of these efforts, however, have two limitations: they rely only on medical or administrative records as sources of information, and they define ''quality" in terms of a relatively narrow range of technical processes and physiological outcomes (Caper, 1988; Cleary and McNeil, 1988; Cleary et al., 1991a, b; Davies and Ware, 1988; Donabedian, 1988; Garvin, 1984; Lohr et al., 1988; Matthews and Feinstein, 1988; Meterko et al., 1990; Steffen, 1988). Interestingly, little of the systematic work to date on quality assessment and quality assurance has taken advantage of the information and perspective that only patients can provide.

Patient reports can be extremely useful in evaluating the quality of medical care. Many critical aspects of medical care, such as difficulty obtaining care, waiting time in an office, adequacy of communication, education, pain control, and emotional support, and whether patients were appropriately involved in important decisions about their care, are not recorded routinely by hospitals, health plans, or individual clinicians.

Furthermore, providers frequently have priorities different from those of patients and perceive events differently than patients do. In a Picker/Commonwealth Program for Patient-Centered Care-American College of Physicians study of 74 physicians and 814 patients, both groups agreed that clinical skill is most important, but patients ranked information and effective communication second in importance, whereas physicians ranked it sixth out of seven. The two groups differed substantially on 59 percent of the attributes in an item-by-item comparison of the ratings. Equally important, patients can provide information about important processes of care that is not available from other sources, for example, the length of waiting time in the doctor's office or the adequacy of pain control.

How Do Consumers Define High-Quality Medical Care?

It often is assumed that consumers are particularly interested in knowing about other consumers' evaluations of health care providers or systems. Surprisingly little information is available on this topic.

Different types of consumers, for example, healthy persons



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