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Purpose: Donabedian's 1966 framework of structure, process, and outcome has guided three decades of study in the United States of the elements needed to evaluate and compare medical care quality. Donabedian's perspective was essentially linear, assuming that structures affect processes, which in turn affect outcomes. Patient characteristics are sometimes considered as mediating outcomes and clinical interventions are considered to be processes. A model is presented in the following article that relates multiple factors affecting quality of care to desired outcomes. It extends previous models by positing dynamic relationships with indicators that not only act upon, but reciprocally affect the various components.
Scope and Sources: The proposed model was derived from a synthesis of the authors' experience in quality of care practice and research, as well as selected previous theories. Conclusions: The quality health outcomes model is sufficiently broad (a) to guide development of databases for quality improvement and outcomes management, (b) to suggest key variables in clinical intervention research, and (c) to provide a framework for outcomes research and outcomes management that compares not only treatment options, but organizational or system level interventions. The model also has several policy implications.
IMAGE: JOURNAL OF NURSING SCHOLARSHIP, 1998; 30(1 ), 43-46. 1998, SIGMA THETA TAu INTERNATIONAL.
[Key words: quality of health care; conceptual models; health policy]
Emphasis on the evaluation and management of healthcare quality has shifted over time from structures to processes to outcomes. The decade of the 1990s was devoted to outcomes research-as comparison of interventions, systems, and technologies on the basis of patient outcomes-and to outcomes management-as managing results by changing processes (Jones, Jennings, Moritz, & Moss, 1997).
For the most part, outcomes have been limited to what Lohr (1988) termed "The SDs": death, disease, disability, discomfort, and dissatisfaction. Only recently has there been an impetus to include more positive outcomes such as improved health status, functional ability, and perceived quality of life as roughly measured by the various health-related quality-of-life scales (Mitchell, Heinrich, Moritz, & Hinshaw, 1997b; Patrick, 1997).
For three decades Donabedian's (1966) views have guided work regarding the elements used to evaluate and compare health care quality. The emphasis on evaluating quality of care has shifted from structures (having the right things) to processes (doing things right) to outcomes...