TABLE 2.1 Desirable Attributes of a Quality Assurance Program

• Addresses overuse, underuse, and poor technical and interpersonal quality

• Intrudes minimally into the patient-provider relationship

• Is acceptable to professionals and providers

• Fosters improvement throughout the health care organization and system

• Deals with outlier practice and performance

• Uses both positive and negative incentives for change and improvement in performance.

• Provides practitioners and providers with timely information to improve performance

• Has face validity for the public and for professionals (i.e., is understandable and relevant to patient and clinical decision making)

• Is scientifically rigorous

• Positive impact on patient outcomes can be demonstrated or inferred

• Can address both individual and population-based outcomes

• Documents improvement in quality and progress toward excellence

• Is easily implemented and administered

• Is affordable and is cost-effective

• Includes patients and the public

who can legitimately be considered a peer, is related more to almost incidental traditional professional boundaries of accountability than to intrinsic ones. One challenge in devising a strategy for quality assurance is to combine the strengths of both internal and external approaches yet avoid replication and counterproductive effects, such as the poisoning of the atmosphere for professional involvement in internal programs.


What are the attributes of a successful quality assurance effort that would be acceptable to those with a stake in the process (i.e., patients, providers, payers, and policymakers)? This section outlines our view of the criteria that a successful quality assurance program, either internal or external, should strive to meet (see Table 2.1). Some of these criteria may appear contradictory (such as minimal intrusion into the patient-provider relationship and ability to deal effectively with outlier providers), but the mark of a good program is an appropriate balance between such elements. We use these attributes later in this chapter to evaluate two conceptual models of quality assurance.

A successful quality assurance program has the following 15 attributes):

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