Quality Assessment and Quality Assurance in Medical Care

Throughout this century, quality assurance has been the explicit purpose of the medical profession in reforming medical education, establishing certi­ fication of specialists, initiating peer review, and promoting continuing medical education. During this period, hospital standards have been up­ graded, first by the Hospital Standardization Program and, since 1952, by its successor organization, the Joint Commission on Accreditation of Hos­ pitals (JCAH). Despite these manifestations of self-regulation, the effective­ ness of these measures in upgrading the quality of care has been sharply questioned (1-4). Within the past 15 years, political, social, and legal forces have combined to abruptly supplant traditional professional autonomy with regulation, mandating explicit accounting for the quality of care. The result has been rapid, nation-wide implementation of medical auditing in hospi­ tals, using methods developed independently of fundamental principles and concepts established by earlier students of quality assessment and quality assurance. The major issues surrounding this tum of events have been addressed at length in statements of policy (5, 6), in symposia and confer­ ences (7-9), and in a major private sector study (10). This review is limited to a small portion of the literature on quality assessment and assurance of personal medical care, i.e. services given by or at the direction of a physician to individual patients and the results of that care. Some important, highly relevant subjects are omitted. Practical con­ straints also dictate the exclusion of literature pertaining to the performance