Structure Measures in Quality Assessment
Structure measures assess the characteristics of the setting in which care is delivered. They are one of three measurement categories in the Donabedian model, alongside process and outcome measures, and remain important in healthcare quality assessment.
The Donabedian Model
Avedis Donabedian proposed that healthcare quality can be assessed through three dimensions. Structure refers to the physical and organizational properties of the care setting. Process refers to the activities involved in delivering care. Outcomes refer to the effects of care on patients and populations. Donabedian theorized that good structure increases the likelihood of good processes, which in turn increases the likelihood of good outcomes.
What Structure Measures Capture
Structure measures encompass a broad range of organizational characteristics. Physical attributes include facility design, equipment availability, and technology infrastructure. Organizational attributes include staffing ratios, staff qualifications and credentials, governance structures, and committee composition. Financial attributes include resources allocated to quality improvement, patient safety, and staff development. Policies and procedures, including the existence of specific protocols and guidelines, are also structural elements.
Strengths and Limitations
Structure measures are relatively easy to collect and can be assessed through surveys, site visits, and document review. They are commonly used in accreditation and regulatory assessments (for example, The Joint Commission evaluates many structural requirements). However, structure measures have a significant limitation: they measure capacity and capability, not actual performance. An organization may have the right structures in place without consistently executing effective processes or achieving good outcomes.
Examples in Practice
Common structure measures include nurse-to-patient staffing ratios, board-certified physician percentages, availability of electronic health records, existence of a patient safety committee, and presence of rapid response teams. CMS Conditions of Participation include many structural requirements that hospitals must meet.
Balanced Measurement
Quality professionals should use structure measures as part of a balanced measurement approach that includes all three Donabedian dimensions. Structure provides the foundation, but process and outcome measures are needed to confirm that structural investments translate to better care delivery and patient results.