summarized in the first section. The chapter then examines quality-of-care issues from clinical and systems perspectives and concludes with an examination of barriers to the implementation of clinical and systems strategies.
Appendix C contains the committee’s working definitions of several key terms used in this chapter, including diagnosis, treatment, psychotherapy, and quality.
Avedis Donabedian articulated as early as the 1960s a conceptual model for measuring health-care quality that remains highly relevant today. The model assesses three main components of health-care quality: structure, process, and outcome (Donabedian, 1966). Structure refers to characteristics of the health-care system or provider, such as training or clinic resources adequate for serving the population. Process refers to the care that is delivered—assessments, tests, and treatments. Outcome refers to the health status of patients after they receive care. Access to care and patient satisfaction are other important components of health-care quality (Donabedian, 1998).
Although it is desirable to know whether the care that is delivered to patients produces good outcomes, many factors that are independent of treatment quality can also affect a person’s health status after treatment, including illness severity and the patient’s ability and desire to adhere to a treatment regimen. Process measures of care, if they have a demonstrated link with outcomes, can therefore be useful tools for measuring treatment quality.
In the late 1990s, evidence, largely from research in processes of care, that health-care quality in America had serious and pervasive problems was mounting. Examples were inadequate access to care, unacceptable rates of medical errors, and patients receiving care that was not needed or not receiving care that was needed. IOM’s Committee on the Quality of Health Care in America identified several underlying causes of the problems: the growing complexity of science and technology, which made it increasingly difficult for clinicians to stay abreast of new information; the shift from an acute-disease management paradigm to