population as a whole) are important targets of quality assurance. This orientation helps ensure that underuse of services, especially as it is reflected in poor access to care in the first place, receives due attention as part of a quality assurance effort.

  1. It documents improvement in quality and progress toward excellence. A quality assurance program must be able to track and evaluate the effect of its efforts. Documenting improvement implies that quality-related information will be analyzed with appropriate statistical tools over time and that such information will be shared among appropriate staff and organizations.

  2. It is easily implemented and administered. A successful quality assurance strategy must find a middle ground between (on the one hand) an excessively simplistic system that has little specificity, relevance, or involvement of professionals but is relatively easy to mount and administer and (on the other) an excessively complex, costly, labor-intensive system that may itself detract from the ability of providers to render adequate patient care. Thus, although we do not intend by this criterion to discount the need for considerable investment in a Medicare quality assurance program, we do want to emphasize the need for ease of implementation and administration.

  3. It is affordable and cost-effective. Determining whether a quality assurance program is acceptable in cost and is cost-effective is very difficult; in the public sector the history of evaluations of the Professional Standards Review Organizations makes that clear. Nevertheless, the use of public monies to assure quality requires accountability. Part of the challenge of the Medicare quality assurance strategy will be to develop mechanisms to evaluate the costs and cost-effectiveness of that program; this requires articulating criteria for acceptability and effectiveness in this domain and applying those methods and criteria objectively.

  4. It includes patients and the public. An effective program must have a mechanism to listen to and respond to complaints and suggestions and a mechanism for change to act as a safety valve. Considering the size and complexity of the Medicare program, this is especially important for the external quality assurance efforts.


Designing a strategy for quality assurance for the Medicare program requires us to describe the program we expect to be in place and the steps we believe are necessary to implement that program. This in turn requires a clear conceptual framework and a set of program goals. This section summarizes important conceptual models relating to quality of health care and introduces concepts and terms that we will rely on throughout this report.

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