Measuring the quality of a complex service like critical care that
combines the highest technology with the most intimate caring is a
challenge. Recently, con- sumers, clinicians, and payers have requested
more formal assessments and comparisons of the quality and costs of
medical care [2). Donabedian [1) pro- posed a framework for thinking
about the quality of medical care that separates quality into three
components: structure, process, and outcome. An instructive analogy for
understanding this framework is to imagine a food critic evaluating the
quality of a restaurant. The critic might comment on the decoration and
lighting ofthe restaurant, how close the tables are to each other, the
extent ofthe wine list and where the chef trained. These are all
evaluations of the restaurant structure. In addition, the critic might
comment on whether the service was courteous and timely - measures of
process. Finally, the critic might comment on outcomes like customer
satisfaction or food poisoning. Similarly, to a health care critic,
structure is the physical and human resources used to deliver medi- cal
care. Processes are the actual treatments offered to patients. Finally,
outcomes are what happens to patients, for example, mortality, quality
of life, and satisfac- tion with care (Table 1). There is a debate about
which of these measurements is the most important measure of quality.