tive. The development process included a thorough review of the literature but placed a great deal of emphasis on eliciting directly from patients the ways in which they defined and evaluated care. For example, we conducted numerous focus groups with patients, their families, other laypersons, and health professionals.
We also conducted pilot interviews with patients and their families from different parts of the country. Subsequently, we had patients and health professionals critique the types of questions that we asked about the quality of health care and tell us about the priority that they gave to the different aspects of care that we asked about (Cleary et al., 1991a, 1992).
We conducted focus groups to find out more about the patients' experiences of illness and health care and the systems that do and do not work to meet patients' needs. What is it about their interactions with providers, systems, and institutions that patients say matters to them and affects them either positively and negatively (Gerteis et al., 1993). On the basis of that work, we defined several dimensions of care that we think describe how consumers define quality and reflect the most salient processes of care for which they might want comparative assessments. For hospital inpatients, the dimensions are as follows:
The Picker Institute and its collaborators have conducted similar studies of ambulatory care. Focus groups have been used to identify the needs of ambulatory patients receiving care in emergency rooms, private doctor's offices, hospital outpatient clinics, community health centers, and managed care plans.