come together to press for the legislative and administrative changes called for.

Why should such an effort be undertaken? If it is undertaken, will it succeed? Why should it be supported? I think the shift of definition of purpose—to achieving outcomes for patients—is very important. It needs to be understood, internalized, and externalized, and I have come to understand that this shift in purpose represents a major cultural change. It does not come overnight. It does not come because we all sit here and agree with one another. The changes need a broad and public appreciation and understanding.

The shift to outcomes is not just a technical process. The more I look at this, the more I think we have been obsessed in this country with reducing risk through accuracy and data collection. We have gotten so carried away that we believe that if it is not measurable, it is not real. The fact that we now have outcomes and health status measures that are broader than our physiologic measures is, I think, critical to our ability to make the shift to a broader definition of quality and outcome. We can measure things now—accurately, reliably, and repeatedly—that simply were not available in the past to be measured and incorporated into a quality assurance effort.

Within the issue of outcomes, functional status, and satisfaction is another critical shift—namely, a redressing of the balance between those of us who give care and those of us who receive it. There must be a growing understanding that this is a partnership and that we cannot do it alone. Patient preferences, patient control, and levels of patient compliance do affect outcomes. That is one important theme that must be more broadly understood as well as written into legislation.

I believe that we need to understand the culture of physicians and hospitals with the objective of getting medical care providers to internalize this broader view of their objectives and roles. Someone asked whether hospitals were willing to look at outcomes. I must say I was a bit taken aback by that. I think many of us have been struggling with it as our purpose for being here. Some might resist, but I cannot imagine that they are very many in number.

The report calls for re-recognizing the role of the professional, re-recognizing some assumptions that people do have positive, virtuous goals. Yes, there are ''bad apples,'' but let us not concentrate all of our time and energy on them because as Relman (1991) says, "We have a lot of sullen people