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Quality, Quality Assurance, and the Health
Care System

In this section, we begin with an overview of the concept of health care quality and how we use it in this report. We draw a distinction between quality assessment and quality assurance, which is important for our discussion of the need for a national, comprehensive quality assurance strategy in section 2. We note some instances in which the design and operation of the health care system itself can influence quality quite independently of any formal mechanism for reviewing the quality of care. Finally, we briefly describe the different levels in the health care system at which quality issues may be addressed.

Quality Is
Multidimensional

The quality of care is a multidimensional concept that defies simple definition. Quality encompasses many aspects of care and means different things to different people. Patients, health care providers, and purchasers may have different notions about what constitutes high-quality care.

To patients, "getting better” (that is, the outcome of care) is probably
the primary concern. In addition, having access to care that is afforda-
ble, conveniently available, and provided in a manner that respects their
concerns and preferences is important. The responsiveness of the deliv-
ery system may also be important-for example, meeting patients' indi-
vidual needs for emergency care, coordinating services, and making
appropriate referrals.
Health care providers may emphasize the decisionmaking process that
underlies diagnosis and treatment, the clinical content of care, and the
technical skill with which it is rendered.
Purchasers may place greater weight on questions of cost-effectiveness,
including the need for individual diagnostic and therapeutic services,
the appropriateness of the setting in which care is delivered, and the
frequency, timing, and duration of services.

All these views of quality are legitimate and important. However, our primary focus is on the appropriateness of medical services and their clinical and technical quality. This implies a concern for such issues as whether necessary care was provided, whether the outcome was acceptable, whether unnecessary services were provided, and whether the location of care (that is, hospital, nursing home, home, ambulatory setting, and so on) was consistent with the patient's needs.

There are important reasons for this focus. First, and perhaps most important, providing appropriate medical care that is effective is the common denominator of the preferences of all three groups. Second, providing improved access to inappropriate care or poor-quality care is not

Quality, Quality Assurance, and the Health
Care System

likely to result in improved health outcomes. Third, currently available strategies for assessing and assuring quality are targeted especially to the appropriateness of care and to technical aspects of quality. As a result, focusing attention in these areas offers the greatest potential for near-term improvements in quality.

Quality Assessment
Should Be
Distinguished From
Quality Assurance

It is important to distinguish between quality assessment and quality assurance. Quality assessment involves the use of measures of quality, based on either explicit or implicit criteria, to assess the structure, process, and outcome of care and to monitor levels of quality over time. Quality assurance goes beyond the simple assessment of quality to include its improvement. This requires identifying and confirming problems in the quality of medical care, planning interventions to lessen or eliminate the problems, monitoring the effectiveness of the interventions, and instituting additional changes and monitoring where warranted.

Quality assessment is a prerequisite to quality assurance. It can be performed by an external assessor, assuming that the information necessary to assess the medical care is available and that criteria exist for specifying the constituents of high quality. Under these conditions, potential problems with the quality of care can be easily identified.

Successful quality assurance is more difficult, since it involves either preventing poor-quality care from occurring or improving levels of quality, which frequently requires behavior change on the part of health care providers. One example of an approach to preventing poor-quality care is to require external approval of health care interventions before the care is provided. This approach works because care that is not approved is unlikely to be reimbursed and this lessens the likelihood that the presumably inappropriate care will be provided.

But such approaches apply to individual services or procedures patient by patient. They do little to encourage providers to change their behavior or to create an environment for improving general levels of quality over time. Accomplishing the latter is generally assumed to require the commitment and involvement of the health care providers whose care is under review. This involvement is particularly important in the "gray" areas of medicine where there may be uncertainty about what the proper course of treatment is and considerable variation among physicians in how they currently care for patients. If physicians and other

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