grams and resources are available and dedicated to assure coordination and continuity. The need for attention to continuity has been greatly heightened by the shifts in settings of care resulting from the Prospective Payment System (PPS) and other cost-containment policies.

Our definition identifies both individuals (but not just “patients”) and populations for three reasons. First, even though traditionally quality assurance has focused on the technical care rendered to individuals (for instance, in medical record review), we believe advances must be made in population-based measures. This is particularly important for assessments of overuse of certain services and of underuse that results from lack of access to the health care system or from less than adequate care for those who do have access to the system. Second, we believe that only by emphasizing both individuals and populations can we underscore the importance of identifying determinants of health and illness. Third, we have described some strategies for assessing and assuring quality of care that can be used more widely than in a single public program.

The committee adopted a broad set of outcome measures to encompass health-related quality-of-life variables, which include physical and social functioning, mental health, and physiologic measures (Lohr, 1988; Kane and Kane, 1989). We also intend to include both patient and provider satisfaction as important elements of the process and the outcomes of care. Provider-patient trust and the art of care emphasize the humaneness with which health care is delivered and contribute to the level of patient satisfaction experienced in the health care encounter; they are thus critical to quality assurance (Davies and Ware, 1988; Cleary and McNeil, 1988).

Although our definition emphasizes outcome measures, it links the processes of health care to outcomes. Interpersonal and technical skills used in health care are important in increasing the likelihood of desired outcomes and decreasing the likelihood of undesired outcomes. In contrast, several definitions reviewed by the committee focused only on process or only on outcomes. Because chance and other factors such as the environment also influence outcomes, our definition focuses on the selection of treatment courses (processes) believed to provide the best possible desired outcome rather than on the frequency of outcomes. In this manner, the committee’s definition is consistent with that proposed by Avedis Donabedian (1980), which also emphasizes the expected net benefit attendant on the process of care.

Health care goals may differ for the government, administrators, patients, health care providers, or other parties such as payers. The decision-making process frequently must consider the values of multiple parties before the desired goal is defined.

The lack of professional knowledge of the effectiveness of many technologies and the vast dimensions of medical science yet unexplored limit



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