size the actual systems and processes of care as a means of knowing where to act when problems arise or where to improve care more generally.

Internal programs should document their quality-assurance procedures and results. Although the choice of specific approaches to solve quality problems would be left to individual providers or institutions, they should be able to document that their surveillance systems identify and attempt to solve important quality problems.

For instance, providers might institute programs designed to monitor and correct overuse of inappropriate and unnecessary services, to identify problems with underuse of services (including poor access to care across an episode of care as well as inappropriately low use of specific types of services), and to examine the process of care for poor performance. Because of our emphasis on patient-provider decision making, we also hope that providers would give more attention to educating their professional and support staffs in this area, and to informing patients about health and quality-of-care issues and about the choices they can make concerning their own health care. Education for professionals should include feedback of new knowledge from clinical practice data to inform their ongoing clinical decisions.

If internal programs cannot document their quality assurance procedures and impact, or if the results of the external MQRO monitoring suggest that these activities are not being done well, then the MQRO will have to become more actively involved. Such MQRO interventions might involve abstracting process-of-care information on-site, consulting in the planning of quality assurance activities, imposing corrective actions of the sort now available to PROs, and pursuing new intervention strategies developed during the implementation of the MPAQ.

Operational Overview of the Proposed Model

An Emphasis on Outcomes

A central theme of our recommendations and the proposed program for quality assurance in Medicare is a greater emphasis on the outcomes of care. Attention to outcomes offers several advantages. It allows monitoring of the system while leaving the providers unconstrained to undertake their own quality improvement efforts. It calls for systematic data collection that can be used to inform workers in the health care field about how process components are related to specific outcomes. It fosters looking across time and appreciating the temporal and service links within episodes of care. It emphasizes those aspects of care that are most relevant to patients and to society.

The evolution of an outcome-based quality assurance program will re-



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