It is axiomatic that health-care systems should aspire to high quality of care, but progress toward this requires thatquality can be assessed. Before this is possible, ‘‘quality’’must first be defined. Donabedian [3], in a view now widely endorsed, suggested that quality of care should be considered in each of three domains: ‘‘structure’’ (the attributes of the settings in which care occurs); ‘‘process’’ (the giving and receiving of care); and ‘‘outcome’’ (the effects that care has on health status)