of truly bad providers, and more on the continuous improvement of quality by all providers. Theoretically, such a system would be better at preventing poor quality from occurring in the first place.

Quality assurance and improvement programs to provide oversight to this rapidly changing system are only beginning to be developed and implemented. Chapter 3 identifies several problem areas in regard to the overall appropriateness, effectiveness, and adequacy of existing quality assurance and improvement programs. This committee hopes the programs that eventually evolve will both address the concerns and capitalize on the opportunities presented by this extraordinary transformation. It also hopes that the development of such programs will be guided not merely by the desire to avoid bad outcomes, but also by the goal of improving the care that individual consumers receive. Clearly, a balance of strong external and internal programs to ensure quality will be needed.

Who will decide how to achieve a good balance? Consumers and their families have an obvious role in defining and achieving quality LTC services, and efforts need to be undertaken to ensure that their needs and preferences are at the heart of the evolving quality assurance and improvement system. Yet, families must also be considered in another dimension—in their roles as providers of care. Many issues remain unresolved regarding the extent to which government and other official organizations can apply judgements to the quality of the care provided by these informal providers.

Government clearly has a role to play. In the words of one committee member, “Federal and state governments have continuing responsibilities for establishing and enforcing a minimum definition of quality and for fostering the conditions under which programs can be innovative, responsive to consumer preferences, and encouraged to exceed minimum standards” (Kane, 1995, p. 9). In lieu of federal action, some states are moving ahead on their own to develop carefully conceived and comprehensive quality assurance and improvement programs. The committee applauds and encourages their important efforts. At the same time, it recognizes that other states have done relatively little in this area. The study called for in this report will provide a rallying point and blueprint for all of them.

The Institute of Medicine (IOM) is well qualified to lead such a project. The potentially contentious nature and broad scope of the study point to the utility of the IOM model, which employs a study committee composed of experts from a variety of disciplines who hold a range of different perspectives. Recommendations are formulated after a rigorous process of seeking input from many sources and developing consensus among the committee's different stakeholders. The IOM's national reputation as an objective, scientific, and policy-relevant organization adds the considerable credibility necessary to influence policies at all levels of government. The product of this particular study is also intended to be of immediate, practical value to individual providers and consumers as well.

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