The Institute of Medicine report includes recommendations for increased public accountability and program evaluation. This reflects the desire by members of the committee to ensure that both the beneficiary and provider communities have opportunities to critique the quality assurance system. The concerns that prompted these recommendations can be placed into four general categories.
First, to promote professionalism and attention to the process of quality assurance, professionals must believe in the system. Physicians, hospital administrators, nurses, and other providers need to have opportunities to help shape the system over time. In this way, they will be more likely to "buy into" the process than if they have no input. Second, a formal role for public input also helps to ensure that the concerns of the users of health care are explicitly built into any quality assurance system. Third, a system for assessing and assuring quality will likely raise controversial and public issues over time—issues that ought to be discussed in a public forum. Finally, the committee felt strongly that it did not have all the answers and that a system needed to be designed with enough flexibility to change with the times. A formal role for accountability and evaluation establishes a structure to develop recommendations for change and adjustment.
With these concerns in mind, the committee proposed several specific organizations as a means of implementing a review and evaluation component of the system. Maxwell Mehlman, director of the Law-Medicine Center at Case Western Reserve University and a member of the IOM panel, discusses more fully the goals and implications of these recommendations. Duncan vB. Newhauser, professor of epidemiology at Case Western Reserve University, offers a commentary and response, with a particular focus on broad programmatic change within the entire Medicare program.