The quality of care: how can it be assessed?

To the Editor. —

A critical problem in the schema of quality assessment described by Dr Donabedian¹in his recent superb article lies in the area of measuring standards of care. With regard to technical aspects of care, the great time, effort, and expense needed to conduct studies from which generally accepted standards of care may be derived ensures that most clinical decisions are based on art rather than science. Furthermore, we live in an era of such rapid scientific and technological advances that study results may be outmoded by the time of publication. A kind of medical Heisenberg Uncertainty Principle exists: the act of deriving standards changes (advances) those standards. Therefore, technical aspects of care are difficult to measure and, when measured, are often inapplicable to assessing quality of care. Another method for establishing standards of quality technical care is that of consensus of experts. These standards, too,