Concern since the early part of this century for the quality of health care services has led to external controls in the United States that are more extensive, more intrusive, and more complex than they are elsewhere in the world. I suggest that this is the result of the decentralized nature of our health care system and the dominance of the American legal system and its adversarial orientation. This in turn has led to external control processes that focus on quantifiable, but often secondary or tangential, aspects of service that measure what is minimally acceptable rather than what is optimal. Perhaps it would be more fruitful for external control to intervene at a higher level by creating expectations for the process of quality assurance--that is, to create a system of external controls over internal controls. This, in turn, may lead to a quality assurance system focused on the more central, if more subjective, dimensions of health care.