Health Services Information: Application of Donabedian’s Framework to Improve the Quality of Clinical Care

  • A. Laurie W. ShroyerEmail author
  • Brendan M. Carr
  • Frederick L. Grover
Reference work entry
Part of the Health Services Research book series (HEALTHSR)


This chapter provides a summary of the well-established conceptual models related to measuring and improving the overall quality of medical care as described by the Institute of Medicine and founded upon Donabedian’s historical triad for quality measures. The subcomponents required for quality measurement are first identified, including (1) patient risk factors, (2) processes of care, (3) structures of care, (4) clinical outcomes, and (5) resource utilization or costs of care. The key challenges associated with applying this quality of care conceptual model to designing and implementing new research projects are then discussed, including the following cutting-edge measurement-related topics: (1) dealing with missing data (e.g., clinical substitution versus statistical imputation), (2) differentiating planned versus unplanned processes of care (e.g., distinguishing between interventions used as a matter of routine and those interventions that were initiated in response to observed changes in the patient’s status), (3) evaluating the differential impact of sequential versus nonsequential timing of events (e.g., cascading of outcomes), and (4) assessing the relative impact of medical versus nonmedical care influences upon the quality of patient medical care rendered. Historical projects designed to define, measure, and evaluate the quality of cardiac surgical care in the Department of Veterans Affairs Continuous Improvement in Cardiac Surgery Program and Society of Thoracic Surgeons National Adult Cardiac Database are presented to illustrate how these quality of care concepts can be applied. The challenges in using clinical databases to evaluate quality of care are then summarized. Finally, several innovative approaches are described toward advancing the future practice of quality measurement research.



This book chapter was supported, in part, by the Offices of Research and Development at the Northport and the Eastern Colorado Health Care System, Department of Veterans Affairs Medical Centers, as well as by the Stony Brook University School of Medicine’s Department of Surgery and the Stony Brook University Health Science Center Library. Additionally, special thanks are extended to Ms. Sarah Miller (University of Colorado at Denver), Ms. Carol Wollenstein (Nursing Editor, Stony Brook University), and Ms. Jennifer Lyon (Reference Librarian, Stony Brook University) for their proofreading and editorial assistance.


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Copyright information

© This is a U.S. government work and not under copyright protection in the U.S.; foreign copyright protection may apply 2019

Authors and Affiliations

  • A. Laurie W. Shroyer
    • 1
    Email author
  • Brendan M. Carr
    • 2
  • Frederick L. Grover
    • 3
  1. 1.Department of Surgery, School of MedicineStony Brook UniversityStony BrookUSA
  2. 2.Department of Emergency MedicineMayo ClinicRochesterUSA
  3. 3.Department of Surgery, School of Medicine at the Anschutz Medical CampusUniversity of ColoradoAuroraUSA

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