Health Care Structures & Processes

Introduction #

Health Systems Science (HSS) represents a foundational pillar of medical education and healthcare delivery, alongside basic and clinical sciences. At its core, HSS encompasses the study and understanding of how care is delivered, how health professionals work together, and how the health system can improve patient care [1]. Health Care Structures & Processes constitute one of the fundamental domains of HSS, providing the essential framework for understanding healthcare delivery quality and outcomes. The Donabedian structure-process-outcome model, first introduced in 1966, remains the dominant paradigm for assessing healthcare quality and forms the conceptual foundation for understanding how healthcare systems function [2,3]. This review examines the key components of healthcare structures and processes, their interrelationships, and their implications for healthcare delivery and patient outcomes.

The Donabedian Framework: Structure, Process, and Outcome #

Avedis Donabedian developed the seminal framework for measuring quality in healthcare, describing the importance of measuring not only health outcomes but also the healthcare processes and structures required to achieve ideal health outcomes [4]. This structure-process-outcome (SPO) triad has become the benchmark for measuring healthcare quality and remains central to contemporary quality improvement efforts [2,5].

Structure refers to the attributes of the setting in which care occurs, including all resources needed for healthcare provision such as material resources (facilities, capital, equipment, pharmaceuticals), intellectual resources (medical knowledge, information systems), and human resources (healthcare professionals and their qualifications) [3,6]. Structural measures give consumers a sense of a healthcare provider’s capacity, systems, and processes to provide high-quality care, such as whether the organization uses electronic medical records, the number or proportion of board-certified physicians, and the ratio of providers to patients [7].

Process encompasses all actions that constitute healthcare delivery, including diagnosis, treatment, preventive care, and patient education [2,6]. Process measures indicate what a provider does to maintain or improve health and typically reflect generally accepted recommendations for clinical practice, such as the percentage of people receiving preventive services [7]. Donabedian considered process measurement nearly equivalent to measuring quality of care because process contains all acts of healthcare delivery [6].

Outcomes refer to the effects of healthcare on the health status of patients and populations, including changes to health status, behavior, knowledge, patient satisfaction, and clinical indicators [2,6]. Outcome measures reflect the impact of healthcare services or interventions, such as surgical mortality rates, complication rates, or hospital-acquired infections [7]. While outcomes may appear to represent the gold standard in measuring quality, they result from numerous factors beyond providers’ control, necessitating risk-adjustment methods [7].

The Donabedian model has been validated across various healthcare settings. Studies demonstrate significant correlations between structure and process quality indicators, and between process and outcome quality indicators, suggesting that healthcare centers performing well in structural terms also tend to perform well in clinical processes, which in turn favorably influences patient outcomes [8,9].

Healthcare Organizational Structures #

Healthcare organizational structures vary considerably but all perform essential functions including governance, health financing, ensuring availability of medical products and technologies, generating relevant health information, creating and sustaining a health workforce, and providing health services [10]. Understanding these diverse organizational models is essential for optimizing healthcare delivery.

Patient-Centered Medical Home (PCMH)

The Patient-Centered Medical Home represents an approach to delivery of advanced primary care that addresses and integrates high-quality health promotion, acute care, and chronic condition management in a planned, coordinated manner [11]. The PCMH model encourages patients and providers to work closely together to ensure comprehensive, coordinated, and consistent care [12]. Unlike episodic care, the medical home necessitates an ongoing, full-spectrum approach requiring the primary healthcare provider and patients to maintain complete awareness of healthcare needs and experiences [12].

Key features of the PCMH include comprehensive care delivery through a primary care nexus, care coordination by dedicated coordinators (typically registered nurses, physician assistants, or social workers), enhanced access to care including telehealth options, and focus on quality and safety [11,12]. The PCMH is a systems-based approach in which structures and processes are established to ensure holistic and coordinated care delivery to patients [13]. The model has been associated with improved patient outcomes, increased patient satisfaction, and reduced healthcare costs compared to standard care models [13].

Accountable Care Organizations (ACOs)

An Accountable Care Organization is a group of providers—including physicians and hospitals—that accepts joint responsibility for healthcare spending and quality for a defined population of patients [14]. ACOs can be considered an extension of the health maintenance organization model and share features with the PCMH in focusing on robust primary care that coordinates patient care [14]. The ACO model emphasizes accountability through value-based reimbursement that incorporates voluntary collaboration among providers [13].

Three key characteristics define ACOs: (1) joint accountability at the organizational level for financial risks and rewards, (2) accountability for both quality and spending based on defined metrics across domains including patient experience, care coordination and safety, preventive health, and at-risk populations, and (3) responsibility for care of a defined population with attribution typically occurring retrospectively [14,15]. Studies comparing ACO and PCMH models have shown both are associated with reduction in healthcare costs compared with standard care, with stand-alone models demonstrating greater cost reduction than hybrid models [13].

Managed Care Organizations

Managed Care Organizations focus on managing and coordinating healthcare services, coming in various models including Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), and Point of Service (POS) plans, each offering specific advantages and trade-offs regarding patient choice and cost-effectiveness [16]. These organizational structures aim to balance quality care delivery with cost containment through various mechanisms including provider networks, utilization management, and care coordination protocols.

Healthcare Processes and Care Delivery #

Healthcare processes represent the sum of all actions that make up healthcare delivery, encompassing both technical processes (how care is delivered) and interpersonal processes (the manner in which care is delivered) [2,6]. Contemporary healthcare emphasizes several key processes that fundamentally impact quality and outcomes.

Interprofessional Collaboration

Interprofessional collaboration (IPC) is recognized as the gold standard of comprehensive care [17]. IPC can be described as the capability of every healthcare professional to effectively embrace complementary roles within a team, work cooperatively, share responsibilities for problem-solving, and make decisions needed to formulate and carry out patient care plans [18]. Improved healthcare collaboration has been shown to improve patient outcomes including reducing preventable adverse drug reactions, decreasing morbidity and mortality rates, and optimizing medication dosages [19,20].

Essential elements of effective interprofessional collaboration include shared understanding, respect for team members, effective communication, conflict management, and collective leadership [19,21]. Studies demonstrate that IPC increases collective awareness of each team member’s knowledge and skills, contributing to quality of care through continued improvement in decision-making [18]. However, implementation barriers include perceived threats to professional identity, role definition issues, poor communication, lack of co-location, and insufficient time allocated for collaborative activities [20,22].

The evidence supports that practice-based interprofessional collaboration interventions can improve professional practice and healthcare outcomes [23]. Types of IPC interventions evaluated include externally facilitated interprofessional activities, interprofessional rounds, interprofessional meetings, and interprofessional checklists, with studies demonstrating improvements in clinical processes, adherence to recommended practices, and patient functional status [23].

Care Coordination and Transitions

Effective care coordination represents a critical process for ensuring patients receive appropriate care across settings and over time. Successful coordination requires clear communication between healthcare providers, standardized processes for information transfer, and active engagement of patients and families in care planning [24]. Care transitions, particularly for complex patients, depend on interprofessional team collaboration with all members understanding information needs and care continuity requirements [24].

Quality Improvement Methodologies #

Healthcare quality improvement relies on systematic approaches to enhance care delivery structures and processes. The Plan-Do-Study-Act (PDSA) cycle represents one of the most frequently used tools in healthcare quality improvement [25,26].

The PDSA Cycle

The PDSA methodology is an iterative, four-step model for improving processes [25,26]. The Plan phase involves developing a plan with clear predictions of outcomes and assigned tasks. The Do phase implements the plan and collects data. The Study phase analyzes results obtained. The Act phase adopts, adapts, or abandons the plan based on data evaluation [25].

PDSA cycles are designed to facilitate learning through iterative testing of changes in small-scale, controlled environments before scaling to larger implementation [26,27]. The method has been adapted to healthcare from its manufacturing origins and focuses on building fundamental knowledge necessary to enable improvement [25,26]. A systematic review of 120 quality improvement projects using PDSA found that while 98% reported improvement, only 27% described specific, quantitative aims and reached them, and only 4% adhered to all four key methodological features [28]. This highlights challenges in PDSA implementation, including oversimplification, insufficient investment in planning phases, and deviation from core principles [27,28].

The FOCUS-PDSA model extends the basic PDSA approach by adding initial steps: Find a problem, Organize a team, Clarify the problem, Understand the problem, and Select an intervention [29]. This comprehensive approach emphasizes interdisciplinary team formation and systematic data collection as essential components of sustainable quality improvement [29].

Other Quality Improvement Approaches

Beyond PDSA, healthcare organizations employ various quality improvement methodologies including Lean, which focuses on reducing waste and redesigning workflows, and Six Sigma, which emphasizes reducing defects through root cause analysis [30]. These approaches share common goals of improving quality, outcomes, and cost-effectiveness while requiring organizational culture change, leadership buy-in, and sustained resource commitment [31].

Patient Safety Culture #

Patient safety culture represents the shared values, attitudes, competencies, and patterns of behavior related to patient safety work at multiple levels within an organization [32,33]. A robust patient safety culture is characterized by organizational commitment to safety, acknowledgment and learning from errors, supportive environment for reporting, and emphasis on continuous improvement [33,34].

Research demonstrates that patient safety culture significantly influences healthcare outcomes. Studies show strong associations between positive safety culture and reduced adverse events, with adverse events affecting approximately 10% of in-hospital patients [32,35]. Key dimensions of patient safety culture identified across studies include leadership commitment to safety, teamwork and collaboration, communication openness, organizational learning, non-punitive response to errors, staffing adequacy, and management support [33,36].

Effective adverse event reporting is essential for identifying causes of failures and improving safety [33,37]. However, evidence indicates reporting rates remain low in many healthcare settings, with cultures of blame evident in approximately 43% of surveyed organizations [37]. Interventions to enhance patient safety culture include executive and interdisciplinary walk rounds, team training programs, comprehensive unit-based safety programs, and structured communication protocols, with studies demonstrating statistically significant improvements in both safety culture perceptions and patient outcomes [38].

The relationship between patient safety culture and clinical outcomes has been established through multiple studies. Meta-analyses demonstrate significant negative correlations between overall patient safety culture and missed nursing care [39], and positive associations between teamwork culture interventions and decreased adverse outcome scores [38]. Healthcare worker burnout, affecting 34-35% of clinicians in recent studies, negatively impacts both individual well-being and patient safety, creating a concerning cycle where adverse events contribute to burnout which in turn increases the risk of future safety events [34].

Healthcare Sustainability and Program Implementation #

Sustaining healthcare improvement programs represents a significant challenge, with sustainability influenced by multiple factors across individual, organizational, and system levels [31]. A systematic review of healthcare program sustainability identified key barriers and facilitators, with the most frequently noted factors including organizational support and resources, staff engagement and buy-in, leadership commitment, compatibility with existing workflows, and financial sustainability [31].

Effective sustainability requires attention to inner setting characteristics including organizational culture, implementation climate, and structural characteristics [31]. Successful programs typically demonstrate alignment between program goals and organizational priorities, involvement of stakeholders in planning and implementation, adequate resource allocation, and mechanisms for ongoing evaluation and adaptation [31].

Healthcare Informatics and Technology #

Healthcare informatics and health information technology represent critical structural components of modern healthcare delivery, enabling communication, coordination, documentation, and data-driven decision-making. Electronic health records (EHRs) serve as the foundation for information exchange, providing comprehensive patient data accessible across care settings and over time.

The integration of health information technology into healthcare delivery requires attention to both structural and process considerations. Structural elements include technical infrastructure, interoperability standards, data security protocols, and user interface design. Process considerations encompass clinician training, workflow integration, standardized documentation practices, and optimization of clinical decision support [40].

Studies of eHealth integration using the Donabedian framework have identified numerous indicators across structure, process, and outcome categories, with the most frequently noted indicators related to inner organizational setting, care receivers (patients), and technology characteristics, along with their mutual interactions [40]. Successful integration requires addressing technical issues, ensuring adequate training and support, managing workflow disruptions, and maintaining focus on the ultimate goal of improved patient care.

Conclusion #

Healthcare structures and processes form the essential foundation for understanding and improving healthcare delivery and outcomes. The Donabedian framework continues to provide a valid and practical approach for evaluating healthcare quality across diverse settings. Contemporary healthcare emphasizes organizational models that promote coordination and accountability, including Patient-Centered Medical Homes and Accountable Care Organizations. Effective healthcare delivery requires attention to critical processes including interprofessional collaboration, care coordination, systematic quality improvement, and robust patient safety culture.

Success in healthcare improvement depends on understanding the complex interrelationships between structural elements, care delivery processes, and patient outcomes. Organizations must invest in building supportive infrastructure, developing collaborative practice environments, implementing systematic quality improvement methodologies, fostering positive safety cultures, and thoughtfully integrating health information technology. As healthcare systems continue to evolve, maintaining focus on these fundamental structures and processes while adapting to emerging challenges and opportunities will be essential for achieving the goals of improved patient outcomes, enhanced population health, and sustainable healthcare delivery.

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