although it is the first step in quality assurance, it does not imply a solution to problems that may be uncovered.

Classically, quality assurance encompasses a full cycle of activities and systems for maintaining the quality of patient care. One definition has it as “a formal and systematic exercise in identifying problems in medical care delivery, designing activities to overcome the problems, and carrying out follow-up monitoring to ensure that no new problems have been introduced and that corrective steps have been effective” (Lohr and Brook, 1984, p. 585). Generally, that cycle involves a set of steps proceeding from identification and verification of quality-related problems and their causes to the implementation of solutions to the problems with the specific intent that the solution be long-lasting or preventive; these activities are followed by a timely review to determine if the problem has been solved and no new ones generated in the process. If the last two conditions are met (one problem solved and no new ones generated), attention turns away from that aspect of patient care to other areas or topics.

Quality improvement is a set of techniques for continuous study and improvement of the processes of delivering health care services and products to meet the needs and expectations of the customers of those services and products. It has three basic elements: customer knowledge, a focus on processes of health care delivery, and statistical approaches that aim to reduce variations in those processes. In understanding the place of continuous quality improvement it is helpful to think in terms of a bell-shaped curve that distributes numbers of providers or volume of care against quality. The leading tail is the province of research, the lagging tail is the focus of regulation; and the middle is the focus of continuous improvement. The design of a quality assurance system (for Medicare or for any other health care program) should attend to all three parts of the distribution.

Purposes of Quality Assurance

Quality assurance neither promises nor guarantees error-free health care. Its ultimate goal is to build confidence and faith in the quality of the health care being rendered. Achieving error-free health care at all times is impossible; trying to do so ultimately discourages quality assurance efforts. The ultimate goal, however, is achievable and thus encourages continuous effort. An effective quality assurance program is not an end in itself; rather, it is a means of maintaining and improving health care (O’Leary, 1988).

Quality assurance programs vary widely in their purposes, targets, and methods. Four major purposes can be identified.2 First, in some circumstances the main goal is to identify providers whose delivery of care is so far below an acceptable level that immediate actions are needed to ensure that they no longer deliver care or that responsible third-party payers, such

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