The quandary of quality assessment.

Inevitably, quality assurance reflects the context of which it is a part (e.g., underuse or overuse of services is partly a function of their availability and financing). Thus, it can promote change or rationalize lack of it, save money or cost money. Given the current state of the art, it is imperative to develop quality assurance on an evolutionary path while options are kept open and focus is clearly on outcomes. Also, quality assessment must be conceptualized as a behavioral tool, not a policing mechanism; its scope must be broadened to include the total episode of illness, taking into account life-style and environmental factors, with criteria developed and applied as close to the point of patient care as possible, within broad guidelines; it is essential to build on in-place capacities -- e.g., carrier data -- rather than to create new overlapping systems. Finally, the management setting within which quality assurance functions, in both the public and private sectors, must be improved.