the achievable level of quality (Brook, 1988; Greenfield, 1988; Roper et al., 1988). Our definition accepts this reality but acknowledges that the information base is dynamic. It also implies that professionals have a responsibility to stay informed about current advances in the technical and scientific knowledge pertinent to their profession (Farber, 1988) rather than adopting an average standard of practice that may fall short of the best wisdom.
The committee acknowledges limitations in the scope and level of benefits covered in the Medicare program; we also acknowledge that use of the term “health services” in our quality definition could be interpreted as broadening the mission of the Medicare program. This clearly poses a challenge to Medicare and to society. Issues of financing, access, and health care delivery can restrict the capacity for achieving quality care.
After deliberating whether its definition should explicitly incorporate resource constraints, the committee agreed that it should not. (Several existing definitions of quality do reflect considerations of resource availability; a few explicitly state that resource considerations should not be included in defining quality.) The committee decided that quality should not be defined on a sliding scale and that judgments of quality should not fluctuate just because resources are constrained or unavailable. Excluding resource constraints in the definition of quality should enable quality assurance efforts to identify situations in the health care system where quality would be improved if additional resources were available. Responsible parties (individuals, public and private payers, and societal agents) should be able to distinquish quality problems from those arising from resource availability and subsequently be able to make informed decisions about the level of quality that is desired and affordable.
The committee recognizes the implications of excluding explicit consideration of the theoretical and real constraints on what our society can spend on health care. Efficiency in the delivery of services necessary to produce health benefits is important. Equity, too, is important. Delivery of all health services including those that provide only the smallest of benefits to everyone would divert resources from education, housing, or other services that could provide greater benefits to individuals and society. The highest level of quality, as defined by the committee, may not be attainable for everyone; it may not be a societal goal to attempt to achieve the highest level. Such conflicts between individual and societal goals challenge our capacity for collective decision making and action.2
Most of society perceives health care to be different from other goods and services. Many health problems occur beyond the control of individuals, and the consequent need for health care is distributed very unevenly