A. (1982). Explorations in quality assessment and monitoring. Vol. 2. The criteria and standards of quality. Ann Arbor, Mich.: Health Administration Press.
Donabedian, A. (1985). Explorations in quality assessment and monitoring. Vol. 3. The methods and findings of quality assessment and monitoring: an illustrated analysis. Ann Arbor, Mich.: Health Administration Press.