Donabedian’s framework: structure, process and outcome

The correct answer: D. The percentage of heart attack patients given aspirin on arrival

✅ Why this answer

Donabedian’s framework divides quality measures into three types. A process measure measures what is done for the patient: was the right care provided? Giving aspirin on arrival is a step of proven benefit, so the share of patients who received it is a process measure.

❌ Why the other options are wrong

• (A): the number of physicians is a structure measure: the resources available.
• (B): 30-day mortality is an outcome measure: what ultimately happened to the patient.
• (C): having the lab available around the clock is also a structure measure.

💡 Key concept

• Structure: what do we have? (staff, equipment and systems).
• Process: what do we do? (following the right steps).
• Outcome: what happened to the patient? (mortality, complications and recovery).

Process measures are easier to measure and change quickly, while outcome measures matter more but are affected by many factors and need risk adjustment for case severity.

In the exam: if the measure is the share of patients who received an action, it is a process measure. If it is an available resource, it is structure. If it is the patient’s condition in the end, it is an outcome.

🔗 Related facts and questions

• The same framework on a technology project: having a computerized provider order entry (CPOE) system in the hospital is a structure measure. The share of medication orders actually entered through it is a process measure. The rate of adverse drug events is an outcome measure.
  Practice question: “the share of patients with a known drug allergy whose allergy was recorded in the EHR before the first medication order”: what kind of measure is it? → A process measure, because it measures whether a step was done, not what is available or what happened to the patient.
• Risk adjustment for outcome measures: a hospital that receives sicker patients may have higher mortality even though its care is better. So mortality and complication results are adjusted for patients’ age and comorbidities before they are compared.
  Practice question: two hospitals are compared on “aspirin on arrival” and on “30-day mortality after heart attack”. Which of the two most needs risk adjustment before the comparison is fair? → 30-day mortality, because an outcome depends on how sick the patients were, while a process measure already counts only patients who should receive the step.
• The intermediate outcome: a clinical value linked to the final outcome, such as the share of diabetes patients whose HbA1c (glycated hemoglobin, the average blood sugar over about three months) is now below the target. It is not an action, and not yet a complication or a death.
• Measures the patient reports: PROMs (patient-reported outcome measures) measure an outcome the patient reports, such as their ability to walk after knee surgery. PREMs (patient-reported experience measures) measure their experience of care.
• The structure of an electronic clinical quality measure (eCQM): each measure has a numerator (those who received the action), a denominator (those who should have), denominator exclusions (patients removed from the denominator before the numerator is checked, such as those in hospice care) and denominator exceptions (patients who did not receive the action for a documented medical, patient or system reason, such as an aspirin allergy; they are removed only when the numerator is not met). An exclusion or exception must be recorded as structured data; otherwise the patient stays in the denominator and counts as a failure if the action was not given.
• Core measures: a related question in the full bank.
• The domains of electronic clinical quality measures: "The measurement domains of electronic clinical quality measures (eCQMs)" (in the full bank).
• Balancing measures: "Balancing measures in improvement projects" (in the full bank).
• Practice question: “the share of beds equipped with monitors”: what type is it? → Structure.