Donabedian's three approaches to assessment of quality of care are explained
a. Structure. This approach to assessment focuses on the settings in which care
occurs. Physical aspects of the facilities and equipment, the characteristics of the
administrative organization, and the number, mix, and qualifications of the staff are
examined. In brief, all the properties and resources used to provide care and the manner
in which they are organized are evaluated in the structural approach.
(1) Assumptions. When structure is used as an indicator of quality, there are
two underlying assumptions:
(a) First, it is assumed that better care is likely to be provided with better
qualified staff, improved physical facilities, and more sound fiscal policy and
(b) Second, it is assumed that what is "good" in staff, physical structure,
and formal organization can be identified.
(2) Elements of structural appraisal. In appraising structure, the following
elements are examined:
(a) Licensure. The consumer is protected from untrained and/or
unscrupulous practitioners by state licensure of physicians and nurses.
(b) Board certification. Professional organizations and associations
certify special qualifications and training of professionals.
(c) Credentialing. Hospitals delineate the clinical privileges for individual
practitioners within their facility.
(d) Accreditation. The Joint Commission on Accreditation of Healthcare
Organizations (JCAHO) gives its official approval to a hospital and vouches that JCAHO
standards have been met by awarding accreditation. This means public acknowledgement
that the hospital provides quality health care in a physically safe place, that it provides
essential services through a well-organized and efficient professional and administrative
b. Process. This approach to assessment relates to what is actually done in
giving and receiving care. Assessment is accomplished through examining the activities
of physicians and other health professionals in making a diagnosis and recommending or
implementing treatment. It also includes the activities of the patient in seeking care.