The health care industry has seen increased pressure from payers, consumers, and regulators as they demand improved quality in patient care. In the early 1990s, the efforts to improve medical quality in the United States occurred on a case-by-case basis (quality assurance) rather than following a systemic approach. This paradigm shifted after publication of the Institute of Medicine report demanding 21st century health care goals be focused on quality, safety, efficiency, and patient-centered care.