Situation: The quality committee of a 200-bed hospital notes that the adult medical ward's rate of hospital-acquired pressure injury has risen for three quarters. The head nurse forms a team of staff nurses, a nursing attendant, a dietitian, and a physical therapist, which will work through the Plan-Do-Study-Act (PDSA) cycle. Using the structure-process-outcome framework, which measure is a process indicator for this project?

In the Donabedian model, structure is the resources and setting (equipment, staff qualifications), process is what is actually done for the client, and outcome is the change in the client's health. Repositioning at-risk clients on schedule is care delivered to clients, so it is a process measure. The pressure injury rate is an outcome, and mattresses and staff training are structure.

Structure-Process-Outcome Framework
The Donabedian model divides quality measures into three categories. Structure refers to the resources, staffing, equipment, and organizational characteristics of the care setting. Process refers to what is actually done when delivering and receiving care—the actions performed for the client. Outcome refers to the resulting change in the client’s health status. In this pressure injury prevention project, the correct process indicator is the proportion of at-risk clients who are repositioned on schedule, because repositioning is a direct nursing action delivered to the client ^[1][3].

A process measure captures whether evidence-based care was actually performed, not whether the resources existed or whether the client’s condition changed. The Delphi study on orthopedic pressure injury indicators used this same distinction: process indicators included actions such as risk assessment completion, skin inspection, and repositioning implementation, while structure indicators covered staffing ratios and equipment availability, and outcome indicators covered the incidence of new pressure injuries ^[1]. The quality improvement initiative described in the hospital-acquired pressure injury study likewise tracked process measures such as adherence to the prevention bundle and repositioning compliance, separate from the outcome measure of HAPI rates ^[3].

Watch out! Staff training completion (option 4) is a structure indicator because it reflects the qualification and preparation of the workforce—an attribute of the setting—not the care delivered to a specific client. The number of pressure-redistributing mattresses (option 2) is also structure, since it describes available equipment. The new pressure injuries per 1,000 patient-days (option 3) is an outcome indicator because it measures the change in client health status ^[1][4].

Key point! When a question asks for a process indicator, look for an action verb describing care performed on or for the client—assessing, repositioning, educating, administering, documenting. If the option describes a resource, qualification, or setting characteristic, it is structure. If it describes a health result or complication rate, it is outcome ^[1][3].

The Medicare pressure ulcer quality study illustrates how process measures are operationalized in real audits: reviewers examined whether at-risk patients received daily skin assessment, whether pressure-reducing devices were used, and whether repositioning was documented at appropriate intervals ^[4]. These are all process elements because they reflect what clinicians did, not merely what was available or what ultimately happened to the patient’s skin. In the PDSA cycle for this ward, tracking the proportion of at-risk clients repositioned on schedule allows the team to see whether the new care protocol is being carried out as planned—a process check that can then be linked to the outcome of reduced pressure injury incidence ^[3].

Category	Definition	Example from this project
Structure	Resources, staffing, equipment, organizational characteristics	Pressure-redistributing mattresses, proportion of staff who completed wound care training
Process	Care actually delivered to the client	Proportion of at-risk clients repositioned on schedule
Outcome	Change in client health status	New pressure injuries per 1,000 patient-days

The Chilean national implementation study reinforces this framework in practice: the program tracked process indicators such as completion of pressure injury risk assessment on admission and documentation of repositioning, while system-level outcomes included the incidence of hospital-acquired pressure injuries . A rise in the outcome measure (HAPI rate) triggers a review of process measures to identify where care delivery broke down. In this scenario, the team would first examine whether repositioning is actually being performed on schedule—the process—before concluding that more mattresses or more training (structure) are needed. The PDSA cycle is well suited to this because each cycle can test a small change in process and measure its effect on both process adherence and the downstream outcome ^[3].