Although choosing which criteria to examine can be difficult, assessing structural elements tends to be fairly straightforward. With respect to structure, one can ask the following: Does the facility meet appropriate fire, safety, and sanitation codes? Do staff have relevant or legally required professional credentials? Are adequate records kept?

In home care and residential care, process elements are slightly more difficult to assess than is true for care rendered in hospitals or physicians' offices because the actual processes of care are invisible and cannot always be inferred from records. Moreover, the more socially oriented aspects of care concerning the way personnel relate to consumers are difficult to observe and measure. Nonetheless, regarding the processes of care, questions such as the following arise: Did a nurse visit the consumer in a timely manner? Was her assessment accurate and comprehensive? Did she follow the correct procedures for treating the consumer's condition? Did she inform the consumer about his or her condition? Did she treat the consumer with respect and involve him or her in the decisionmaking process?

Outcomes can be viewed from the perspective of consumers and their families, care providers, and the community. Outcomes are somewhat more elusive to measure than is the case for structural or process variables, but arguably they are the most important aspect of quality. Outcomes measures prompt questions such as: Did the provision of care achieve the goals intended and expected? Was the patient, resident, or consumer satisfied with the services rendered and the results achieved?

Recently, the emphasis of regulation at all levels of government and industry has shifted to improving performance based on outcomes measurement. Although structure and process measures are still considered valuable, greater importance has been placed on ensuring that a regulated entity achieves a desired goal, instead of merely complying with basic capacity standards and procedural steps that presumably lead to the achievement of that goal. This shift can be seen in the Clinton administration's initiation of a far-ranging series of regulatory reforms and in Congress' passage of the Government Performance and Results Act of 1993, which requires federal agencies to develop clear statements of what their regulations are intended to accomplish (GAO, 1995d).

The shift to outcomes measurement has recently picked up momentum in the field of home and community-based care. The Health Care Financing Administration (HCFA) is sponsoring work on the development of an outcomes-based quality improvement approach, which has the capability to examine specific patient-level outcomes, for use by Medicare home health agencies and the Medicare system (Peter Shaughnessy, University of Colorado, personal communication, September 22, 1995). Similarly, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has recently restructured its survey and accreditation procedures for home health agencies to be much more focused on outcomes measurement (JCAHO, 1994). Many residential care



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