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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