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along both dimensions for health care in general or for specific conditions. The conceptual framework should also provide for the analysis of equity as an issue that cuts across both dimensions and is reflected in differences in the quality of care received by different groups of the population.

The four system components of health care quality are defined as follows:

    1. Safety refers to “avoiding injuries or harm to patients from care that is intended to help them” (Institute of Medicine, 2001).

    2. Effectiveness refers to “providing services based on scientific knowledge to all who could benefit, and refraining from providing services to those not likely to benefit (avoiding overuse and underuse)” (Institute of Medicine, 2001). Overuse occurs when “a health care service is provided under circumstances in which its potential for harm exceeds its potential benefit.” Underuse “is the failure to provide a health care service when it would have produced a favorable outcome for a patient” (Chassin and Galvin, 1998:1002).

    3. Patient centeredness refers to health care that establishes a partnership among practitioners, patients, and their families (when appropriate) to ensure that decisions respect patients' wants, needs, and preferences and that patients have the education and support they need to make decisions and participate in their own care.

    4. Timeliness refers to obtaining needed care and minimizing unnecessary delays in getting that care.

The relative importance of the four components of health care quality may vary over time and for different providers and policy makers. These quality components apply across all health care settings—from institutionalized to inpatient and ambulatory care; from clinicians' offices to home health care and hospice care.

Consumers have several perspectives on health care. They want a system that will respond to their needs or reasons for seeking care, ranging from staying healthy to coping with the end of life. These needs vary over the life span and across groups of the population. Consumers would like to know about the overall quality of care, but they are particularly interested in care for specific conditions or situations that affect them or their families.

Equity in health care quality is considered an important cross-cutting issue. The framework allows for its consideration by comparing the quality of care for different groups of the population, across geographic areas and by condition, as appropriate.

Efficiency is not included in the committee's framework. Some aspects of efficiency are reflected in other components of quality. For example, errors in health care that result in additional procedures, hospitalizations, or other treat-



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