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Avedis Donabedian: A Framework for Measuring Quality

Clinical Example: 

It’s a busy night on labor and delivery.  Census and acuity are high and the unit is short staffed. Sally, a new nurse, offers to work extra to help out the unit. Despite being overtime and feeling exhausted, she wants to support her colleagues. She is assisting in triage and caring for two similar antepartum patients diagnosed with chronic hypertension and being monitored for preeclampsia. They are both taking labetalol. Sally enters her patient’s room to administer an additional dose of labetalol when she gets called out to the nurse’s station to answer a phone call from a provider. She had appropriately identified this patient and followed the correct medication verification steps. However, after speaking with the provider and getting pulled into triage to help out a resident, she then walked into her other patient’s room and administered the medication to her other patient. Sally did not follow the 5 rights of medication administration and the patient did not question her because she was getting her hypertensive medications adjusted as well.  As a result the patient later developed hypotension and had a syncopal episode while in the bathroom.  

Structure-Process-Outcome Model by Avedis Donabedian

Avedis Donabedian was a physician and researcher known for developing a framework for healthcare quality that consists of 3 components: structure, process and outcome. Structure refers to the environment and organization of health care delivery and includes resources such as staff to patient ratios, drugs, supplies, equipment, and use of electronic medical records. Think of structure as the factors that impact how care is delivered, and reflect the overall organization of care. In the example above, the structure of the unit (staffing model) results in the nurse having to care for too many patients.  

Process includes the steps performed by health care providers, within the structure, to achieve the desired outcome.  Examples of this include staff compliance rate with handwashing, the process of admitting patients, doing a surgical operation, and adherence to interventions as defined in policies & guidelines. Process is also described as what was done.  In the example above, Sally did not follow the correct steps in the medication verification process, resulting in a process failure.   

Finally, outcome reflects the impact of the health care service or intervention on the health status of patients (ex. blood transfusion rate, readmissions rate, complication rate, morbidity rate, medication errors). Simply stated, outcome is described as what happened to the patient. 

The clinical scenario is a good example of how these components are connected together.  Patient outcomes are linked to both the structure of the healthcare delivery and the process by which the care is performed, with staffing influencing the medication administration process and ultimately contributing to an error in patient care. 

*If this article interests you, you may also enjoy my book titled: Obstetric and Neonatal Quality and Safety (C-ONQS) Study Guide: A Practical Resource for Perinatal Nurses, available on amazon: Amazon_obneonatalstudyguide


Fondahn, E., Lane, M., & Vannucci, A. (2016). The Washington Manual of patient safety and quality improvement. Wolters Kluwer.

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