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Quality Measurement at CMS

Measure Development Theory

At a high level, CMS uses measures to assess and compare the quality of health care organizations. Most measures have the designation as structure, process, or outcome measures. This triad is also known as the Donabedian model named after Avedis Donabedian, the physician who developed it.


The Donabedian Model 

Donabedian defined process of care as “a set of activities that go on within and between practitioners and patients” (Donabedian, 1980, p. 79) and process is the primary object of assessment. Process is the normative care and is dependent on the state of the science of health care, values, and ethics. Donabedian defined outcome as “a change in a patient’s current and future health status that can be attributed to antecedent health care” (Donabedian, 1980, pp. 82-83). He noted assessing outcome is an indirect method of measuring quality of care. He argued that it is indirect because one cannot judge changes in health status as quality of care until you have eliminated other causes of the change. With respect to process, once you have established a process as clearly associated with good results, there is acceptance that the presence or absence of the process is evidence of good or bad quality. With outcome, you must also establish that there are no other possible factors to explain the change in status. The third piece, structure, is also an indirect method of measuring quality of care. Structure includes the physical setting, organizational policies, financial resources, the tools and resources available to providers of care, and much more. Donabedian noted that structure “is relevant to quality in that it increases or decreases the probability of good performance” (Donabedian, 1980, p. 82).

The triad of structure, process, and outcome have a relationship in that the structural aspects have an influence on the processes of care which, in turn, influence the effect of care on health status. Donabedian noted other aspects of quality of care can fit into these three categories. He acknowledged the triad designation is somewhat arbitrary because the differentiation of reality into these three parts is not clear and we should treat the triad as a guide, not as a straitjacket. Thus, quality measures have categorizations that extend beyond the triad.

Types of Measures discusses the categories of measures with definitions for the different measure types.


About Avedis Donabedian

Considered the father of modern health care quality management, Avedis Donabedian was a prolific writer penning 11 books and more than 100 articles addressing the topic of health care quality (Best & Neuhauser, 2004). His 1966 article, Evaluating the Quality of Medical Care, laid the groundwork for the Framework for Health Care Quality. Donabedian’s Framework outlines the structure, process, and outcome model, which is the basis for most current quality measures (Donabedian, 1966/2005). 

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