determining whether provider organizations have met those conditions. One condition should be that the organization has a viable internal quality assurance program that can document solutions to important quality problems. Information from MQROs should contribute to those determinations.

Process-of-care information. For quality assurance purposes, information on the process of care is central. It is required for: (1) documenting continuity of care across settings and among providers; (2) detecting and verifying problems of overuse of services; (3) identifying populations having difficulty gaining access to care or otherwise facing problems of underuse of services; and (4) pinpointing cases of obviously poor performance.

Process information may indicate the reasons for those problems, which can range from Medicare program policies and financial incentives, resource constraints, and cost-containment efforts, to deteriorating practitioner knowledge or technical skills. Examining the process of care will also be important for those providers identified as having poor outcomes. Presumably, by correcting processes of care they know to be deficient, they can improve those outcomes. Finally, process data point to inappropriate, unnecessary, and poor care, especially in situations in which outcomes are not a good measure (e.g., ambulatory care for acute ailments).

We have emphasized patient and clinician decision making in our conceptual model. Assessment of this activity clearly belongs more to the provider organization and its internal quality improvement program than to the federal Medicare program and the MQROs. The practical consequence of this is to place the bulk of the process measurement effort on the internal programs. An important aspect of this will be to ensure that such internal data collection serves as many purposes simultaneously as possible—that is, the needs of the organization and those of external quality assurance bodies.

There are instances, however, in which the MQROs might conduct their own process-of-care evaluations. The first instance is in serious cases of poor performance of those providers monitored chiefly by outcomes, at least (or especially) when such providers voluntarily seek such outside help and technical assistance. The second is in routine collection of process data for all providers, so that information on the process-outcome links can be expanded.

The third instance is when individuals or agencies file complaints about providers. Some quality assurance groups have found this a productive way to identify quality problems (especially those of poor technical or interpersonal practices). Furthermore, it helps to meet the MPAQ’s responsibility to maintain constructive relationships with the patient community.

The fourth instance is in evaluating ambulatory care, such as that delivered in physician office-based practice, where process measures are pres-



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