One of the important frameworks and performance measurement in healthcare is Donabedian's model. I'm going to share a little bit about Donabedian's model, but first I'm going to share a little bit about who Dr. Donabedian was. Dr. Avedis Donabedian was a physician and a professor of medical care organization at the University of Michigan School of Public Health. Dr. Donabedian grew up in Lebanon, and came to the United States in his mid 30s. He saw himself as an outsider, in that he, because he didn't grow up in the U.S. and didn't necessarily grow up with the U.S. healthcare system, saw his ability as an outsider to more objectively and independently assess how the U.S. healthcare system works. Dr. Donabedian proposed a framework, a triad of structures, processes, and outcomes that can be used to evaluate the quality of healthcare. He defined each of the terms in the following ways. He defined structures as the settings, the qualifications of providers, and administrative systems through which care takes place. He defined processes as the components of care delivered, and defined outcomes as the recovery, the restoration of function and survival of patients. I'll give you some more specific examples of each of those in some following slides. There are three components of the Donabedian model: structures, processes, and outcomes. Structures includes things such as the environment in which care is provided, the human resources that are used to provide care, the organizational policies that an organization or a hospital may have in place to support quality and safety of care. And then the actual physical materials and equipment. All of those would be considered structures that support quality and safety of care. Processes I like to think of as the interaction between the clinician or healthcare provider and the patient. So, this is what is occurring between the provider providing care and the patient receiving care. And the outcomes are what happened to the patient. Some examples are mortality, the patient's functional status, and complications. Here is a specific example of Donabedian's model in the context of preventing hypothermia for surgical patients. So, a structural measure would be how is care organized. And a specific example for hypothermia prevention would be, are there patient warmers in the pre-op area? So those physical equipment, the patient warmers would be the example of the structural measure. The process measure was, are the patients warm? Did a health care provider actually use those patient warmers and apply them to the patient to wrap the patient in the warmers? So that's the process. That's the interaction between the healthcare provider and the patient. And the outcome is, what was the results? What happened to the patient? And in this very specific example, we would be concerned with, was hypothermia reduced? Did the patient somehow have hypothermia or did they not have hypothermia? So that's just one example of a structural measure, a process measure, and an outcome measure for a specific area of care. Ultimately, the idea is that the structures help support the processes which help support the outcomes. And it's really that outcome that we're most interested in and concerned about. One of the great tensions in performance measurement and health care is should we put our focus on outcome measures or should we put a focus on process measures. There's really a couple of considerations to think about in regards to this debate. One is that the process measures don't always correlate well with outcome measures. One example is a facility's adherence in providing discharge instructions doesn't necessarily correlate with their 30-day readmission rate. It's often been found that it's actually adherence to a bundle of process measures that actually can correlate better with the outcome measures as opposed to individual process measures. Also process measures may actually exhibit a stronger relationship with longer-term outcomes. It may not necessarily be that that process measure correlates with how the patient does immediately in the hospital or immediately after their discharge, it may actually better correlate to how the patient does six months from now, or a year from now. Sometimes there isn't necessarily a strong link between processes and outcomes. So, is there still value in measuring those processes of care that don't correlate with outcomes? I think we're still doing research on that to really understand that distinction. One possible idea which we'll talk later about is this idea of a composite measure. And could you actually bring together process measures and outcome measures together into a single measure of performance that could reflect performance in both. And really, at the end of the day what we really need is more research to understand really what does improve patient outcomes. We do know that some processes do correlate with that. We know some don't, but we really need to dig in more to understand that link. To wrap up this information on Donabedian's model, I wanted to share with you a final thought from Dr. Donabedian. This was a quote he provided. This was actually in the last days of his life. "Ultimately, the secret of quality is love. You have to love your patient. You have to love your profession. You have to love your God. If you have love, you can then work backward to monitor and improve the system." I think Dr. Donabedian leaves us with a lasting legacy, both in that quote, and in the model he proposed of structures, processes, and outcomes.