in part the reason for deficient care. How often ignorance and ineptitude are a cause of poor care, and to what degree, is not known, but their contribution can be expected to vary considerably from setting to setting. McDonald and his co-workers (McDonald, 1976; McDonald et al., 1984; Tierney et al., 1986) concluded after a controlled study that errors in ambulatory care occurred more often because of overload of tasks and information than because of lack of knowledge. To the extent that mistakes are caused by lack of access to current knowledge, online computer-aided management, warning, and reminder systems may hold promise for affecting physician behavior. We do not, however, know a great deal about the circumstances in which these systems are used or are useful, and we recognize that available tools and attitudes may be changing dramatically as the professionally trained population becomes increasingly computer literate.

The conditions detailed above underscore the importance of establishing a clearly defined link between quality monitoring and continuing education, as typified by the “bi-cycle” model proposed many years ago by Brown and Uhl (1970) and repeatedly advanced since.7 Donabedian (1989) believes that the relative effectiveness of alternative ways of linking monitoring to education, and of conducting the educational effort itself, should be high on the agenda of research on the effectiveness of quality assurance through monitoring.

Incentives and Disincentives

Professional behavior can also be changed by directive. The net effect of such an approach on the health of patients and the morale of professionals has not been explored. Likewise, little is known about the effects of positive versus negative incentives or ways to link informal professional incentives to quality assurance activities.

Feedback and education are meant to appeal to internalized values and to mobilize the personal resources of practitioners. Various factors in the environment may well enhance or diminish these efforts. Much depends on the implicit expectations and informal understandings of medical colleagues, but a great deal may also depend on the structure of a more formalized system of rewards and penalties. The relative impotence of quality assurance efforts in directly modifying practitioner behavior may be attributable to the absence of a clearly defined, consistently operative link between the results of monitoring and the career prospects of practitioners. Thus, the formal system of incentives and disincentives deserves particular attention in any analysis of effectiveness.

Incentives are commonly regarded as rewards and disincentives as penalties, but not receiving a reward when a system of rewards has been instituted can be a disincentive, and not being penalized when a system of



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