To identify issues related to the quality of health care in the United
States, including its measurement, assessment, and improvement, requiring
action by health care professionals or other constituencies in the public
or private sectors.
The National Roundtable on Health Care Quality, convened by the Institute
of Medicine, a component of the National Academy of Sciences, comprised 20
representatives of the private and public sectors, practicing medicine and
nursing, representing academia, business, consumer advocacy, and the health
media, and including the heads of federal health programs. The roundtable
met 6 times between February 1996 and January 1998. It explored ongoing, rapid
changes in health care and the implications of these changes for the quality
of health and health care in the United States.
Roundtable members held discussions with a wide variety of experts,
convened conferences, commissioned papers, and drew on their individual professional
At the end of its deliberations, roundtable members reached consensus
on the conclusions described in this article by a series of discussions at
committee meetings and reviews of successive draft documents, the first of
which was created by the listed authors and the Institute of Medicine project
director. The drafts were revised following these discussions, and the final
document was approved according to the formal report review procedures of
the National Research Council of the National Academy of Sciences.
The quality of health care can be precisely defined and measured with
a degree of scientific accuracy comparable with that of most measures used
in clinical medicine. Serious and widespread quality problems exist throughout
American medicine. These problems, which may be classified as underuse, overuse,
or misuse, occur in small and large communities alike, in all parts of the
country, and with approximately equal frequency in managed care and fee-for-service
systems of care. Very large numbers of Americans are harmed as a direct result.
Quality of care is the problem, not managed care. Current efforts to improve
will not succeed unless we undertake a major, systematic effort to overhaul
how we deliver health care services, educate and train clinicians, and assess
and improve quality.