with several different emphases that present extraordinary challenges. It looks more to professionalism and internal quality improvement than to regulation and external inspection. It gives more attention to patient and consumer concerns and decision making, and it adopts an aggressive regard for outcomes. It seeks to generate new knowledge from clinical practice and to return that information to providers in a timely way that improves clinical decision making. It places stronger emphasis on systems of care, the joint production of services by many different providers, and continuity and episodes of care. Related to this, it moves more forcefully into settings not traditionally subjected to formal quality assurance, such as physician office-based care and home health care. It becomes far more publicly accountable through an extensive program oversight and evaluation effort. It intends to be responsive to a changing environment, with principles that will stand the tests of time and change. Finally, it is grounded in a clear definition of quality of care.

The Medicare program has a large responsibility to assure the quality of care for the elderly population. By no means does it have the sole responsibility. Patients, providers, and societal agents must work together if we are to meet the challenges inherent in this strategy for quality review and assurance.

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