areas of research needed for further progress. First, we advance a framework for setting priorities for research topics; we also review past and current research efforts in the quality-of-care area. Second, we discuss in more detail the research efforts we believe should be pursued. Third, because we are not persuaded that research by itself will stimulate and support the progress that is needed (at least not in the timeframe contemplated), we discuss aspects of capacity building that we believe deserve high priority attention.

RESEARCH NEEDS

Overview

Research in quality-of-care measurement and quality assurance is our main concern. We do not address fields such as biomedical research or technology assessment, both of which have an indirect role in the information base for quality assurance, or research into the organization and financing of health care, access to care, or continuity of care. These aspects of health care delivery can strongly influence the quality of health care, but solutions to access and continuity problems are likely to lie outside the purview of quality measurement and assurance programs. A federal quality assurance program and its national, population-based databanks offer an unparalleled opportunity to track and document problems of access to care, fragmentation of care, and underuse of services.

We also do not survey the field of health services research, which is closely related to research in quality assurance. Two important links between these fields should be noted. First, the formal research methods and approaches for health services research are those most likely to be used in much of the research that will be called for later in this chapter. Second, much of the existing theory, tools and methods, and investigators in the quality assurance field come out of the health services research community.

A decade ago an Institute of Medicine (IOM) study committee stated that the “need for more knowledge about health services in the United States is becoming increasingly apparent to health care professionals, government officials, and the public” (IOM, 1979, p. 1). More recently Reinhardt (1989, p. 5) noted that “the development and implementation of a sustained, multidisciplinary research agenda is the only way that we will attract the best minds to this field [of health services research] and build a knowledge base over the next decade that will be useful for health professionals, consumers, payers, and policy makers.” Substituting “quality of care” for “health services” yields equally true observations.

Berwick (1989) has proposed a broad conceptual framework on which a quality-related research agenda for the next decade might be built. One



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