information they need to make informed choices, care for themselves, or adhere to treatment plans. Those problems, as well as poor organization and coordination of various aspects of patient care, can lead to harm ranging from discomfort or distrust to disfigurement or death.

The classic approaches to quality assurance, including risk management and infection control, focus on poor technical quality, particularly problems of skill, performance, and system functioning. Within hospitals, such methods of problem detection as surgical review, morbidity and mortality conferences, incident reporting, and review for adverse occurrences have this focus.

Problems with poor technical quality may involve one or more “outlier” practitioners whose skills are inadequate, or they may involve broader weaknesses in a system. Practitioners or institutions that are outliers in one area cannot be presumed to be outliers in all areas of practice. For instance, the hospital-specific mortality data released by the Health Care Financing Administration (HCFA) identified very few hospitals that were high-mortality outliers across several different diagnoses and very few that were outliers across several years (see Chassin et al., 1989). Moreover, “good” practitioners or providers cannot be assumed to be uniformly good (Palmer, 1988). In any case, methods for dealing with outliers may differ from those appropriate for responding to problems with average performance.

Some problems with quality of health care can be classified under the term overuse. Overuse is the provision of services whose likelihood of harm to the patient outweighs the likelihood of benefit. Benefits include increased life expectancy, relief of pain, reduction in anxiety, or improved functional capacity. Harms include the morbidity and mortality that accompany the provision of service (such as a surgical procedure). They also include other, less commonly measured adverse effects such as the anxiety of anticipating and undergoing a procedure, time lost from work, and time spent in rehabilitation.

Excessive diagnostic services may have direct negative side effects and may also, if falsely positive, lead to other more invasive and hence more risky examinations and treatments. A case in point is the patient who has an unnecessary exercise stress test that is falsely positive and who as a result undergoes coronary angiography (Graboys, 1989).

Excessive use of medications such as antibiotics (Foxman et al., 1987) exposes patients and the population in general to unjustified side effects, for example the proliferation of antibiotic-resistant organisms. When patients are hospitalized unnecessarily, they risk falls, medication errors, and hospital-acquired infections.