TABLE 1—
Description of Framework Domains and Elements, With Examples of Possible Measures
| Domain/Element | Description | Measures (Illustrative Examples) |
| I. Capacity (physical and human assets) | ||
| Size | The system’s productive capacity | Metrics of scale, such as number of clinicians, number of beds, number of outpatient encounters, number of patients served |
| Metrics of output, such as number of patient encounters in a time period | ||
| Capital assets | The property, facilities, physical plant and the property’s ownership, equipment, and other infrastructure used to provide and manage health care services | Number and type of facilities |
| Additional considerations that affect the assets, such as facility and equipment age, accessibility, cost, depreciation | ||
| Comprehensiveness of services | The scope and depth of services available in terms of setting, specialty, ancillary services, and acuity of care | Scope of settings in which care is provided, such as hospital, home, clinic, nursing home, rehabilitation facility, hospice |
| Scope and number of care providers, such as primary care, specialty, and subspecialty (e.g., medical, surgical, behavioral health, palliative care) | ||
| Scope and number of providers of ancillary services, categorized as diagnostic, therapeutic, and custodial (based on a standard list of ancillary services) | ||
| Scope of services provided, such as preventive, acute, chronic, long term, hospice, and rehabilitation | ||
| II. Organizational structure | ||
| Configuration | The arrangement of the functional units in the system in terms of workflow, hierarchy of authority, patterns of communication, and resource flows among them | Diagrams of nodes or functional units and directional lines serving as links between units for any type of interaction–resource flow, communication, or instruction |
| Social network analysis to calculate indices from a matrix of linkages among the units, such as the centrality of any node in the network, the centralization of the network, or the density of interactions | ||
| Leadership structure and governance | The level of formal decision-making authority for an office holder in terms of the scope of decisions that can be made independently and with concurrence of others | Formal organizational authority, measured by hierarchical level and the scope of decisions at that level |
| Power and influence, determined by the interdependencies between units for critical resources, such as the ratio of resources provided to the total, and the ratio of resources received to the total | ||
| Research and innovation | The extent to which participation in clinical and basic scientific research and health care innovation is a feature of the mission and activities of the organization | Ratio of research activity to clinical activity or total activity on a variety of dimensions |
| The number of innovative processes, diagnostic procedures, products, and technologies | ||
| Involvement in clinical trials | ||
| A centralized office for technology transfer or intellectual property | ||
| The extent to which scientific research, new therapies, and innovation are important parts of the mission and activities of the system and its units | ||
| Professional education | The extent to which professional education and training is a feature of the mission and activities of the organization | Ratio of educational activity to clinical activity or total activity |
| Number of health professional student or trainee positions maintained by the organization | ||
| The extent to which professional education is an important part of the mission and activities of the system and units within the system | ||
| III. Finances | ||
| Payment received for services | The categorical types of payment received, the approach to accountability for services provided, the proportion of each payment type, and the degree of financial risk held | Proportion of payments received for patient care that are fee for service, bundled payments, fully capitated, or partially capitated |
| Provider payment systems | The categorical types of payment to individual providers for their services and the proportion of each payment type | Proportion of provider pay that comes from salary or base pay, productivity or relative value units, quality performance measures, patient satisfaction |
| Ownership | The corporate status and health care industry affiliation of the owner of the health care system | Government, for-profit, or nonprofit entity |
| Health plan, hospital, physician, or group of physicians or clinicians | ||
| Financial solvency | The extent to which the organization’s financial resources exceed the organization’s current liabilities and long-term expenses | Organization’s operating margin as a proportion of expenses and debt |
| Whether the organization operates at a surplus, break even, or a loss | ||
| IV. Patients | ||
| Patient characteristics | Proportion of patients with different characteristics, health conditions, and coverage types | Demographic indicators such as age, gender, race, ethnicity, education, and income |
| Proportion of patients with Medicare, Medicaid, commercial, and no insurance | ||
| Measure of diversity of system and patient population size | ||
| Measures of medical complexity, such as the Charlson Comorbidity Index or the Case Mix Index | ||
| Patient Activation Measure17 | ||
| Geographic characteristics | Geographic location as well as the type of community in which the health care delivery system functions and the size of the catchment area | Urban, suburban, rural, or frontier |
| Geolinked characteristics of the catchment area, such as population density and median household income | ||
| V. Care processes and infrastructure | ||
| Integration | The extent to which a network of organizations or units within 1 organization provides or arranges to provide a coordinated continuum of services to a population and is willing to be held clinically and fiscally accountable for the outcomes and health status of the population served | Functional Integration measure,18 which is a pilot measure of the 3 integration domains: structure, finance, and function |
| Standardization | The extent to which the health care delivery system reduces unnecessary variation while encouraging differences dictated by diversity among patients in their conditions and preferences | A preliminary measure, though difficult to operationalize, of the proportion of the medical care provided by the organization that is covered by protocols and guidelines |
| Performance measurement, public reporting, and quality improvement | The extent to which the organization conducts regular measurement of performance with public reporting, feedback, and a systematic process of improvement | Number of clinical performance measures assessed at least yearly |
| Proportion of those measures with results reported to the public and those providing measured care | ||
| Proportion of those measures with active action plans for improvement | ||
| Health information system | The extent to which clinical and administrative information is organized and available to those who need it in a timely way and the extent to which they have electronic support for those functions | Whether clinical information system is paper only, paper with some electronic ordering or data systems, electronic with separate order and data systems, or electronic that handles all functions |
| Patient care team | Extent to which patient care is delivered by clinicians and staff who regularly work together in an integrated way to serve patients and their families. | AHRQ TeamSTEPPS and Teamwork Attitudes Questionnaire19 |
| Clinical decision support | Extent to which clinical guideline-based reminders and decision aids are incorporated in the process of patient care | E-clinician surveys |
| Average number of reminders or suggestions provided automatically to clinicians during patient visits that are perceived by them as valuable | ||
| Ability of electronic medical record system to link from within the system to established clinical guidelines | ||
| Care coordination | The deliberate organization of patient care activities between ≥ 2 participants involved in a patient’s care to facilitate and maximize the appropriate delivery of health care services to achieve optimal patient experience and outcomes | Approximate number of personnel and clinicians whose job is primarily to coordinate services from different providers for patients |
| AHRQ’s Care Coordination Measures Atlas20 that includes measures of the patient and family perspective, health care professional perspective, and systems representatives perspective | ||
| National Quality Forum’s 24 preferred practices for care coordination20 | ||
| VI. Culture | ||
| Patient centeredness | The degree to which health care delivery is designed to serve the interests of patients (vs providers) | Coordination of care measures |
| Versions of the CAHPS patient experience surveys, especially PCMH | ||
| Shared decision-making | ||
| Various provider continuity measures | ||
| Cultural competence | Ability of systems to provide care to patients with diverse values, beliefs, and behaviors, including tailoring delivery to meet patients’ social, cultural, and linguistic needs | Availability of informational materials and translators |
| Whether cultural competence goals are identified in strategic plan | ||
| Whether there are strategies to recruit, retain, and promote a diverse leadership and staff | ||
| National Quality Forum’s 45 preferred practices for measuring and reporting cultural competency | ||
| Competition–collaboration continuum | Where the organization falls on a scale from competitive to collaborative in relation to other organizations in its locale | Number and scope of collaborative initiatives with competitors |
| Community benefit | Extent to which the organization is concerned about the health of the local community and takes advantage of community services for its patients through collaboration | Level of uncompensated care provided |
| Number and value of formal community partnerships | ||
| Existing mechanism to assess and prioritize local health care needs | ||
| Collaborations with local organizations and public health to improve community health | ||
| Financial contributions to local community organizations | ||
| Innovation diffusion | The degree to which the health care delivery organization or system is focused on creating and adopting new ways to provide care and accomplish its mission | Implementation of regular process improvement via quality improvement mechanisms such as plan–do–study–act |
| Working climate | The degree to which the organization’s employees perceive an environment of openness and fair process | Employee satisfaction survey |
| Proportion of employees who report feeling | ||
| informed about where their company is going | ||
| espected for their contributions at work | ||
| involved in making changes to improve care, service, and efficiency |
Note. AHRQ = Agency for Healthcare Research and Quality; CAHPS = Consumer Assessment of Health Providers and Performance Systems; PCMH = Patient Centered Medical Home. A health care delivery system is an organization of people, institutions, and resources to deliver health care services to meet the health needs of a target population.