ciencies in quality in all parts of the health sector—what we have called the burden of harm of quality problems. Some of these deficiencies relate to poor technical and interpersonal skills or judgment in the delivery of appropriate services, some to the overuse of unnecessary and inappropriate services, and some to underuse of needed services by those receiving some care and by those having difficulty obtaining access to the health care system.

Both the types of quality problems and the level of quality may vary considerably across geographic areas, among beneficiaries, and among individual and institutional health care providers. The use of health care services varies greatly even across small geographic areas of the country in ways for which we cannot fully account. The effectiveness and the outcomes of that care may also vary greatly. Chapter 7 provides a more detailed discussion on quality problems and the burden of harm.

Assuring Quality: A Professional and a Public Responsibility

As we increase our knowledge and understanding of the complexities of good health care, we also increase the quantity of factors that apparently impinge on the quality of health care. Furthermore, advances in health care are accompanied by a corresponding increase in our expectations for even better quality of care.

No single party or individual can be held accountable for all that happens in health care; the factors are too diverse and diffuse. Patients have different preferences, needs, and capacities. Numerous providers render care in thousands of delivery settings. Interventions of vast number occur over both short and long time frames. Finally, a multiplicity of outcomes can occur with only fuzzy and wavering lines to distinguish causal relationships from chance occurrences.

The lack of a single point of accountability can be perceived as both a blessing and a misfortune. The opportunities for improving health care singly and through cooperative ventures are almost unlimited. Conversely, lack of a single point of accountability creates an environment conducive to shifting or shirking responsibility. Helping to focus on the appropriate points of accountability in the system should be the aim of a successful quality assurance program.

Professional Responsibilities

Through the activities of the study (public hearing testimony, the focus groups, and the site visits), we heard almost without exception that the single party most responsible for quality care is the party closest to the point of delivery of care, that is, the professional care provider. Historically

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