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The Quality of Care How Can It Be Assessed? Avedis Donabedian, MD, MPH

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.

(JAMA 1988;260:1743-1748)

THERE was a time, not too long ago, when this question could not have been asked. The quality of care was consid¬ ered to be something of a mystery: real, capable of being perceived and appreci¬ ated, but not subject to measurement.

For editorial comment see p 1759.

The very attempt to define and measure quality seemed, then, to denature and belittle it. Now, we may have moved too far in the opposite direction. Those who have not experienced the intricacies of clinical practice demand measures that are easy, precise, and complete—as if a sack of potatoes was being weighed.

True, some elements in the quality of care are easy to define and measure, but there are also profundities that still elude us. We must not allow anyone to belittle or ignore them; they are the secret and glory of our art. Therefore, we should avoid claiming for our capa¬ city to assess quality either too little or too much. I shall try to steer this middle course.

SPECIFYINGWHAT QUALITY IS Level and Scope of Concern Before we attempt to assess the qual¬

ity of care, either in general terms or in any particular site or situation, it is nec¬

essary to come to an agreement onwhat the elements that constitute it are. To proceed to measurement without a firm foundation of prior agreement on what quality consists in is to court disaster.1 As we seek to define quality, we soon

become aware of the fact that several formulations are both possible and legitimate, depending on where we are

located in the system of care and on what the nature and extent of our re¬

sponsibilities are. These several formu¬ lations can be envisaged as a progres¬ sion, for example, as steps in a ladder or as successive circles surrounding the bull's-eye of a target. Our power, our

responsibility, and our vulnerability all flow from the fact that we are the foun¬ dation for that ladder, the focal point for that family of concentric circles. We must begin, therefore, with the perfor¬ mance of physicians and other health care practitioners. As shown in Fig 1, there are two ele¬

ments in the performance of practitio¬ ners: one technical and the other interpersonal. Technical performance depends on the knowledge and judg¬ ment used in arriving at the appropriate strategies of care and on skill in imple¬ menting those strategies. The goodness of technical performance is judged in comparison with the best in practice. The best in practice, in its turn, has earned that distinction because, on the average, it is known or believed to produce the greatest improvement in health. This means that the goodness of technical care is proportional to its ex¬

pected ability to achieve those improve¬ ments in health status that the current science and technology of health care have made possible. If the realized frac¬ tion ofwhat is achievable is called effec¬ tiveness, the quality of technical care becomes proportionate to its effective¬ ness (Fig 2). Here, two points deserve emphasis.

First, judgments on technical quality are contingent on the best in current knowledge and technology; they cannot go beyond that limit. Second, the judg-

From the University of Michigan School of Public Health, Ann Arbor. This articlewaswritten for the AMA Lectures inMedi-

cal Science: it is the basis for a lecture in that series given on Jan 11, 1988, by invitation of the Division of Basic Sciences, American Medical Association, Chicago.

Reprint requests to 1739 Ivywood Dr, Ann Arbor, MI 48103.

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_ Care by Practitioners

~"" and Other Providers Technical Knowledge, Judgment Skill

Interpersonal 1----- Amenities

Care Implemented * by Patient

Contribution of Provider Contribution of Patient and Family

.„ Care Received by Community Access to Care Performance of Provider Performance of Patient and Family

Fig 1.—Levels at which quality may be assessed.

ment is based on future expectations, not on events already transpired. Even if the actual consequences of care in any given instance prove to be disastrous, quality must be judged as good if care, at the time it was given, conformed to the practice that could have been ex¬

pected to achieve the best results. Themanagement of the interpersonal

relationship is the second component in the practitioner's performance. It is a

vitally important element. Through the interpersonal exchange, the patient communicates information necessary for arriving at a diagnosis, as well as preferences necessary for selecting the most appropriate methods of care.

Through this exchange, the physician provides information about the nature of the illness and its management and motivates the patient to active collabo¬ ration in care. Clearly, the interper¬ sonal process is the vehicle by which technical care is implemented and on

which its success depends. Therefore, the management of the interpersonal process is to a large degree tailored to the achievement of success in technical care. But the conduct of the interpersonal

process must also meet individual and social expectations and standards, whether these aid or hamper technical performance. Privacy, confidentiality, informed choice, concern, empathy, honesty, tact, sensitivity—all these and more are virtues that the interpersonal relationship is expected to have. If the management of the interper¬

sonal process is so important, why is it so often ignored in assessments of the

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to CO £ 75 <D I

Time

Fig 2.—Graphical presentation of effectiveness (in a self-limiting disease). Solid line indicates course of illness without care; dotted line, course of illness with care to be assessed; and dashed line, course of illness with "best" care. Effectiveness equals A/(A + B).

quality of care? There are many rea¬ sons. Information about the interper¬ sonal process is not easily available. For example, in the medical record, special effort is needed to obtain it. Second, the criteria and standards that permit pre¬ cise measurement of the attributes of the interpersonal process are not well developed or have not been sufficiently called upon to undertake the task. Part¬ ly, it may be because themanagement of the interpersonal process must adapt to so many variations in the preferences and expectations of individual patients that general guidelines do not serve us

sufficiently well. Much of what we call the art ofmedi¬

cine consists in almost intuitive adap¬ tions to individual requirements in tech¬ nical care as well as in the management of the interpersonal process. Another element in the art of medicine is the way, still poorly understood, in which practitioners process information to ar¬ rive at a correct diagnosis and an appro¬ priate strategy of care.2 As our under¬ standing of each of these areas of performance improves, we can expect the realm of our science to expand and that ofour art to shrink. Yet I hope that some of the mystery in practice will always remain, since it affirms and celebrates the uniqueness of each individual. The science and art ofhealth care, as

they apply to both technical care and the management of the interpersonal process, are at the heart of the meta¬ phorical family ofconcentric circles de¬ picted in Fig 1. Immediately surround¬ ing the center we can place the

amenities of care, these being the de¬ sirable attributes of the settings with¬ in which care is provided. They include convenience, comfort, quiet, privacy, and so on. In private practice, these are the responsibility of the practitio¬ ner to provide. In institutional prac¬ tice, the responsibility for providing them devolves on the owners and man¬ agers of the institution. By moving to the next circle away

from the center ofourmetaphorical tar¬ get, we include in assessments of quali¬ ty the contributions to care of the pa¬ tients themselves as well as ofmembers of their families. By doing so we cross an

important boundary. So far, our con¬ cern was primarily with the perfor¬ mance of the providers of care. Now, we are concerned with judging the care as it actually was. The responsibility, now, is shared by provider and consumer. As already described, the management of the interpersonal process by the practi¬ tioner influences the implementation of care by and for the patient. Yet, the patient and family must, themselves, also carry some of the responsibility for the success or failure of care. Accord¬ ingly, the practitioner may be judged blameless in some situations in which the care, as implemented by the patient, is found to be inferior.

We have one more circle to visit, an¬ other watershed to cross. Now, we are concerned with care received by the community as a whole. We must now judge the social distribution of levels of quality in the community.3 This de¬ pends, in turn, on who has greater or lesser access to care and who, after gaining access, receives greater or lesser qualities of care. Obviously, the performance of individual practitioners and health care institutions hasmuch to do with this. But, the quality of care in a

community is also influenced by many factors over which the providers have no control, although these are factors they should try to understand and be concerned about. I have tried, so far, to show that the

definition of quality acquires added ele¬ ments as we move outward from the performance of the practitioners, to the care received by patients, and to the care received by communities. The defi¬ nition of quality also becomes narrower or more expansive, depending on how narrowly or broadly we define the con¬

cept ofhealth and our responsibility for it. It makes a difference in the assess¬ ment of our performance whether we

see ourselves as responsible for bring¬ ing about improvements only in specific aspects of physical or physiological function or whether we include psycho¬ logical and social function as well.

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CO CD S m mU <D *- ^ 2 O CO — O 2 O "¡D

; Benefits

iCost

°

A B

Useful Additions to Care

Fig 3.—Hypothetical relations between health benefits and cost of care as useful additions are made to care. A indicates optimally effective care; and B, maximally effective care.

Valuation of the Consequences of Care Still another modification in the

assessment of performance depends on who is to value the improvements in health that care is expected to produce. If it is our purpose to serve the best interest of our patients, we need to in¬ form them of the alternatives available to them, so they can make the choice most appropriate to their preferences and circumstances. The introduction of patient preferences, though necessary to the assessment of quality, is another source of difficulty in implementing assessment. It means that no precon¬ ceived notion ofwhat the objectives and accomplishments of care should be will precisely fit any given patient. All we can hope for is a reasonable approxima¬ tion, one that must then be subject to individual adjustment." Monetary Cost as a Consideration Finally, we come to the perplexing

question of whether the monetary cost of care should enter the definition of quality and its assessment.1,7 In theory, it is possible to separate quality from inefficiency. Technical quality is judged by the degree to which achievable im¬ provements in health can be expected to be attained. Inefficiency is judged by the degree to which expected improve¬ ments in health are achieved in an un¬ necessarily costly manner. In practice, lower quality and inefficiency coexist because wasteful care is either directly harmful to health or is harmful by dis¬ placingmore useful care.

Cost and quality are also confounded because, as shown in Fig 3, it is believed that as one adds to care, the correspond¬ ing improvements in health become pro¬ gressively smaller while costs continue to rise unabated. If this is true, there will be apoint beyond which additions to care will bring about improvements that are too small to be worth the added cost. Now, we have a choice. We can ignore cost and say that the highest quality is represented by care that can be expected to achieve the greatest im¬ provement in health; this is a "maximal¬ ist" specification of quality. Alterna¬ tively, if we believe that cost is important, we would say that care must stop short of including elements that are disproportionately costly compared with the improvements in health that they produce. This is an "optimalist" specification ofquality. A graphical rep¬ resentation of these alternatives is shown in Fig 3. Health care practitioners tend to pre¬

fer a maximalist standard because they only have to decide whether each added element of care is likely to be useful. By contrast, the practice of optimal care requires added knowledge of costs, and also some method ofweighing each add¬ ed bit of expected usefulness against its corresponding cost.8 Yet, the practice of optimal care is traditional, legitimate, even necessary, as long as costs and benefits are weighed jointly by the prac¬ titioner and the fully informed patient. A difficult, perhaps insoluble, problem arises when a third party (for example, a private insurer or a governmental agency) specifies what the optimum that defines quality is.* Preliminaries to Quality Assessment Before we set out to assess quality,

we will have to choose whether we will adopt amaximal or optimal specification of quality and, if the latter, whether we shall accept what is the optimum for each patient orwhat has been defined as

socially optimal. Similarly, we should have decided (1) how health and our

responsibility for it is to be defined, (2) whether the assessment is to be of the performance ofpractitioners only or also include that of patients and the health care system, and (3) whether the amenities and the management of the interpersonal process are to be included in addition to technical care. In a more

practical vein, we need to answer cer¬ tain questions: Who is being assessed? What are the activities being assessed? How are these activities supposed to be conducted? What are they meant to accomplish? When we agree on the answers to these questionswe are ready to look for the measures that will give

us the necessary information about quality. Approaches to Assessment The information from which infer¬

ences can be drawn about the quality of care can be classified under three categories: "structure," "process," and "outcome."110 Structure.—Structure denotes the

attributes of the settings in which care occurs. This includes the attributes of material resources (such as facilities, equipment, and money), of human re¬ sources (such as the number and qualifi¬ cations of personnel), and of organiza¬ tional structure (such as medical staff organization, methods of peer review, andmethods of reimbursement). Process.—Process denotes what is

actually done in giving and receiving care. It includes the patient's activities in seeking care and carrying it out as well as the practitioner's activities in making a diagnosis and recommending or implementing treatment. Outcome.—Outcome denotes the ef¬

fects of care on the health status of patients and populations. Improve¬ ments in the patient's knowledge and salutary changes in the patient's behav¬ ior are included under a broad definition of health status, and so is the degree of the patient's satisfactionwith care. This three-part approach to quality

assessment is possible only because good structure increases the likelihood of good process, and good process in¬ creases the likelihood of a good out¬ come. It is necessary, therefore, to have established such a relationship before any particular component of structure, process, or outcome can be used to as¬ sess quality. The activity of quality as¬ sessment is not itselfdesigned to estab¬ lish the presence of these relationships. There must be preexisting knowledge of the linkage between structure and process, and between process and out¬ come, before quality assessment can be undertaken. Knowledge about the relationship be¬

tween structure and process (or be¬ tween structure and outcome) proceeds from the organizational sciences. These sciences are still relatively young, so our knowledge of the effects of struc¬ ture is rather scanty.1112 Furthermore, what we do know suggests that the rela¬ tionship between structural character¬ istics and the process of care is rather weak. From these characteristics, we can only infer that conditions are either inimical or conducive to good care. We cannot assert that care, in fact, has been good or bad. Structural characteristics should be a major preoccupation in sys¬ tem design; they are a rather blunt in-

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strument in quality assessment. As I have already mentioned, knowl¬

edge about the relationship between at¬ tributes of the interpersonal process and the outcome of care should derive from the behavioral sciences. But so far, these sciences have contributed rela¬ tively little to quality assessment. I can¬ not say whether this is because of a

deficiency in these sciences or a narrow¬ ness in those who assess quality. Knowledge about the relationship be¬

tween technical care and outcome de¬ rives, of course, from the health care sciences. Some ofthat knowledge, as we know, is pretty detailed and firm, deriv¬ ing from well-conducted trials or exten¬ sive, controlled observations. Some of it is of dubious validity and open to ques¬ tion. Our assessments of the quality of the technical process of care vary ac¬ cordingly in their certainty and persua¬ siveness. If we are confident that a cer¬ tain strategy of care produces the best outcomes in a given category of pa¬ tients, we can be equally confident that its practice represents the highest qual¬ ity of care, barring concern for cost. If we are uncertain of the relationship, then our assessment of quality is corre¬

spondingly uncertain. It cannot be em¬

phasized too strongly that our ability to assess the quality of technical care is bounded by the strengths and weak¬ nesses of our clinical science. There are those who believe that di¬

rect assessment of the outcome of care can free us from the limitations imposed by the imperfections of the clinical sci¬ ences. I do not believe so. Because a multitude of factors influence outcome, it is not possible to know for certain, even after extensive adjustments for differences in case mix are made, the extent to which an observed outcome is attributable to an antecedent process of care. Confirmation is needed by a direct assessment of the process itself, which brings us to the position we started from. The assessment of outcomes, under

rigorously controlled circumstances, is, of course, the method by which the goodness of alternative strategies of care is established. But, quality assess¬ ment is neither clinical research nor

technology assessment. It is almost never carried out under the rigorous controls that research requires. It is, primarily, an administrative device used to monitor performance to deter¬ mine whether it continues to remain within acceptable bounds. Quality as¬ sessment can, however, make a contri¬ bution to research if, in the course of assessment, associations are noted be¬ tween process and outcome that seem inexplicable by current knowledge.

Such discrepancies would call for eluci¬ dation through research. If I am correct in my analysis, we

cannot claim either for the measure¬ ment of process or the measurement of outcomes an inherently superior valid¬ ity compared with the other, since the validity of either flows to an equal de¬ gree from the validity of the science that postulates a linkage between the two. But, process and outcome do have, on the whole, some different properties that make them more or less suitable objects of measurement for given pur¬ poses. Information about technical care is readily available in the medical record, and it is available in a timely manner, so that prompt action to cor¬ rect deficiencies can be taken. By con¬

trast, many outcomes, by their nature, are delayed, and if they occur after care is completed, information about them is not easy to obtain. Outcomes do have, however, the advantage of reflecting all contributions to care, including those of the patient. But this advantage is also a

handicap, since it is not possible to say precisely what went wrong unless the antecedent process is scrutinized. This briefexposition of strengths and

weaknesses should lead to the conclu¬ sion that in selecting an approach to assessment one needs to be guided by the precise characteristics of the ele¬ ments chosen. Beyond causal validity, which is the essential requirement, one is guided by attributes such as rele¬ vance to the objectives of care, sensitiv¬ ity, specificity, timeliness, and costlin- ess_i(ppioo.i18) As a generai j^ it js best to include in any system of assessment, elements of structure, process, and out¬ come. This allows supplementation of weakness in one approach by strength in another; it helps one interpret the findings; and if the findings do not seem to make sense, it leads to a reassess¬ ment of study design and a questioning of the accuracy of the data themselves. Before we leave the subject of ap¬

proaches to assessment, it may be use¬ ful to say a few words about patient satisfaction as a measure of the quality of care. Patient satisfaction may be con¬ sidered to be one of the desired out¬ comes of care, even an element in health status itself. An expression of satisfac¬ tion or dissatisfaction is also the pa¬ tient's judgment on the quality ofcare in all its aspects, but particularly as con¬ cerns the interpersonal process. By questioning patients, one can obtain in¬ formation about overall satisfaction and also about satisfaction with specific attributes of the interpersonal relation¬ ship, specific components of technical care, and the outcomes of care. In doing so, it should be remembered that, un-

less special precautions are taken, pa¬ tients may be reluctant to reveal their opinions for fear ofalienating theirmed¬ ical attendants. Therefore, to add to the evidence at hand, information can also be sought about behaviors that indirect¬ ly suggest dissatisfaction. These in¬ clude, in addition to complaints regis¬ tered, premature termination of care, other forms of noncompliance, termina¬ tion ofmembership in a health plan, and seeking care outside the plan. It is futile to argue about the validity

of patient satisfaction as a measure of quality. Whatever its strengths and limitations as an indicator of quality, information about patient satisfaction should be as indispensable to assess¬ ments of quality as to the design and management ofhealth care systems.

SAMPLING

If one wishes to obtain a true view of care as it is actually provided, it is nec¬

essary to draw a proportionally repre¬ sentative sample of cases, using either simple or stratified random sampling. Because cases are primarily classified by diagnosis, this is themost frequently used attribute for stratification. But, one could use other attributes as well: site of care, specialty, demographic and socioeconomic characteristics of pa¬ tients, and so on. There is some argument as to wheth¬

er patients are to be classified by dis¬ charge diagnosis, admission diagnosis, or presenting complaint. Classification by presenting complaint (for example, headache or abdominal pain) offers an opportunity to assess both success and failure in diagnosis. If discharge diag¬ noses are used, one can tell ifthe diagno¬ sis is justified by the evidence; the fail¬ ure to diagnose is revealed only if one has an opportunity to find casesmisclas- sified under other diagnostic headings. A step below strictly proportionate

sampling, one finds methods designed to provide an illustrative rather than a

representative view of quality. For ex¬

ample, patients may be first classified according to some scheme that repre¬ sents important subdivisions of the realm of health care in general, or im¬ portant components in the activities and responsibilities of a clinical department or program in particular. Then, one pur- posively selects, within each class, one or more categories of patients, identi¬ fied by diagnosis or otherwise, whose management can be assumed to typify clinical performance for that class. This is the "tracer method" proposed

by Kessner and coworkers.1314 The validity of the assumption that the cases selected for assessment represent all

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cases in their class has not been established. Most often, those who assess quality

are not interested in obtaining a repre¬ sentative, or even an illustrative pic¬ ture of care as a whole. Their purposes are more managerial, namely, to identi¬ fy and correct the most serious failures in care and, by doing so, to create an environment of watchful concern that motivates everyone to perform better. Consequently, diagnostic categories are selected according to importance, perhaps using Williamson's15 principle of "maximum achievable benefit," meaning that the diagnosis is frequent, deficiencies in care are common and se¬

rious, and the deficiencies are correctable. Still another approach to sampling for

managerial or reformist purposes is to begin with cases that have suffered an adverse outcome and study the process of care that has led to it. If the outcome is infrequent and disastrous (amaternal or perinatal death, for example), every case might be reviewed. Otherwise, a

sample of adverse outcomes, with or without prior stratification, could be studied.16"18 There is some evidence that, under certain circumstances, this ap¬ proach will identify a very high propor¬ tion ofserious deficiencies in the process of care, but not of deficiencies that are less serious.19 MEASUREMENT The progression of steps in quality

assessment that I have described so far brings us, at last, to the critical issue of measurement. To measure quality, our concepts of what quality consists in must be translated to more concrete representations that are capable of some degree of quantification—at least on an ordinal scale, but one hopes bet¬ ter. These representations are the cri¬ teria and standards of structure, pro¬ cess, and outcome.20'21 Ideally, the criteria and standards

should derive, as I have already im¬ plied, from a sound, scientifically vali¬ dated fund of knowledge. Failing that, they should represent the best in¬ formed, most authoritative opinion available on any particular subject. Cri¬ teria and standards can also be inferred from the practice of eminent practitio¬ ners in a community. Accordingly, the criteria and standards vary in validity, authoritativeness, and rigor. The criteria and standards of assess¬

ment can also be either implicit or ex¬ plicit. Implicit, unspoken criteria are used when an expert practitioner is giv¬ en information about a case and asked to use personal knowledge and experience to judge the goodness of the process of

care or of its outcome. By contrast, ex¬ plicit criteria and standards for each cat¬ egory of cases are developed and speci¬ fied in advance, often in considerable detail, usually by a panel of experts, before the assessment of individual cases begins. These are the two ex¬ tremes in specification; there are inter¬ mediate variants and combinations as well. The advantage in using implicit crite¬

ria is that they allow assessment of rep¬ resentative samples of cases and are

adaptable to the precise characteristics of each case, making possible the highly individualized assessments that the conceptual formulation of quality envis¬ aged. The method is, however, ex¬ tremely costly and rather imprecise, the imprecision arising from inatten- tiveness or limitations in knowledge on the part of the reviewer and the lack of precise guidelines for quantification. By comparison, explicit criteria are

costly to develop, but they can be used subsequently to produce precise assess¬ ments at low cost, although only cases for which explicit criteria are available can be used in assessment. Moreover, explicit criteria are usually developed for categories of cases and, therefore, cannot be adapted readily to the vari¬ ability among cases within a category. Still another problem is the difficulty in developing a scoring system that repre¬ sents the degree to which the deficien¬ cies in care revealed by the criteria influence the outcome of care. Taking into account the strengths and

limitations of implicit and explicit crite¬ ria, it may be best to use both in sequence or in combination. One fre¬ quently used procedure is to begin with rather abridged explicit criteria to sepa¬ rate cases into those likely to have re¬ ceived good care and those not. All the latter, as well as a sample of the former, are then assessed in greater detail using implicit criteria, perhaps supplemented bymore detailed explicit criteria. At the same time, explicit criteria

themselves are being improved. As their use expands, more diagnostic cat¬ egories have been included. Algorith¬ mic criteria have been developed that are much more adaptable to the clinical characteristics of individual patients than are the more usual criteria lists.22,23 Methods for weighting the criteria have also been proposed, although we still do not have a method of weighting that is demonstrably related to degree of impact on health status.24 Whenoutcomes are used to assess the

quality of antecedent care, there is the corresponding problem of specifyingthe several states of dysfunction and of weighting them in importance relative

to each other using some system ofpref¬ erences. It is possible, of course, to identify specific outcomes, for example, reductions in fatality or blood pressure, and to measure the likelihood of attain¬ ing them. It is also possible to construct hierarchical scales of physical function so that any position on the scale tells us what functions can be performed and what functions are lost.25 The greatest difficulty arises when one attempts to represent as a single quantity various aspects of functional capacity over a life span. Though several methods of valua¬ tion and aggregation are available, there is stillmuch controversy about the validity of the values and, in fact, about their ethical implications.26,27 Neverthe¬ less, such measures, sometimes called measures of quality-adjusted life, are

being used to assess technological inno¬ vations in health care and, as a conse¬ quence, play a role in defining what good technical care is.28,29 INFORMATION All the activities of assessment that I

have described depend, of course, on the availability of suitable, accurate information. The key source of information about

the process of care and its immediate outcome is, no doubt, the medical record. But we know that the medical record is often incomplete in what it documents, frequently omitting signifi¬ cant elements of technical care and in¬ cluding next to nothing about the inter¬ personal process. Furthermore, some of the information recorded is inaccu¬ rate because oferrors in diagnostic test¬ ing, in clinical observation, in clinical assessment, in recording, and in coding. Another handicap is that any given set of records usually covers only a limited segment of care, that in the hospital, for example, providing no information about what comes before or after. Ap¬ propriate and accurate recording, sup¬ plemented by an ability to collate records from various sites, is a funda¬ mental necessity to accurate, complete quality assessment. The current weakness of the record

can be rectified to some extent by inde¬ pendent verification of the accuracy of some of the data it contains, for exam¬ ple, by reexamination of pathological specimens, x-ray films, and electrocar- diographic tracings and by recoding diagnostic categorization. The informa¬ tion in the record can also be supple¬ mented by interviewswith, or question¬ naires to, practitioners and patients, information from patients being indis¬ pensable ifcompliance, satisfaction, and some long-term outcomes are to be assessed. Sometimes, if more precise

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information on outcomes is needed, pa¬ tients may have to be called back for reexamination. And for some purposes, especially when medical records are

very deficient, videotaping or direct observation by a colleague have been used, even though being observed might itself elicit an improvement in practice.30'31 CONCLUSIONS In the preceding account, I have de¬

tailed, although rather sketchily, the steps to be taken in endeavoring to assess the quality of medical care. I hope it is clear that there is a way, a path

worn rather smooth by many who have gone before us. I trust it is equally clear that we have, as yet, much more to learn. We need to know a great deal more about the course of illness with and without alternative methods of care. To compare the consequences of these methods, we need to have more

precise measures of the quantity and quality of life. We need to understand more profoundly the nature of the inter¬ personal exchange between patient and practitioner, to learn how to identify and quantify its attributes, and to deter¬ mine in what ways these contribute to the patient's health and welfare. Our

information about the process and out¬ come of care needs to be more complete and more accurate. Our criteria and standards need to be more flexibly adaptable to the finer clinical peculiari¬ ties of each case. In particular, we need to learn how to accurately elicit the pref¬ erences of patients to arrive at truly individualized assessments of quality. All this has to go on against the back¬ ground of the most profound analysis of the responsibilities of the health care

professions to the individual and to society.

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