Structure describes the context in which care is delivered, including hospital buildings, staff, financing, and equipment.

Process denotes the transactions between patients and providers throughout the delivery of healthcare.

The sequential progression from structure to process to outcome has been described by some as too linear of a framework, The model has also been criticized for failing to incorporate antecedent characteristics (e.g.

patient characteristics, environmental factors) which are important precursors to evaluating quality care.

For example, systemic lupus erythematosus (SLE) is a condition with significant morbidity and mortality and substantial disparities in outcomes among rheumatic diseases.

The propensity for SLE care to be fragmented and poorly coordinated, as well as evidence that healthcare system factors associated with improved SLE outcomes are modifiable, points to an opportunity for process improvement through changes in preventive care, monitoring, and effective self-care.

To improve this process, a healthcare administrator may look at the structure and decide to purchase an information technology (IT) solution of pop-up alerts for actionable lab results to incorporate into the EHR.

The process could be modified through a change in standard protocol of determining how and when an alert is released and who is responsible for each step in the process.Donabedian’s model can also be applied to a large health system to measure overall quality and align improvement work across a hospital, group practice or the large integrated health system to improve quality and outcomes for a population.In 2007, the US Institute for Healthcare Improvement proposed “whole system measures” that address structure, process, and outcomes of care.The process for information exchange, in this case the transfer of lab results to the attending physician, depends on the structure for receiving and interpreting results.The structure could involve an electronic health record (EHR) that a laboratorian fills out with lab results for use by the physician to complete a diagnosis.A researcher may develop evidence within these areas to analyze the relationship between structure and process to outcomes in SLE care for the purposes of finding solutions to improve outcomes.