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This chapter addresses the following Geriatric Fellowship Curriculum Milestones: #32, #33, #38


Learning Objectives

  • Identify the different ways that quality of care can be assessed.

  • Discuss the quality-of-care issues particular to older adults.

  • Explain which patient safety practices are most relevant for older adults.

  • Understand the basic elements of quality improvement.

Key Clinical Points

  1. Quality can be measured as structure, process, and outcome. Most quality measurement schemes have used process measures, but outcome measures are becoming more common, and will likely continue to do so into the future.

  2. There are a great many existing US quality measurement efforts. Particularly prominent examples are those led by the Centers for Medicare and Medicaid Services (CMS), the National Committee for Quality Assurance (NCQA), the Consumer Assessment of Healthcare Providers and Systems, and The Joint Commission (TJC).

  3. There is no cookbook that can be followed for quality improvement initiatives. Success depends on many factors, and context is important.


The traditional framework for understanding how quality of care can be measured is one proposed by Donabedian (Figure 23-1). The underpinning of this framework is that high-quality medical care is defined as care which is expected to achieve the best balance of health benefits and risks, in other words medical care that does the best job at improving health or preventing health decline. Within this framework, quality is conceptualized as pertaining to technical and interpersonal care, each of which may influence the other.

Figure 23-1.

Donabedian frame work. (Adapted from Donabedian A. The Definition of Quality and Approaches to Its Management, Vol 1: Explorations in Quality Assessment and Monitoring. Ann Arbor, MI: Health Administration Press; 1980.)

Technical Care

Technical care can be measured in three domains: structure, process, and outcomes. Structure refers to the relatively stable characteristics of the providers, the tools and resources available to them, and the physical environment and organizational characteristics of the health system. Examples of structural measures of quality include board certification of physicians and accreditation of health organizations such as hospitals and health plans; the use of electronic health records or computerized provider order entry; and designation as a level 1 trauma center, which requires several structural requirements be met, including but not limited to, 24-hour in-house coverage by general surgeons, a minimal annual volume of severely injured patients and a comprehensive quality assessment program. The validity of structural measures depends on the evidence to support a relationship between the structure and a health outcome. An advantage of structural measures is that they are relatively easy to measure. However, given the stability of most health care structures, structural measures are generally not suitable for continuous quality assessment/improvement activities, but rather for periodic assessment.


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