No abstract

T his paper is an attempt to describe and evaluate current methods for assessing the quality of medical care and to suggest some directions for further study. It is concerned with methods rather than findings, and with an evaluation of methodology in general, rather than a detailed critique of methods in specific studies. This is not an exhaustive review of the pertinent literature. Certain key studies, of course, have been included. Other papers have been selected only as illustrative examples. Those omitted are not, for that reason, less worthy of note.This paper deals almost exclusively with the evaluation of the medical care process at the level of physician-patient interaction. It excludes, therefore, processes primarily related to the effective delivery of medical care at the community level. Moreover, this paper is not concerned with the administrative aspects of quality control. Many of the studies reviewed here have arisen out of the urgent need to evaluate and control the quality of care in organized programs of medical care. Nevertheless, these studies will be discussed only in terms of their contribution to methods of assessment and not in terms of their broader social goals. The author has remained, by and large, in the familiar territory of care provided by physicians and has avoided incursions into other types of

T his paper is an attempt to describe and evaluate current methods for assessing the quality of medical care and to suggest some directions for further study. It is concerned with methods rather than findings, and with an evaluation of methodology in general, rather than a detailed critique of methods in specific studies. This is not an exhaustive review of the pertinent literature. Certain key studies, of course, have been included. Other papers have been selected only as illustrative examples. Those omitted are not, for that reason, less worthy of note.This paper deals almost exclusively with the evaluation of the medical care process at the level of physician-patient interaction. It excludes, therefore, processes primarily related to the effective delivery of medical care at the community level. Moreover, this paper is not concerned with the administrative aspects of quality control. Many of the studies reviewed here have arisen out of the urgent need to evaluate and control the quality of care in organized programs of medical care. Nevertheless, these studies will be discussed only in terms of their contribution to methods of assessment and not in terms of their broader social goals. The author has remained, by and large, in the familiar territory of care provided by physicians and has avoided incursions into other types of

Before assessment can begin we must decide how quality is to be defined and that depends on whether one assesses only the performance of practitioners or also the contributions of patients and of the health care system; on how broadly health and responsibility for health are defined; on whether the maximally effective or optimally effective care is sought; and on whether individual or social preferences define the optimum. We also need detailed information about the causal linkages among the structural attributes of the settings in which care occurs, the processes of care, and the outcomes of care. Specifying the components or outcomes of care to be sampled, formulating the appropriate criteria and standards, and obtaining the necessary information are the steps that follow. Though we know much about assessing quality, much remains to be known.

A commentary on the papers in the two special issues on Quality Assurance which shows how they contribute to some important conceptual, methodological, and policy issues. These issues pertain to the definition of quality; the distinction between quality assessment and program evaluation; the role of the market in regulating the quality of care; the role of more direct consumer participation in defining and assessing quality; professional responsibility for quality; the applicability of the structure-process-outcome paradigm to quality assessment; the format, methods of formulation, and validity of the criteria; probability sampling and purposive selection of the topics to be assessed; problems of scaling and measurement; the applicability of industrial control methods to quality monitoring; bringing about behavior change in response to the findings of quality monitoring; measuring the costs and benefits of quality assessment methods, including a consideration of their screening efficiency; and the relationship between quality monitoring and cost containment through competition or by other means.