Methods of control for hospital quality assurance systems.

The major failure of hospital quality assurance systems is the failure to influence physicians' therapeutic decision making in a way that will ensure their ordering necessary and only necessary services. The primary reason for this is insufficient recognition of the "intensive" technology used to treat acute patients, a technology characterized by the interdependence of therapeutic services and the patient's response to these services. In such situations, the appropriate method of achieving quality control is to provide performance feedback to the physician on a regular basis. To the extent that there is uncertainty about the impact of therapeutic services on the patient's response, the physician should be allowed discretion over the therapeutic process. In contrast, when process-outcome relations in the therapeutic process are relatively certain, feedback should be reinforced with sanctions.