penalties for noncompliance, some of which have been evolving for over a century.

In recent years, reliance on external strategies has been criticized as costly and relatively ineffective, and strategies emphasizing internal responsibility for continuing improvement in quality have been encouraged (see, e.g., Batalden and Buchanan, 1989; Berwick, 1989; Berwick et al., 1990; IOM, 1990; Horn and Hopkins, 1994). Continuous quality improvement (CQI) models (sometimes termed Total Quality Management or TQM) are generally described in terms of a set of reinforcing principles for implementing change. These principles include targeting systemic defects (e.g., burdensome protocols for patient referral) rather than individual mistakes; encouraging close relationships among the participants in health care transactions (e.g., physicians, patients, purchasers); using planning, control, assessment, and improvement activities that are grounded in statistical and scientific precepts and techniques; feeding statistical information back to practitioners on how their practices may differ from their peers' or depart from evidence-based standards for practice; standardizing processes to reduce the opportunity for error and link specific care processes to outcomes; and striving for continuous improvement in contrast to merely meeting established goals or criteria (IOM, 1992).

Typical of quality improvement strategies reflecting these principles are the guidelines recommended by the American Pain Society for the treatment of acute pain and cancer pain (APS, 1995). The guidelines, which focus on inpatient care and address institutions rather than single individuals, are summarized in Box 5.1. They do not explicitly consider the special circumstances of dying patients but are consistent with the discussion in Chapter 3.

Evidence of Quality Problems in End-of-Life Care

Conventionally, several broad types of health care quality problems have been differentiated (see, e.g., IOM, 1990). They are overuse of care (e.g., unwanted treatments or hospitalizations; diagnostic tests that will not inform patient care but may cause physical and emotional distress); underuse of care (e.g., failure to assess and treat pain; late referral for hospice care, premature hospital discharge); poor technical performance (e.g., errors in surgical technique); and poor interpersonal performance (e.g., inept communication of difficult news). In general, underuse of care is more difficult to detect than overuse. For example, in population-based analyses, it may be difficult to distinguish problems of inadequate access to care from problems of undertreatment for identified patients (IOM, 1990).

Care at the end of life is characterized by problems in each of these areas. Said differently, systems have much room to improve the extent to

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