Quality of Care: A Quarter-Century of Work

Kathleen N. Lohr, Ph.D.*

Director, Division of Health Care Services, Institute of Medicine

Can the quality of health care in this nation be maintained, and indeed improved, in the face of serious public debate about access to basic services or controversy about how to control spiraling costs of care? These issues confront the Institute of Medicine (IOM) today; they were equally significant at its creation. Addressing them has, therefore, been a constant focus of IOM attention and work. The details, over 25 years, necessarily have evolved and matured; the underlying concern with ensuring high-quality health to all has not deviated.

The major contributions of the IOM date to the early 1970s. Some are concerned specifically with contemporary issues in quality of care. Other projects stem from related health policy questions, such as health status and quality-of-life measurement, technology assessment, information dissemination and systems, health care organization, and the health care work force (see the chapter “Institute of Medicine Reports on the Health Work Force” by Marilyn J. Field in this volume). The chronicle below highlights selected IOM work in

*

The author thanks Karl Yordy and Linda Demlo, both former directors of the Division of Health Care Services, for their assistance in providing background information on studies they carried out or supervised during their tenures; she also acknowledges the helpful comments of her IOM colleague Molla Donaldson, a senior program officer in the division. Errors of fact or interpretation are, of course, those of the author.



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For the Public Good: Highlights from the Institute of Medicine, 1970–1995 Quality of Care: A Quarter-Century of Work Kathleen N. Lohr, Ph.D.* Director, Division of Health Care Services, Institute of Medicine Can the quality of health care in this nation be maintained, and indeed improved, in the face of serious public debate about access to basic services or controversy about how to control spiraling costs of care? These issues confront the Institute of Medicine (IOM) today; they were equally significant at its creation. Addressing them has, therefore, been a constant focus of IOM attention and work. The details, over 25 years, necessarily have evolved and matured; the underlying concern with ensuring high-quality health to all has not deviated. The major contributions of the IOM date to the early 1970s. Some are concerned specifically with contemporary issues in quality of care. Other projects stem from related health policy questions, such as health status and quality-of-life measurement, technology assessment, information dissemination and systems, health care organization, and the health care work force (see the chapter “Institute of Medicine Reports on the Health Work Force” by Marilyn J. Field in this volume). The chronicle below highlights selected IOM work in * The author thanks Karl Yordy and Linda Demlo, both former directors of the Division of Health Care Services, for their assistance in providing background information on studies they carried out or supervised during their tenures; she also acknowledges the helpful comments of her IOM colleague Molla Donaldson, a senior program officer in the division. Errors of fact or interpretation are, of course, those of the author.

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For the Public Good: Highlights from the Institute of Medicine, 1970–1995 the past quarter-century; it underscores key conceptual, methodologic, and policy contributions. A full list of relevant IOM publications appears as the Bibliography.† QUALITY ASSURANCE PROGRAMS In the mid-1970s, an IOM committee issued a strong statement—Advancing the Quality of Health Care (1974)—that began the IOM's long interest in federal quality assurance (QA) programs. This statement addressed the new Professional Standards Review Organization (PSRO) program, created by legislation to review and ensure health care for the elderly through the Medicare program. The committee laid out a series of principles of QA in several general areas—scope, methods and data requirements, costs and evaluation, and research —and these tenets could (with technical updating) serve equally well today. It also called attention to certain characteristics of health care, such as the importance of the “consumer's exercise of choice” and the role that information on the “relative effectiveness of various health providers” might play in that decision-making, which still ring true 20 years later. With considerable prescience, the committee cautioned that expectations for PSROs should be limited in the immediate future. It also warned that no single QA program could fulfill the many specific goals that different groups had for the program, such as reducing costs, improving resource allocation, expanding access to care, decreasing the “depersonalization of care,” “punishing rascals,” or improving performance of health personnel. By the early 1980s, the PSRO program's results were being called severely into question. In retrospect, the 1974 IOM committee's worries, especially about the program's abilities to control costs or improve access and resource allocation, had been justified. In 1982, the PSRO program was supplanted by the Utilization and Quality Control Peer Review Organization program, commonly known as the PRO program, which exists to this day. Within a short time, separate legislation created the Prospective Payment System for Medicare, which involved hospital reimbursement according to † This account deals chiefly with IOM projects and studies. In 1974, however, Avedis Donabedian, a distinguished philosopher-physician and IOM member, delivered a seminal address to the “fall meeting” of the IOM. In it, he mapped a “domain of quality evaluation” that touched on virtually all of the core issues that confront the field today. Answers to many, if not most, of those issues have become vastly clearer in the intervening 20 years, chiefly because of advances in measurement technologies and data; the underlying messages about the overriding importance of quality evaluation—in human, ethical, professional, and policy terms—remain deserving of rereading.

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For the Public Good: Highlights from the Institute of Medicine, 1970–1995 several hundred diagnosis-related groups rather than payment on cost reimbursement or per diem bases. Because this created, in theory, considerable incentives for too little or poor hospital care, attention was drawn even more to the procedures and results of PRO activities. By 1986, Congress was sufficiently concerned that it called on the IOM to conduct a broad study “to design a strategy for quality review and assurance in Medicare.” The project began in late 1987 and led to the publication, in 1990, of the two-volume report Medicare: A Strategy for Quality Assurance. The expert committee that oversaw this project decided at an early stage that its work had to be solidly grounded in a definition of quality of care—something no other IOM panel had done. Its definition, cited and briefly discussed below, has not only been used in subsequent IOM studies but also been cited or adopted well beyond the IOM (for instance, by government spokespersons, managed care plans, and academics). “Quality of care is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.” Designating the core as health services meant that the definition applies to a broad range of services, many types of health care professionals (physicians certainly, but also nurses, dentists, therapists, and various other health professionals), and all settings of care (from hospitals and nursing homes to physicians ' offices and even private homes). Specifying populations as well as individual patients implied an emphasis on access to health care, covered other potential problems of the underuse of care, and suggested that the perspectives of both individuals and society are important. Stipulating desired health outcomes was especially important because it drew attention to a link between the processes of health care and outcomes of that care, to patient well-being and welfare, to the importance we should place on patients and their families being well informed about alternative health care interventions and their related expected outcomes, and to the need for health care professionals to take their patients' preferences and values into account. Finally, emphasizing current professional knowledge underscored the need for health professionals to stay abreast of a dynamic knowledge base in health care and to take responsibility for clarifying for their patients the processes and expected outcomes of care. One of the legislative charges for this study called on the IOM “to develop prototype criteria and standards for defining and measuring quality of care.” Taken literally, this would have proved an impossible task. To meet the spirit of the charge, however, the committee developed a set of critical attributes of quality-of-care criteria and standards. These were targeted specifically at appropriateness guidelines, patient care evaluation and management criteria, and

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For the Public Good: Highlights from the Institute of Medicine, 1970–1995 case-finding screens and were split into two basic categories: (1) substantive (or structural) attributes and (2) implementation (or process) attributes. Although the specifics of the committee's observations and recommendations about significant properties for guidelines and similar quality criteria were not immediately adopted elsewhere, they formed the basis for pivotal IOM work on clinical practice guidelines (discussed below). The Medicare QA study was conducted at a time when industrial management theories of quality improvement—known variously as “continuous quality improvement” and “total quality management”—were coming into greater prominence in health care. These approaches were predicated, philosophically, on far different bases than traditional quality assessment and assurance; for example, they rejected the notion of identifying “bad apples” (compare the 1974 committee's language about “punishing rascals”). The study committee was not convinced that the nation, or the PRO program, should wholly jettison established QA methods, but it did endorse the view that health care providers and practitioners, as well as PROs, ought to move deliberately to internal quality improvement efforts based on these newer ideas. Thus, in the early 1990s the PRO program undertook a substantial reworking of both its philosophy and its technical, operational expectations of individual PROs, through an effort that came to be known as the Health Care Quality Improvement Initiative. Yet another element of the IOM's Medicare QA study drew attention to the fact that the PRO program, since its inception nearly a decade before, had never been formally evaluated, and the study committee issued a strong recommendation that a rigorous evaluation of the program be conducted and reported to the public. These various threads came together when, in 1994, the Health Care Financing Administration (HCFA) asked the IOM to provide short-term, technical advice on its plans to evaluate the PRO program and, specifically, the emerging Health Care Quality Improvement Initiative activities. Recently HCFA has taken steps, based on the IOM work (published in 1994 as two brief reports entitled An Assessment of the HCFA Evaluation Plan for the Medicare Peer Review Organization Program), to revamp its evaluation strategy and to move ahead with a demanding review of the program. HEALTH AND QUALITY-OF-CARE DATA AND INFORMATION SYSTEMS One question that dogged the earlier PSRO program was the extent to which various private or public parties can gain access to the data generated or collected by medical peer-review organizations. The issue pits the public's interest in having good information on utilization and quality of health care services against the perceived need, if professional peer review is to be a vi-

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For the Public Good: Highlights from the Institute of Medicine, 1970–1995 able method of ensuring quality of care, not to divulge information on quality-of-care problems and their resolution. To explore this question, the IOM conducted a wide-ranging study Access to Medical Review Data (1981). It concluded that protection of patient privacy had to be a primary element of any disclosure policy, but that disclosure of utilization data about identified institutions (but not identified practitioners) could be justified on arguments related to enhanced consumer choice and public accountability. Regarding quality-of-care data, however, the committee decided that “the potential harms of requiring public disclosure [i.e., by PSROs] in identified form would outweigh the potential benefits.” The questions did not go away in the ensuing years, as evidenced by the considerable controversy generated by the forced disclosure of hospital-specific mortality rate data generated by HCFA for the use of the PRO program in the late 1980s and thereafter (until the practice was stopped in 1994)—an issue also addressed in Medicare: A Strategy for Quality Assurance. Moreover, the extraordinary rise in capabilities for generating, transmitting, storing, and analyzing health care data in the past two decades made such information more accessible to researchers, policymakers, and potentially journalists and the public. Thus, in 1992, the IOM began a study of the “potential that existing and emerging health database organizations offer in improving the health of individuals and the performance of the health care system,” and it gave particular attention to public disclosure of quality-of-care information and to the protection of the confidentiality of personal health information. Published in 1994 as Health Data in the Information Age: Use, Disclosure, and Privacy, the study advanced several recommendations concerning how entities acquiring or holding sensitive health data should (a) ensure the accuracy, completeness, and validity of those data; (b) support or conduct provider-specific studies and evaluations; and (c) promote widespread applications and use of such data. The committee also issued strong calls for stringent protections of the privacy and confidentiality of person-identifiable health data, including support for the idea that the Congress should enact preemptive legislation to ensure the confidentiality and protection of privacy rights across the nation. Large administrative data files are not the only sources of core information for quality-of-care purposes. Most experts believe that far more clinical information is needed, particularly detailed and accurate data on diagnoses and processes of care. In 1991, the IOM released The Computer-Based Patient Record: An Essential Technology for Health Care, a unique examination of the potential that computer-based patient records (CPRs) and CPR systems

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For the Public Good: Highlights from the Institute of Medicine, 1970–1995 have to improve care for both individuals and populations and to reduce waste and inefficiency in the health care system. That study committee advanced a vision of CPRs as a “key infrastructural requirement to support the information management needs” of a wide array of parties concerned with the delivery and evaluation of health care. Of its several recommendations, the most momentous was that “the public and private sectors should join in establishing a Computer-Based Record Institute . . . to promote and facilitate development, implementation, and dissemination of the CPR.” By early 1992, such an institute had indeed been established and was engaged in a variety of activities relating to data standards, privacy, and other issues aimed at expanding the nation's use of electronic media in patient care. Although wide use of CPRs in quality assurance and improvement lies in the future, few doubt the eventual role of CPRs in all facets of health care delivery. The IOM report, and the efforts of the IOM committee itself, are considered to have played a consequential role in these developments. METHODOLOGIC ADVANCES Walsh McDermott brought to the early days of the IOM the belief that the nation needed a better way to know if disadvantaged populations were being harmed by lack of health care, and a landmark series of studies began just as the IOM charter was approved. Known in quality circles as the “tracer studies,” the three-volume report brought prominence to significant questions about the access to and quality of care for low-income populations, especially children. To carry out significant epidemiologic evaluations of care, for example, in the Washington, D.C., area, study staff developed methods for assessing measures such as hearing loss in children and, from them, generalizing to like areas of health services and inferring the level of overall care. The resulting reports, published in 1973–1974 under the series title Contrasts in Health Status, laid significant groundwork for empirical quality-of-care assessment that served well into the next decade; this was especially true of the second and third volumes—A Strategy for Evaluating Health Services and Assessment of Medical Care for Children. In the late 1980s and 1990s, the belief that performance on one set of quality measures—that is, carefully selected “tracer conditions”—could be easily extrapolated to like services, such as care rendered in different hospital departments or by different specialists caring for similar patients and illnesses, came under criticism because of vastly improved data collection and analysis techniques and a further 10 years of quality-of-care work. Nevertheless, the IOM monographs, by virtue of their methodologic breakthroughs and pointed attention to generally understudied populations, provided a significant impetus

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For the Public Good: Highlights from the Institute of Medicine, 1970–1995 to a wide array of policy and health services research in the quality-of-care area. In another landmark set of empirical studies, the IOM issued in the late 1970s a series of reports on issues related to the reliability of data contained in hospital discharge abstracts. The first study, reported in Reliability of Hospital Discharge Abstracts (1977), was done to determine whether these data were sufficiently reliable to serve as baseline data against which to evaluate the impact of the PSRO program. (Before the PSRO program was implemented, considerable effort had been devoted to prospectively developing an evaluation plan, and this study was part of that effort.) The study faced numerous tricky sampling, logistical, and confidentiality issues, because it investigated discharge abstracts processed by private abstract services and yet needed a nationally generalizable sample. The problems were solved in creative ways, in part through the help of the forerunner of the American Medical Records Association (which later was to lead the way in establishing the Computer-Based Patient Record Institute). Among the methodologic contributions of this study were methods for reabstracting medical records and response options to characterize instances in which the original and reabstracted data disagreed. The second study, Reliability of Medicare Hospital Discharge Records (1977), was done for HCFA primarily to see how Medicare data compared with those from private systems. The assumption was that Medicare data would be worse because they were obtained as part of the billing process, but this proved not to be the case. Confidence in the reliability and validity of Medicare data grew over the 1970s and 1980s to such an extent that the Medicare files, especially for hospital inpatient care, are often regarded as the most useful sources of population data for many health services research and health policy efforts. The third study, Reliability of National Hospital Discharge Survey Data (1980), focused on the National Center for Health Statistics National Hospital Discharge Survey data and was derived from a follow-on request. Among other questions, it looked at whether data abstracted by persons working for the U.S. Census would be comparable to data abstracted by the hospitals themselves, and it determined that no major differences could be identified. All three studies have been widely cited and replicated. One significant finding overall was that in hospitals in which these data were not only collected but actually used, they tended to be better. This was not, at the time, a well-understood point, but today it is a “given” in quality improvement programs. In a completely different realm—that of patient-reported data—the IOM organized two significant international invitational conferences on advances in health status measurement in 1988 and 1991. (The conference proceedings were published as supplements to the journal Medical Care in March 1989 and May 1992, respectively.) These works documented the progress made in the previous decades, and especially since the early 1970s, in ways to assess health

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For the Public Good: Highlights from the Institute of Medicine, 1970–1995 status and health-related quality of life by using questionnaire techniques to elicit reliable and valid responses from people of all ages and states of health. In addition, they added to the growing understanding that a complete conceptualization of patient outcomes was not possible unless significant attention was paid to the outcomes that matter to individuals: physical functioning, mental and emotional states, functioning in usual daily roles, and other aspects of health that are best reported by patients themselves. QUALITY OF CARE AND SPECIAL POPULATIONS Among the more celebrated IOM works related to quality of care was the 1986 “nursing home regulation” study, Improving the Quality of Care in Nursing Homes. Done in response to informal requests from both the legislative and the executive branches of government, the report brought about near-instantaneous reform in the care provided throughout the nursing home sector to the more than 1.3 million elderly persons residing in such facilities. After the report was issued, the Finance Committee of the U.S. Senate scheduled hearings; before the hearings, the Coalition for Nursing Home Reform (a citizen activist lobby), the nursing home industry, and state Medicaid directors agreed on a common approach that strongly supported the report's recommendations. Because these had been the contending parties before the report was issued, the impact on interested senators was dramatic. Thus, when legislation was introduced in the Senate and the House, the bill's purpose was stated to be: “To implement the recommendations of the Institute of Medicine.” Among the more dramatic changes recommended was the elimination of both physical and chemical restraints on nursing home residents, an advance hailed by many parties concerned with humane, high-quality care for such people. In addition, one significant recommendation called for the development and use of a resident assessment process that would provide information on resident status on admission and regularly thereafter. These health status data were the key to moving the quality review process from the prior focus on structural and some process-of-care measures toward more emphasis on patient-centered outcomes. The eventual “needs assessment” instrument was developed and implemented by HCFA; insufficient time has passed for a solid evaluation of its impact. The path to final federal regulations and implementation of the kinds of recommendations set forth in the nursing home regulation report, as translated into the Omnibus Budget Reconciliation Acts of 1987 and 1990, has been ex-

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For the Public Good: Highlights from the Institute of Medicine, 1970–1995 tremely controversial and beset with delay. For example, one element of the debate following release of the IOM report concerned requirements for nurse staffing in skilled nursing facilities. That issue proved so contentious that Congress eventually called for yet another IOM project on the appropriateness of establishing minimum ratios of caregivers to residents and of supervisors to caregivers; the study (“Adequacy of Nurse Staffing: Stress, Injury, and Quality of Care ”) is presently under way, and the committee's final report is due in late 1995. Care in nursing homes remains problematic in many ways, as documented in a recent IOM report (Real People, Real Problems: An Evaluation of theState Long-Term Care Ombudsman Program, 1994). Public concern about abuse and inferior quality of care in nursing facilities had led Congress to create the long-term-care (LTC) ombudsman program in 1971 to enable ombudsmen to help resolve the problems faced by residents of LTC facilities while also advocating broad policy changes. More than 20 years later, the IOM committee conducting this evaluation concluded that the LTC ombudsman program serves a vital public purpose and merits continuation. It also identified several deficiencies and recommended a variety of remedies to (a) address problems such as conflict of interest and poor data about program activities and effectiveness, (b) improve state compliance with federal statutory mandates, (c) create minimum paid-staff-to-volunteer ratios, and (d) bring more federal and state funding to the programs. The revolution in attitudes about and practices in nursing homes initiated by the nursing home regulation report stands as a tribute to the contributions that the IOM can make to better quality of care, and quality of life, for the American people. Indeed, the conduct and reception of the ombudsman study is testimony to the credibility of the IOM established by the nursing home regulation project. In Kidney Failure and the Federal Government (1991), the IOM examined in detail issues related to the quality of care for people with end-stage renal disease (ESRD), as part of a broad review of the federal ESRD program. (The IOM had first concerned itself with the ESRD program in a 1973 report, Disease by Disease Toward National Health Insurance?) Drawing on the definitional and conceptual underpinnings of the Medicare QA study, this IOM committee advanced significant proposals for revamping HCFA's old-fashioned and ineffective system for reviewing and changing the quality of care delivered to ESRD patients. Among other points, the report underscored the significance of health status and quality of life for ESRD patients (as contrasted with the long-standing concentration on use of services, purely clinical laboratory measures, or mortality). As a result, the nephrology community was keenly supportive of a project carried out in 1992–1993 to explore the uses of health-related quality-of-life measures in quality improvement programs for ESRD patients in dialysis

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For the Public Good: Highlights from the Institute of Medicine, 1970–1995 treatment settings. A large conference in September 1993 prompted considerable debate about how measures of quality might be extended beyond laboratory measures or mortality. It also elicited substantial acknowledgment of the need to move toward patient-reported measures of functioning and emotional well-being. (Conference proceedings were published in the August 1994 issue of the American Journal of Kidney Diseases.) To foster this interest and acceptance, the professional community, dialysis industry, and interested government agencies supported a follow-up conference in December 1994; it clarified technical and feasibility issues about such measures as a means of assisting the ESRD patient and provider communities in moving ahead with their adoption and use. CLINICAL PRACTICE GUIDELINES Landmark legislation in 1989 established the Agency for Health Care Policy and Research (AHCPR) in the Department of Health and Human Services and assigned to a new unit the wholly new responsibility of sponsoring the development and dissemination of clinical practice guidelines. For an agency whose core was a 20-year-old research unit, this was a major challenge. Thus, AHCPR leadership turned to the IOM for assistance in approaching these new responsibilities. In a fast-track study culminating in Clinical Practice Guidelines: Directions for a New Program (1990), the IOM provided technical assistance, a definition of key terms in the 1989 legislation, and specifications of “critical attributes ” of sound practice guidelines. The definition of guidelines—“systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances ”—was immediately adopted by AHCPR (even before the report was released) and has been broadly cited subsequently. In addition, the eight attributes of good guidelines identified in the report served as guides for AHCPR as well as for private-sector programs of guidelines development and, 5 years later, are widely known in this nation and abroad. In a parallel track, planning was under way for a broader study that would build on both the AHCPR study and an early IOM project on utilization management (Controlling Costs and Changing Patient Care? The Role of Utilization Management, 1989). Released in 1992, Guidelines for Clinical Practice: From Development to Use explored a wide range of issues about the development, dissemination, and implementation of practice guidelines pertinent to both the public and the

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For the Public Good: Highlights from the Institute of Medicine, 1970–1995 private sectors. It expanded the understanding of key guidelines attributes, identified significant methodologic and procedural issues that warranted continued work, and explored the then little-understood issues of how best to assess the soundness of existing or emerging practice guidelines. The report provided a detailed provisional instrument for assessing practice guidelines that has subsequently been adapted for use both in the United States and overseas. In addition, it provided background for another study, done at AHCPR's request, on setting priorities for the selection of guidelines topics (Setting Priorities for Clinical Practice Guidelines, 1995). Finally, the IOM monographs have explored several issues about a public–private assessment organization that might have responsibilities to act as a major national clearinghouse for practice guidelines. These questions were, as of early 1995, back on the policy agenda at AHCPR and elsewhere and may be explored further in an upcoming IOM project. RELATED WORK The IOM, since its inception, has conducted many other activities that, collectively, contribute to the improvement in the quality of health care for this nation. During the late 1980s, for example, the IOM was host to the Council on Health Care Technology (itself predicated on recommendations in A Consortium for Assessing Medical Technology [1983] and needs identified for the field in Assessing Medical Technologies [1985]). This committee and its subpanels explored many issues related to the purpose of and methods for technology assessment and produced a unique directory (Medical Technology Assessment Directory, 1988). A spinoff activity on technological innovation has produced, to date, a five-volume series of conference proceedings collectively entitled Medical Innovation at the Crossroads. Another report, The Artificial Heart: Prototypes, Policies, and Patients (1991), also drew on many concepts and approaches related to IOM work in technology assessment, outcomes measurement, and quality of care. In addition, at the request of AHCPR, the IOM developed a conceptually and methodologically rigorous method for priority-setting for technology assessment (Setting Priorities for Health Technology Assessment: A Model Process, 1992). It is, with some modifications, presently being adopted by the agency and has been used by private-sector organizations here and abroad; it also served as the starting point for the guidelines project cited above. Priority-setting was also at the heart of a series of reports issued in 1988–1990 to help both HCFA and AHCPR set their agendas for effectiveness and outcomes research. These documents (Effectiveness Initiative: Setting Priorities for Clinical Conditions; three reports on setting priorities for effectiveness research related to breast cancer, hip fracture, and acute myocardial infarction; and Ef-

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For the Public Good: Highlights from the Institute of Medicine, 1970–1995 fectiveness and Outcomes in Health Care: Proceedings of an Invitational Conference) have provided rationales and guidance not only for medical effectiveness and patient outcomes research but also for the development of practice guidelines. Finally, quality considerations are implicit or explicit in many other IOM reports that deal with a broad range of issues, and this has been particularly true in the past 10 years. Among these studies are For-Profit Enterprise in Health Care (1986), Treating Drug Problems (1990), Toward a National Health Care Survey (1992), Access to Health Care in America (1993), Emergency Medical Services for Children (1993), and Dental Education at the Crossroads (1994). SUMMARY This quarter-century of work has brought the IOM to the cusp of a new era, and a new mission, in quality of care. In 1994, the IOM announced a special, Institute-wide initiative: America's Health Care in Transition: Protecting and Improving Health and the Quality of Health Care. It is motivated by the recognition of the rapid and uncoordinated change occurring in the nation's health care system—a period characterized by increasingly constrained resources, decentralization of decision-making, consolidation of health care delivery plans and insurers, and new divisions of responsibilities among a wide range of health care professionals and organizations, both public and private. As this restructuring unfolded, the IOM came to believe it vital that quality of care for individuals and populations should be a major, continuing focus of attention. In the policy area, therefore, the intention is to inform the public debate about issues that have significant quality-of-care implications, such as the balance between personal and public health services, trade-offs between costs and quality, or the effects of the restructuring of the system on different populations. In the operational arena, the aim is to identify good tools for measuring and monitoring quality as well as solid mechanisms for improving the quality of health care services and informing potential users about how those approaches can best be applied. To set out its philosophy and goals, the IOM Council in mid-1994 issued a White Paper, America's Health in Transition:Protecting and Improving Quality, and as the 25th anniversary celebration of the IOM drew near, plans were well under way for a broad-based set of activities. Thus, as the IOM embarks on its second 25 years, its focus on and contributions to preserving and improving the quality of health care for the nation —a core element of the Institute's long-standing mission statement—remain steady and intense.

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For the Public Good: Highlights from the Institute of Medicine, 1970–1995 BIBLIOGRAPHY Access to Health Care in America,Michael Millman, ed., 1993. Access to Medical Review Data, 1981. Acute Myocardial Infarction: Setting Priorities for Effectiveness Research, Patrick H. Mattingly and Kathleen N. Lohr, eds., 1990. Advancing the Quality of Health Care, 1974. The Artificial Heart: Prototypes, Policies and Patients, John R. Hogness and Malin VanAntwerp, eds., 1991. Assessing Medical Technologies, 1985. An Assessment of the HCFA Evaluation Plan for the Medicare Peer Review Organization Program, 1994. Breast Cancer: Setting Priorities for Effectiveness Research , Kathleen N. Lohr, ed., 1990. Clinical Practice Guidelines: Directions for a New Program , Marilyn J. Field and Kathleen N. Lohr, eds., 1990. The Computer-Based Patient Record: An Essential Technology for Health Care,Richard S. Dick and Elaine B. Steen, eds., 1991. A Consortium for Assessing Medical Technology, 1983. Contrasts in Health Status, Volume 1. Infant Death: An Analysis by Maternal Risk and Health Care, 1973. Contrasts in Health Status, Volume 2. A Strategy for Evaluating Health Services, 1973. Contrasts in Health Status, Volume 3. Assessment of Medical Care for Children: An Analysis of Contrasting Forms of Delivery, 1974. Controlling Costs and Changing Patient Care? The Role of Utilization Management, Marilyn J. Field, Bradford H. Gray, and Jerome H. Grossman, eds., 1989. Dental Education at the Crossroads: Challenges and Change,John P. Howe and Marilyn J. Field, eds., 1995. Disease by Disease Toward National Health Insurance? 1973. Effectiveness Initiative: Setting Priorities for Clinical Conditions 1989. Emergency Medical Services for Children, Jane S. Durch and Kathleen N. Lohr, eds., 1993. For-Profit Enterprise in Health Care, 1986. Guidelines for Clinical Practice: From Development to Use, Marilyn J. Field and Kathleen N. Lohr, eds., 1992. Health Data in the Information Age: Use, Disclosure, and Privacy, Molla S. Donaldson and Kathleen N. Lohr, eds., 1994. Hip Fracture: Setting Priorities for Effectiveness Research, Kim A. Heithoff and Kathleen N. Lohr, eds., 1990. Improving the Quality of Care in Nursing Homes, 1986. Kidney Failure and the Federal Government, Richard A. Rettig and Norman G. Levinsky, eds., 1991. Medical Innovation at the Crossroads, Volume 1. Modern Methods of Clinical Investigation, Annetine C. Gelijns, ed., 1990. Medical Innovation at the Crossroads, Volume 2. The Changing Economics of Medical Technology, Annetine C. Gelijns and Ethan A. Halm, eds., 1991.

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For the Public Good: Highlights from the Institute of Medicine, 1970–1995 Medical Innovation at the Crossroads, Volume 3. Technology and Health Care in an Era of Limits, Annetine C. Gelijns, ed., 1992. Medical Innovation at the Crossroads, Volume 4. Adopting New Medical Technology, Nathan Rosenberg, Annetine C. Gelijns, and Holly Dawkins, eds., 1994. Medical Innovation at the Crossroads, Volume 5. Sources of Medical Technology: Universities and Industry, Nathan Rosenberg, Annetine C. Gelijns, and Holly Dawkins, eds., 1995. Medical Technology Assessment Directory: A Pilot Reference to Organizations, Assessments, and Resources, Clifford Goodman, ed., 1988. Medicare: A Strategy for Quality Assurance, Volume I. Report of a Study, Kathleen N. Lohr, ed., 1990. Medicare: A Strategy for Quality Assurance, Volume II. Sources and Methods, Kathleen N. Lohr, ed., 1990. Real People, Real Problems: An Evaluation of the Long-Term Care Ombudsman Programs of the Older Americans Act, Jo Harris-Wehling, Jill C. Feasley, and Carroll L. Estes, eds., 1995. Reliability of Hospital Discharge Abstracts, 1977. Reliability of Medicare Hospital Discharge Records, 1977. Reliability of National Hospital Discharge Survey Data, 1980. Setting Priorities for Clinical Practice Guidelines, Marilyn J. Field, ed., 1995. Setting Priorities for Health Technology Assessment: A Model Process , Molla S. Donaldson and Harold C. Sox,Jr., eds., 1992. Toward a National Health Care Survey: A Data System for the 21st Century, Gooloo Wunderlich, ed., 1992. Treating Drug Problems, Volume 1: The Report, 1990. Treating Drug Problems, Volume 2, Dean R. Gerstein and Henrick J. Harwood, eds., 1992.