In response to your request of August 11, 1989, we have examined the issues that would need to be addressed in ensuring the quality of health care under any plan to expand health care coverage for the uninsured. We have assumed that the current system of multiple public and private purchasers of health care will remain in place for at least the immediate future. In addition, we have examined the adequacy of the knowledge base for structuring such quality assurance activities. However, because we believe that most of the quality assurance issues that would need to be addressed are generic, much of this report does not distinguish between quality assurance for the uninsured and for the general population. This briefing report presents the results of our work as discussed with your staff on January 23, 1990. We begin by noting that quality is multidimensional and that we have focused our attention on the appropriateness of care and the technical and clinical aspects of quality. We also note that health care system design has important implications for quality, and we briefly describe the various levels at which quality assurance activities are currently conducted. We conclude that there is a considerable body of knowledge about, and experience with, the organization and conduct of quality assessment and assurance activities and a growing interest in improving and expanding these activities among many of the participants, including the medical community, consumers, employers, and purchasers of care. In keeping with this growing interest, we suggest that a comprehensive, national approach and a brief discussion of each of its elements are contained in section 2 of this report. Our conclusions are based primarily on the studies of health care quality assessment and assurance in a number of settings spanning the public and private sectors that we have conducted over the past few years. We have also incorporated concepts and information on quality assurance contained in published sources, including the Institute of Medicine's report entitled Controlling Costs and Changing Patient Care? and the Office of Technology Assessment's report entitled The Quality of Medical Care: Information for Consumers. Finally, we convened a meeting of experts in November 1989 for the explicit purpose of exploring these issues and have had them review a draft of this report. (See appendix I.) We have not conducted a comprehensive review and analysis of existing quality assurance programs. Any references in this report to specific quality assurance programs are examples used to illustrate particular points and do not necessarily represent the "best" programs available. Our work was performed in accordance with generally accepted government auditing standards. We have incorporated the comments of our experts but have not requested comments from any federal agency, since none is evaluated in this work. Unless you publicly announce the contents of this report earlier, we plan no further distribution until 30 days from its date. We will then make copies available to others upon request. If you have any questions or would like additional information, please call me at (202) 275-1854 or Mr. Robert York, Acting Director of Program Evaluation in Human Services Areas, at (202) 275-5885. Other major contributors to this report are listed in appendix II. |