“To Err is Human,” published by the Institute of Medicine in 1999, set off a firestorm of quality initiatives when it announced that at least 44,000 to 98,000 people die in hospitals every year because of medical errors. The first quality initiatives, which were aimed at hospitals, have now trickled down to physician practices. For two years there have been reports of payors moving to a pay-for-performance system or value-based purchasing.