vided in this nation. This report of a committee of the Institute of Medicine (IOM) presents such a strategy to assure the quality of care provided to Medicare beneficiaries.

Congress has evidenced concern for quality of care in the Medicare program since its inception in 1965.1 For instance, legislation in the early 1970s, which created Experimental Medical Care Review Organizations and later Professional Standards Review Organizations (PSROs), dealt directly with ensuring that care met professional standards of quality. This concern continued with the passage in 1982 of legislation that created the Utilization and Quality Control Peer Review Organizations program (commonly called the PRO program). Despite these efforts, Medicare quality assurance to date has been insufficient, in large measure because the programs were also heavily charged to control utilization and costs. The congressional mandate for this study reflects both an appreciation of the shortcomings of the current Medicare quality assurance program and apprehension that past and future efforts to curb Medicare expenditures, control use of services, and reform payment mechanisms will have negative effects on the quality of care rendered to the elderly.

Defining health is difficult because of differences in what may be valued and attainable and because of the sometimes tenuous relationship between health services and health outcomes. These are not theoretical issues for those responsible for operating a program to assure quality health care. The process involves eliciting and balancing value judgments, often when legitimate interests are in conflict. Responsibilities are often shared and are therefore ambiguous. Even when the decisions are sound and the appropriate services are delivered with technical proficiency, poor outcomes can occur. Conversely, bad decisions or inept care will not always be followed by poor outcomes. The quality of care cannot necessarily be judged by the outcome for an individual, so accountability is further diffused. These issues must be understood in defining quality health care and designing programs and systems to assure it.

A pragmatic strategy also requires an understanding of the problem to be solved and the potential barriers. How does one define quality of care? What is the health status of the United States citizenry, and what can we infer about the quality of care from that information? Why is quality of health care a public policy issue? This chapter provides a foundation for the committee’s strategy by addressing these questions.

DEFINING QUALITY OF HEALTH CARE

In 1974 the IOM published the following statement about quality assurance: “The primary goal of a quality assurance system should be to make health care more effective in bettering the health status and satisfaction of a



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