Quality assurance today and tomorrow: forecast for the future

We review here the definition, history, and current findings of quality assessment. Difficulties with quality assessment center principally on methods problems, including using the medical record as a source of information, using process versus outcome criteria, and ignoring decision analysis methods in establishing quality criteria. One overriding issue is placing a value on health and, by extension, on quality assurance and assessment efforts; another is the degree to which improvements in the quality of care can be achieved through changes in physician practices. Several sets of recommendations address these topics. With the assumption that such recommendations could be acted on in a transition period, a hypothetical quality assurance system is described for the 1980s and beyond. This system is based on preservation of the fee-for-service system, adoption of a national health insurance plan, and minimal federal involvement in quality of care decisions at the regional level.