Strategies for Measuring the Quality of Psychotherapy: A White Paper to Inform Measure Development and Implementation. IV. Structure Measures


Structure measures assess the capacity of a provider, clinic, or health care organization to deliver evidence-based care, and they may address such topics as staffing, data systems, and treatment procedures (Donabedian 1988). Structure measures are most often used in accreditation or certification programs that set minimal requirements for health care organizations (AHRQ 2013a) and may be helpful as a roadmap for organizations to follow when they assume responsibility for new activities or new populations (Teague et al. 2012; NCQA 2013).

With current federal efforts to spur delivery system reform, structure measures are being used to qualify organizations for participation in programs or eligibility for new incentives. For example, consistent with the ACA's incentives for developing new models of care and adoption of health information technology, structure measures have been introduced for behavioral health homes that take on responsibility for integrated mental and physical health care (SAMHSA-HRSA Center for Integrated Health Solutions 2012). To receive financial incentives for meaningful use of EHRs, providers are required to meet objectives for collecting and using particular types of data. Structure measures may also be used to certify providers, thereby making them eligible for new payment arrangements. For example, in some states, Medicaid providers must demonstrate that they meet certain standards before they can bill for Multisystemic Therapy (North Carolina MST Funding and Medicaid Standards n.d.).

In mental health care, structure measures are among the diverse means for gauging the fidelity of treatment (Teague et al. 2012). Fidelity can be conceptualized as a combination of provider competence in delivering treatment, provider adherence to treatment, and the extent to which the treatment differentiates itself from other treatments (Schoenwald and Garland 2013; Schoenwald et al. 2011a, 2011b). Because treatments are adapted to fit into service settings, structure measures can assess whether organizations have the capacity to deliver evidence-based psychotherapy (sufficient numbers of trained staff and procedures for supervision, for example) while process measures indicate something about the extent to which the adaptations result in the delivery of treatment that still contains the core components of the evidence-based model. Pairing structure and process measures may help to provide a more comprehensive understanding of the quality of care. For example, a study of mental health care in the U.S. Department of Veterans Affairs (VA) used a facility survey to assess the availability of evidence-based practices such as CBT as well as process measures of the receipt of evidence-based practices (the percentage of patients with PTSD who had any CBT visit during the study period) (Watkins et al. 2010, 2011).

Structure measures to assess the capacity of clinics or organizations to deliver evidence-based psychotherapy could address such topics as:

  • Availability of staff who are trained in evidence-based psychotherapy.

  • Adoption and implementation of protocols or guidelines for the use of evidence-based psychotherapy.

  • Availability of tools that support a consumer's engagement in therapy (web-based tools, workbooks, or homework materials).

  • Availability and use of tools for assessing symptoms and functioning, and the use of those tools to monitor outcomes.

Likely data sources for structure measures include data reported by an organization or clinic through surveys, reports, or documentation. Audits or reviews of documentation may be warranted to ensure the validity of these reports when payment is at stake.

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