pacities for using different types of information. Accountability must be accompanied by access to information; such information must be in the public domain. Meaningful information must provide insight to those parties struggling with the cost-related issues of health care; decision makers need to know the value of health care rather than keep separate “balance sheets” on cost and quality. A focus on decision making promotes the strategy of using information to improve quality overall rather than simply to isolate and punish outliers. Finally, as a unifying factor such a focus on decision making helps bridge the conflicting elements of professionalism, regulation, competition, malpractice, and value purchasing.


The committee identified critical dimensions of quality of care and adopted the following definition: quality of care is “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”

We briefly reviewed the United States health care system and the health status of the population to provide a broader context for the recommendations made in this report. We also discussed several factors that affect the quality of care and promote or retard effective quality assurance, such as rising health care expenditures, geographic and financial access, changes and shifts in settings of care, integration of financing and delivery of services, cost-control and utilization management efforts, and Medicare payment systems. Quality of health care is a transcendent public policy issue. The availability and use of meaningful information for decision making by purchasers, providers, and patients will affect the success in balancing the forces of professionalism, regulation, market forces and competition, malpractice and risk management, and value purchasing in a manner that improves quality overall.



Chapter 4 describes the Medicare program in more detail, and Chapter 6 covers Medicare’s peer review and quality assurance efforts.


The situation characterized by unlimited access to common constrained resources with decreasing nontransferable marginal benefits to individual consumers has been called the “tragedy of the commons.” Pursuit of individual interests will impoverish all in the absence of collective decision making and action (Hardin, 1968; Hiatt, 1975).


The independent literatures on bioethics and on quality of care are extensive; the literature on the intersection of the two fields is sparse. Three recent works in this area are McCullough, 1988; Whiteneck, 1988; and Povar, 1989.


Other conditions are much more important for specific population groups other

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