Donabedian's Framework
Avedis Donabedian's quality framework classifies measures into three categories: structure, process, and outcome. Structure measures assess the capacity and systems in place to deliver care, such as staffing ratios or availability of certified equipment. Process measures assess whether recommended care was actually delivered, such as whether aspirin was given on arrival for a heart attack patient. Outcome measures assess the actual result of care, such as readmission rates or surgical site infection rates. RHIA candidates must be able to classify a given measure into the correct category.
Major Federal Quality Programs
- Hospital Inpatient Quality Reporting Program: requires hospitals to report specific quality measures to CMS or face a reduction in their annual payment update.
- Hospital Readmissions Reduction Program: reduces payments to hospitals with excess readmissions for specific conditions.
- Hospital Acquired Condition Reduction Program: penalizes hospitals in the lowest performing quartile for hospital acquired conditions.
- Value Based Purchasing Program: adjusts payment based on performance across clinical outcomes, patient experience, and efficiency domains.
Role of Coded Data
Accurate ICD-10-CM and ICD-10-PCS coding directly feeds many of these programs, since present on admission indicators, comorbidity and complication capture, and procedure coding determine risk adjustment and measure eligibility. Coding errors can artificially inflate or deflate a facility's reported performance, making coding accuracy a compliance as well as an analytics concern.
Registries and External Reporting
Beyond CMS programs, facilities often participate in clinical registries, such as trauma or cardiac registries, which require specialized data abstraction beyond standard coded data. HIM professionals frequently oversee or coordinate registry data submission given their expertise in data abstraction and quality assurance.
Public Reporting and Transparency
Many of these measures become publicly available through tools such as Hospital Compare, giving consumers comparative information and creating reputational as well as financial incentives for accuracy and improvement.
Exam Tip
When classifying a measure, ask whether it describes a capability that exists, an action that was taken, or a result that occurred. This simple test resolves most structure, process, and outcome classification questions on the exam.