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Jochanan Benbassat: JDC Brookdale Institute, Health Policy Research Program, Jerusalem, Israel
Mark Taragin: JDC Brookdale Institute, Health Policy Research Program, Jerusalem, Israel
Introduction
During the last decade, quality assurance of health care has evolved into an ambiguous and perplexing issue[1, 2]. On the one hand, financial incentives to conserve resources and the aggressive malpractice environment have highlighted the needs for standards of professional accountability[1]. On the other hand, however, calls for quality assurance have been met by the medical community with "anger, skepticism or simply disinterest"[2]. This skepticism was recently expressed by Kassirer[3] who wrote:"
From a system that until recently was dominated by reliance on intelligent and thoughtful decision making by individual doctors, we seem to have embarked on a path of codifying the practice of medicine. In part we are doing so in the name of quality. To be sure, we are developing the tools to measure and monitor quality, but before we embrace them we must be sure that they are equal to their intended tasks, and that the benefits of standardization are worth the costs."
Physicians' ambivalent attitude toward this issue is probably related to the uncertainties regarding why is quality assurance needed to improve cost-effectiveness? to respond to public demand and avoid lawsuits? because we care?), where to look for it (individual performance? that of the health care system?), how can it be achieved (re-education? removal of the "bad apples"? changes in the process of health care delivery?), and above all, what is adequate health care and how should it be measured. Currently used measures have been criticized for focussing on "quantifiable, but often secondary, aspects of service that measure what is minimally acceptable rather than what is optimal"[4], and for their limited validity. Like all diagnostic tests, measures of quality of health care may incorrectly identify some medical interventions as inappropriate when they are actually appropriate, and vice versa[5].
Quality assurance of health care cannot be postponed until these uncertainties are resolved[2]. To maintain its credibility, the medical profession has to define standards of quality of care and implement methods for its monitoring. The objective of this essay is to propose a definition of "quality of care" and to review interventions that have been reported to improve some of...