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In response to the concerns that quality of care might be deteriorating under PPS and that the PROs and other mechanisms for monitoring quality were inadequate, Congress included in the Omnibus Budget Reconciliation Act of 1986 a provision that directed the Department of Health and Human Services (DHHS) to request that the National Academy of Sciences ''design a strategy for quality review and assurance in Medicare.''


In 1987, therefore, the Institute of Medicine (IOM) of the National Academy of Sciences appointed a committee to conduct the requested study, with funding from the Health Care Financing Administration (HCFA). The study committee interpreted the congressional charge as a call for a far-reaching strategic plan for developing a program throughout the next decade for assessing and ensuring the quality of medical care for elderly people. In March 1990 the IOM released the committee's two-volume report Medicare: A Strategy for Quality Assurance.1 Volume I contains the IOM committee's recommendations for a comprehensive quality assessment and assurance strategy for Medicare. Volume II includes an extensive compilation of available information on quality measurement and assurance, and makes available many of the background technical analyses that supported the committee's deliberations.

The report concluded that the current Medicare system to assess and ensure quality is not very effective and may have serious unintended consequences. It pointed out, however, that opportunities are now emerging to set in place a comprehensive system of quality assurance that can address itself to improving the health of U. S. citizens.

The committee articulated several themes as the basis for the major redirection for a quality assurance program for Medicare. These included

  • enhancing professionalism,

  • strengthening organizational systems for quality improvement,

  • improving patient and practitioner decisionmaking,

  • introducing a patient outcomes orientation to quality measurement, and

  • evaluating quality assurance activities.

Largely on the basis of the thrust of these new directions, the committee made ten major recommendations. Two recommendations proposed expanding the statutory mission of the Medicare program to include responsibility for quality of care for the elderly, with quality of care defined as "the


Institute of Medicine. Medicare: A Strategy for Quality Assurance. Volumes I and II. Lohr, K.N., ed. Washington, D.C.: National Academy Press, 1990.

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