Concern about quality of medical education was raised to the level of a major national concern by the Flexner Report of 1910. With support from the Carnegie Foundation, Abraham Flexner visited and scrutinized more than 150 medical schools in the U. S. and Canada. His report was ruthless in its damning evaluations. The report was instrumental in the eventual closing of many of the then private medical schools and in the association of the remaining schools with universities for the furtherance of scientific medicine.

Measures of quality, for accreditation of health care institutions, were categorized by A. Donabedian as:

        Structure (inputs: facilities, staff #s and qualifications)

        Process (skill in applying the inputs)

        Outcome (patient outcomes; now becoming more measurable)

His concern was to broaden the tests for quality, to go beyond inputs. He particularly shifted attention from "structure" to "process," as "outcome" was difficult to measure. Since then, the assemblage of better data sets, particularly through Medicare, has allowed more attention to outcome.

But these focus upon treatment procedures. So the concerns about the quality of health and health care might be further broadened by adding:

        Health (actual health status of the population)