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1

Introduction

The Agency for Healthcare Research and Quality (AHRQ) will soon produce the first annual report on the quality of health care in the United States. To help formulate the new National Health Care Quality Report (also referred to as the Quality Report), AHRQ commissioned the Institute of Medicine (IOM) to conduct a study that would identify

  • the most important questions to answer in evaluating whether the health care delivery system is providing high-quality health care and whether quality is changing over time;

  • the types or domains of information that should be produced; and

  • examples of specific measures that fall into each domain.

The IOM formed the Committee on the National Quality Report on Health Care Delivery to carry out this work. As described in this chapter, the committee studied different approaches to defining and measuring quality. It also reviewed leading national reports on health care quality and major national initiatives on quality measurement. In addition, it examined the ways in which states, other nations, and the World Health Organization (WHO) have. formulated quality measurement and reporting frameworks, along with the ways they have presented information on quality to those outside the traditional audience of the health care community. This chapter begins with a brief presentation on the origins of the new National Health Care Quality Report. It also summarizes the



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Page 19 1 Introduction The Agency for Healthcare Research and Quality (AHRQ) will soon produce the first annual report on the quality of health care in the United States. To help formulate the new National Health Care Quality Report (also referred to as the Quality Report), AHRQ commissioned the Institute of Medicine (IOM) to conduct a study that would identify the most important questions to answer in evaluating whether the health care delivery system is providing high-quality health care and whether quality is changing over time; the types or domains of information that should be produced; and examples of specific measures that fall into each domain. The IOM formed the Committee on the National Quality Report on Health Care Delivery to carry out this work. As described in this chapter, the committee studied different approaches to defining and measuring quality. It also reviewed leading national reports on health care quality and major national initiatives on quality measurement. In addition, it examined the ways in which states, other nations, and the World Health Organization (WHO) have. formulated quality measurement and reporting frameworks, along with the ways they have presented information on quality to those outside the traditional audience of the health care community. This chapter begins with a brief presentation on the origins of the new National Health Care Quality Report. It also summarizes the

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Page 20 origins and work of the IOM Committee on the National Quality Report on Health Care Delivery. ORIGINS OF THE NATIONAL HEALTH CAREQUALITY REPORT The President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry issued a number of recommendations in 1998, among them a call for greater public reporting on health care quality (Advisory Commission on Consumer Protection and Quality in the Health Care Industry, 1998). Congress responded with Title IX of the Healthcare Research and Quality Act of 1999, which requires AHRQ to report to the U.S. Senate and House of Representatives “on national trends in the quality of health care provided to the American people” (Healthcare Research and Quality Act, 1999). The publication of the report, or family of reports, to be made annually, is scheduled to start in fiscal year 2003. THE IOM COMMITTEE ON THE NATIONAL QUALITY REPORT ON HEALTH CARE DELIVERY In its role of advising AHRQ on the Quality Report, the committee worked to provide a vision of what should be included. 1 As an important part of its work, the committee held four two-day meetings in 2000, during which it considered research on major issues related to its charge and formulated its recommendations. At the first meeting, the committee heard testimony from representatives of a number of organizations working in the area of quality measurement, including Donald Berwick, Institute for Healthcare Improvement; Robert Blendon, Harvard School of Public Health and the John F. Kennedy School of Government; Christina Bethell, Foundation for Accountability (FACCT); John Eisenberg and Gregg Meyer, Agency for Healthcare Research and Quality (AHRQ); Margaret O'Kane, National Committee for Quality Assurance (NCQA); Kenneth Kizer, National Forum for Health Care Quality Measurement and Reporting; Paul Schyve, Joint Commission on Accreditation of Healthcare Organizations (JCAHO); and Reed Tuckson, formerly of the American Medical 1 It should be noted that because of the short amount of time between the slated release of this Institute of Medicine report (March 2001) and the production of the first Quality Report in fiscal year 2003 (which begins October 1, 2002), a Department of Health and Human Services working group was formed and held several meetings at about the same time as the IOM committee. The purpose of the working group is to begin preparations in three major areas—measures, report design and market research, and report writing (Meyer, 2000).

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Page 21 Association (AMA). The committee also heard from IOM staff members involved in other studies relevant to this one including Maria Hewitt and Jeffrey Koshel (now at the U.S. Department of Health and Human Services [DHHS]). To gather additional information from a variety of perspectives, the committee held a two-day workshop, “Envisioning a National Quality Report on Health Care.” Twenty-seven speakers delivered testimony on an array of topics, including the feasibility of measuring safety, effectiveness, “patient centeredness,” and efficiency as system aims for quality of care; the availability and appropriateness of public and private data sources to support measures of quality of care; the feasibility of applying experiences in quality measurement and reporting from other sectors; and the need for specific measures to gauge the quality of care for particular populations and to track potential disparities in the quality of care (see Appendix A for the workshop agenda and list of speakers). As part of the workshop, the committee commissioned four papers on issues of particular importance; it heard testimony and held discussions based on these papers: “Patient-Centeredness Measures for the National Quality Report,” by Christina Bethell (FACCT); “Effectiveness and Appropriateness of Care Measures for the National Quality Report,” by Elizabeth McGlynn, Paul Shekelle, and Robert Brook (RAND) (see Appendix B for an excerpt from this paper); “Efficiency Measures for the National Quality Report,” by Mark McClellan (Stanford University); and “Data Sources and Potential Indicators for a National Quality Report,” by Marsha Gold (Mathematica Policy Research). Following the workshop, the committee issued a limited call to organizations and individuals in the private sector for measures of specific aspects of the quality of health care. 2 Specifically, it requested measures of health care safety, effectiveness, patient centeredness, and timeliness. It also requested measures that addressed consumer perspectives or patient needs for care to stay healthy, get better, live with illness, or cope with changing needs (later renamed “coping with the end of life”). These terms are defined in Chapter 2. In response to its call, the committee received 138 suggested measures from eight organizations and two individuals (see Appendix C). The purpose of the call for measures was to gather information about the type of measures available in the private sector and the aspects they addressed. It was not to produce an exhaustive inventory of quality measures. The results obtained provided the committee with information about potential gaps and reflected the absence of measures to assess certain aspects of the proposed framework. The measures submitted covered many of the aspects of health care quality contained in the call, but the greatest number referred to effectiveness of care and living with illness or getting better. Safety and coping with the end of life had the fewest number of submissions. 2 Public-sector agencies were excluded because AHRQ would be issuing that call directly. It did so after the committee had concluded its work, so the results could not be considered for this report.

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Page 22 DEFINING HEALTH CARE QUALITY The Committee on the National Quality Report on Health Care Delivery adopted the definition of health care quality first developed by the IOM in 1990: “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge” (Institute of Medicine, 1990:21). This definition speaks to several key aspects of quality. First, many people, organizations, and institutions provide health care services to patients, and all must be of good quality. Second, quality health care should produce outcomes that patients desire, and patients may vary in their preferences for treatment options (for example, invasive versus noninvasive procedures, limited versus extensive use of lifesaving measures). Third, quality health care does not guarantee desirable outcomes. Factors beyond the control of providers or organizations, such as environmental hazards, can undermine even the best care. It is also true that phenomena such as human resilience may mean that in spite of poor-quality care there may be surprisingly good results. Lastly, it addresses the responsibility that all providers have to inform themselves about the most recent advances in their fields (Chassin and Galvin, 1998). In its consideration of health care quality, the committee examined the seminal work of Avedis Donabedian (1966, 1980), who defined quality in terms of structure (“the settings in which [health care] takes place and the instrumentalities of which it is the product”), process (“whether what is now known as ‘good' medical care has been applied”), and outcomes (“in terms of recovery, restoration of function and of survival”) (Donabedian, 1966:167, 169–170). The committee was also influenced by the work of the Foundation for Accountability, a nonprofit organization that provides support for consumer decision making in health care. Its research has called attention to the need to consider the consumer's perspective on health care quality in communicating messages and measurement results (Foundation for Accountability, 1999). As described in Chapter 2, the committee adopted and slightly revised FACCT's consumer information model as part of the National Health Care Quality Framework. It did this in recognition of the need to measure quality in ways that are meaningful to the consumer. RECENT INITIATIVES ON HEALTH CARE QUALITY AND QUALITY REPORTING The work of the committee has drawn from several recent initiatives on health care quality and quality measurement. Increasing attention has been paid to these issues in the past few years. In recent years, several major reports have been released, each addressing serious gaps in the quality of care. In its consensus statement, the IOM's National Roundtable on Health Care Quality declared

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Page 23 that “[p]roblems in health care quality are serious and extensive; they occur in all delivery systems and financing mechanisms. Americans bear a great burden of harm because of these problems, a burden that is measured in lost lives, reduced functioning, and wasted resources” (Chassin and Galvin, 1998:1001). One of the aspects highlighted by the roundtable was the need to develop new quality measures, particularly those that would appeal to consumers. The President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry found major and widespread shortcomings in health care quality. According to its analysis, these problems “endanger the health and lives of all patients, add costs to the health care system, and reduce productivity” (Advisory Commission on Consumer Protection and Quality in the Health Care Industry, 1998). In addition to greater public reporting on quality, the commission recommended standardized reporting by the health care industry on core sets of quality measures; the development of a framework and increased capacity for quality measurement and reporting; industry support for the development of quality measures; and the creation of a private-sector forum to oversee quality measurement requirements, specifications, and reporting (Advisory Commission on Consumer Protection and Quality in the Health Care Industry, 1998). A review of the scientific literature on the quality of care, conducted by scholars at RAND, further substantiated the statements of both of these groups. Based on an analysis of peer-reviewed publications between 1993 and mid-1997, the review provided strong support for findings of serious deficiencies in health care quality (Schuster et al., 1998; Schuster et al., 2001). The National Cancer Policy Board of the IOM and the National Research Council (NRC) specifically examined quality of care for cancer patients. They issued a report in 1999 that emphasized the importance of using measures to assess the quality of cancer care and of holding providers accountable for care. The board also recommended that providers be required to report quality measures to qualify for Medicare and Medicaid payment (Institute of Medicine and National Research Council, 1999). From 1998 to 2001, the IOM Quality of Health Care in America Project studied ways to improve health care quality in the long and short terms. Related activities included a literature review and synthesis of findings on health care quality to support continuing research; a communications strategy to raise awareness of health care quality on the part of the public and of stakeholders; a framework and measurement strategy to estimate the value of investing in health care services; and the identification of means by which to encourage continuous quality improvement by purchasers, providers, and other stakeholders.

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Page 24 The first report from the project, To Err Is Human: Building a Safer Health System, was released early in 2000. It focuses on ways to improve reporting and prevention (Institute of Medicine, 2000). The second report, Crossing the Quality Chasm: A Health System for the 21st Century, was released in the spring of 2001 (Institute of Medicine, 2001). It examines how the health care delivery system can be redesigned to improve the quality of care in all its dimensions. OTHER NATIONAL AND INTERNATIONAL INITIATIVES ON HEALTH CARE QUALITY MEASUREMENT The Quality Report is part of a larger national and international movement to measure quality in general, and health care quality in particular, as a necessary step in determining where improvements could and should be made (Epstein, 1996; Hussey and Anderson, 2000). While there have been many developments in this direction in the past few years, health care quality reporting and measurement have been the long-term focus of important state, national, and international initiatives. This section surveys those initiatives to provide background on the larger picture of innovations that have influenced the committee's recommendations on the Quality Report. Many of these initiatives also involve reporting, but the focus of the discussion here is on quality measurement. Quality reporting is discussed in Chapter 5. National Initiatives National Committee for Quality Assurance The National Committee for Quality Assurance (NCQA) is a private, non-profit organization that accredits managed care plans and reports on the quality of the care they provide. Established in 1990, it assumed responsibility two years later for the Health Plan Employer Data and Information Set (HEDIS) from its original developer, the HMO Group. In 1993, NCQA issued the first update of HEDIS, which would soon become the standard measurement tool for assessing health plan performance. Since then, NCQA has released several versions. To date, it contains 51 measures (including 16 on effectiveness of care) that provide standard ways to assess and compare plan performance (National Committee for Quality Assurance, 2000). HEDIS 2001 also includes a battery of questions from the Consumer Assessment of Health Plans Survey described in this chapter.

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Page 25 Agency for Healthcare Research and Quality In 1995, the Agency for Healthcare Research and Quality (then the Agency for Health Care Policy and Research [AHCPR]) initiated the development of the CAHPS family of surveys by funding and working with researchers to develop questionnaires, as well as reporting formats, on the experiences that health plan members had in receiving care. The aim of the surveys and the reporting formats was to provide information to consumers that they could use in making decisions on joining health plans. Following the release of CAHPS 1.0 in 1998, AHRQ joined with NCQA and other CAHPS researchers to develop new versions, which include many questions from the original version as well as items from the NCQA's Membership Satisfaction Survey. Since the release of the first version of CAHPS, a variety of groups, including NCQA, the Health Care Financing Administration (HCFA), peer review organizations (PROs), and private sector organizations, have developed their own versions of the survey to fit their objectives (Agency for Healthcare Research and Quality, 2000). Foundation for Accountability Founded in 1995, the Foundation for Accountability has sought to bring the consumer perspective to the issue of quality measurement. In particular, it has been engaged in formulating measures that consumers find relevant and easy to understand. To do so, it has worked to identify measures used by other organizations that fit this description, such as HEDIS measures used by NCQA and measures from CAHPS surveys used by NCQA, HCFA, and others. FACCT has developed measure sets for adult asthma, alcohol misuse, breast cancer, diabetes, major depressive disorder, health status, and health risks, and is in the process of formulating measures in other areas, including child and adolescent health, coronary artery disease, end-of-life care, and HIV/AIDS (Foundation for Accountability, 2000a). FACCT uses the measures that it and other organizations have developed as the basis for defining quality reports that consumers can use to compare health plans (Foundation for Accountability, 2000b). Health Care Financing Administration As part of its responsibility to administer the Medicare program, HCFA carries out a number of quality improvement and measurement programs. The Health Care Quality Improvement Program (HCQIP) has been a major initiative. The agency sets quality improvement targets in certain clinical areas, and state-based PROs monitor performance and encourage improvements (Health Care Financing Administration, 2000). Recently, HCFA released results from its HCQIP program showing wide variation among states in general. It also showed geographic patterns in state performance: northern and/or less populous states

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Page 26 tended to have higher ranking than southern and/or more populous states (Jencks, 2000). National Quality Forum The National Forum for Health Care Quality Measurement and Reporting (known as the National Quality Forum) was established in response to the President's Advisory Commission's call for an organization to address pressing issues in health care quality measurement and reporting (Advisory Commission on Consumer Protection and Quality in the Health Care Industry, 1998). It is a public–private partnership among national, state, and local organizations of consumers, purchasers, providers, labor unions, and others (Foster et al., 1999; Miller and Leatherman, 1999). It is now undertaking a project to analyze quality measures for acute care hospitals that have already been applied or are being developed and to assess the need for new ones (National Quality Forum, 2000). The Leapfrog Group Founded in 1999, the Leapfrog Group consists of a growing number of Fortune 500 companies and other large health care purchasers that have joined forces to “trigger a giant leap forward in quality, customer service and affordability of health care” (Leapfrog Group, 2000a). Their two-pronged strategy to achieve this goal is educating the public about patient safety and defining a set of purchasing principles designed to promote safety and increase the value of health care. The Leapfrog Group is initially focusing on three hospital safety measures that will be the basis for provider performance comparisons and hospital recognition. The measures identified are (1) the use of computerized physician order entry systems; (2) evidence-based hospital referrals of patients with complex problems to specialized facilities; and (3) staffing of intensive care units with physicians specializing in critical care (Leapfrog Group, 2000b). These measures were selected based on research evidence that indicates their potential to improve safety and save lives (Birkmeyer et al., 2000). State Initiatives Almost all states require that health care data be collected, analyzed, and distributed (Gormley and Weimer, 1999). The Vermont Program for Quality in Health Care (VPQHC) illustrates a comprehensive approach—the state contracts with this nonprofit corporation to measure and report quality across several health conditions and dimensions, providing a broad overview of performance (Vermont Program for Quality in Health Care, 2000). Other states such as California, Maryland, Missouri, New Jersey, and New York have adopted more

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Page 27 BOX 1.1 Selective Quality Reporting in Pennsylvania Pennsylvania's Guide to Coronary Artery Bypass Graft Surgery presents risk-adjusted mortality data for individual cardiac surgeons; Medicare and Medicaid; fee-for-service and managed care plans; and public and private hospitals approved by the state to perform the procedure. It also provides risk-adjusted mortality data for length of hospital stay by hospital and by plan. In addition, it presents data on the volume of coronary artery by-pass graft surgeries performed in hospitals and by individual surgeons and data on average hospital charges for the procedure. Publicatiion of the report encourages hospitals, surgeons, and health plans to use the information in their efforts to improve quality and encourages consumers to compare quality and price performance in making their choice. Research shows that about one-third of Pennsylvania hospitals approved for the operation have used performance measures to recruit physicians Some hospitals have also changed practices in marketing and patient care based on the report's results. SOURCES: Bentley and Nash, 1998; Jollis and Romano, 1998; Pennsylvania Health Care Cost Containment Council, 1998; Schneider and Epstein, 1998. selective approaches, measuring and reporting on the quality of particular surgical procedures, specific health conditions, or individual health care institutions (Bentley and Nash, 1998; Hannan et al., 1995; Maryland Health Care Commission, 2000; New Jersey Department of Health and Senior Services, 2000; Zach et al., 1997). For example, the Pennsylvania Health Care Cost Containment Council (PHC4) presents quality-of-care measures in separate publications for hospitals and health maintenance organizations (HMOs) overall; different reports on hospital, doctor, and plan performance in heart attack treatment and in coronary artery bypass graft (CABG) surgery; and reports on HMO management of diabetes ( Box 1.1) (Bentley and Nash, 1998; Jollis and Romano, 1998; Pennsylvania Health Care Cost Containment Council, 1998; Schneider and Epstein, 1998). International Initiatives The World Health Organization, the Organization for Economic Cooperation and Development (OECD), and nations including the United States, England, Canada, and Australia are among those undertaking major initiatives to measure and report on quality and other aspects of health care (Commonwealth Fund, 2000; Hurst and Jee-Hughes, 2001; World Health Organization, 2000). Although these efforts are in different stages of development, all involve the

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Page 28 identification of major aspects of quality, followed by measurement formulation, data collection, and reporting. All aim to take a comprehensive approach to quality reporting. While there are strong similarities across countries, there are also strong differences (Department of Health, 2000; Health Canada, 2000; National Health Performance Committee, 2000). The initiatives by the United Kingdom, Canada, and Australia are in broad agreement on the aspects of health care quality that deserve particular attention and that can be directly—if not solely—influenced by the health care system. These are patient safety, health care effectiveness, patient satisfaction, timely care, efficient care, and equitable care (see Box 1.2 on the United Kingdom's National Health Service) (Department of Health, 2000; Health Canada, 2000; National Health Performance Committee, 2000). Countries often use a variety of terms for some of these aspects of quality and define them somewhat differently. For example, the Australian initiative defines timeliness in terms of accessibility, continuity, and equity, whereas the Canadian initiative defines it only in terms of accessibility and continuity. As Chapter 2 shows, these definitions can also differ from those formulated by the committee for use in the National Health Care Quality Report. For example, the committee uses the broader concept of patient centeredness rather than patient satisfaction as one of the components of health care quality (Health Canada, 2000; National Health Performance Committee, 2000). These international initiatives differ in other ways. Perhaps most importantly, different nations emphasize different aspects of quality. The quality initiative in The United Kingdom emphasizes the importance of measuring and reporting on the quality of health service delivery. Canada highlights the importance of public health concerns as well as health system performance (Health Canada, 2000). Despite these and other differences, the international initiatives commonly recognize the central role that quality measurement plays in efforts to improve quality and the need to develop adequate measures and data sources to make it easier to identify areas in which performance is lagging and reasons for the poor performance. Although they are more implicit, initiatives by The United Kingdom, Canada, and Australia also recognize the significance of consumer information needs, especially those that apply to acute care (Department of Health, 2000a; Health Canada, 2000; National Health Performance Committee, 2000).

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Page 29 BOX 1.2 The United Kingdom's National Health Service Quality Performance Reports In 2000, the National Health Service (NHS) issued its second annual report on quality performance in hospitals These annual reports are part of a new national quality initiative launched by the NHS in 1998 The reports are based on a framework that contains six key areas that patients most care about health improvement, fair access to services, effective delivery of health care; efficiency; patient and carer experience; and health outcomes of NHS care. The report assesses performance at the national and local levels using a growing set of measures in areas such as service utilization, patient satisfaction, care outcomes, and service performance. Future plans call for developing new measures and methods of risk adjustment, which is not currently performed. Also, a National Survey of Patient and User Experience will be conducted to provide a fuller picture of patient satisfaction. The NHS is developing separate National Service Frameworks for specific conditions and population groups These frameworks provide the NHS with national standards and service models, create performance measures with timelines for assessing progress, and establish programs to carry them out. The NHS has already produced National Service Frameworks for mental health and coronary heart disease Frameworks for older people and for diabetes are currently being developed. SOURCES: Department of Health, 2000a, b; Enthoven, 2000; Mulligan et al., 2000. QUALITY MEASUREMENT AND REPORTING IN OTHER SECTORS Although it focused on experiences in the health care sector, the committee also examined quality measurement and reporting initiatives in other areas where such efforts often preceded those in health. In recent years, the popularity of concepts such as Total Quality Management (TQM) have energized efforts to measure quality. TQM and other customer-centered approaches have called attention to the need to measure how well organizations are serving their customers and satisfying their expectations (Dean and Bowen, 1994; Deming, 1982; Drucker, 1993; Merlyn and Parkinson, 1994). At the May 2000 workshop on envisioning a national quality report on health care delivery, the committee heard testimony regarding the American Customer Satisfaction Index (ACSI) (Fornell, 2000) and the National Assessment of Educational Progress (NAEP) (Carr, 2000). First implemented in 1994, the ACSI is based on customer surveys regarding the goods and services provided by 164 companies and 30 government agencies (Fornell et al., 1996; University of Michigan Business School, 1998). Conducted and published annu-

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Page 30 ally, it provides a standard measure of customer satisfaction that can be used to compare service quality across a variety of industries and organizations and guide continuous quality improvement efforts. At the workshop, the committee also learned about an initiative in another service sector—education—which is more closely related to the National Health Care Quality Report. The National Assessment of Educational Progress has been conducted since 1969 to evaluate academic excellence and gauge the state of education in the country ( Box 1.3) (Carr, 2000; National Center for Education Statistics, 2000). BOX 1.3 The National Assessment of Educational Progress The NAEP is known as “the Nation's Report Card.” The only national evaluation of academic: achievement of its kind, it measures how well students perform in reading, mathematics, science, writing, history, geography, and other subjects. Congressionally mandated and conducted since 1969, it reflects the condition and progress of education in the United States over time. One of its main purposes is to provide information for decision making to national- and state-level policy makers as well as school administrators, principals and teachers It is also widely disseminated by the media and of interest to the general public. Since 1990, a state-level version (conducted in 47 of the 50 states as of the year 2000) has produced accurate estimates so that states can compare their results with those of the nation and other states. The results of the NAEP have also been used to compare the quality of education in the United States to that of other countries. The NAEP is administered by the National Center for Education Statistics in the Department of Education and guided by the policies formulated by the National Assessment Governing Board established by Congress in 1988. SOURCES: Carr, 2000; National Center for Education Statistics, 2000; National Research Council, 1998, 2000, 2001. OBJECTIVES OF THE NATIONAL HEALTH CARE QUALITY REPORT Mandated by Congress, the National Health Care Quality Report should supply a much-needed source of authoritative information on health care quality in the United States. The primary audiences for the Quality Report are national-and state-level policy makers (as is later discussed in Chapter 5). The report should also be of interest to consumers, health care providers, and health care purchasers. More specifically, the Quality Report should play a vital role in badly needed quality improvement efforts by

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Page 31 supplying a common understanding of quality and how to measure it that reflects the best current approaches and practices; identifying aspects of the health care system that improve or impede quality; generating data associated with major quality initiatives; educating the public, the media, and other audiences about the importance of health care quality and the current level of quality; identifying for policy makers the problem areas in health care quality that most need their attention and action, with the understanding that these priorities may change over time and differ by geographic location; providing policy makers, purchasers, health care providers, and others with realistic benchmarks for quality of care in the form of national, regional, and population comparisons; making it easier to compare the quality of the U.S. health care system with that of other nations; stimulating the refinement of existing measures and the development of new ones; stimulating data collection efforts at the state and local levels (mirroring the national effort) to facilitate targeted quality improvements; incorporating improved measures as they become available and practicable; clarifying the many aspects of health care quality and how they affect one another and quality as a whole; and encouraging the data collection efforts needed to refine and develop quality measures and, ultimately, stimulate the development of a health information infrastructure to support quality measurement and reporting. To better understand what the Quality Report should try to achieve, it is also important to understand how it differs from other annual reports on health-related topics. The legislation that mandates the Quality Report also mandates a report on disparities in health care delivery by race and socioeconomic status (Healthcare Research and Quality Act, 1999:Sec. 902). Although its content has not been defined yet, the “disparities report” will probably provide in-depth analyses of possible disparities in the quality of care that may also be indicated in the Quality Report. These two efforts will have to be articulated so that they complement each other. Although the Quality Report may include some of the same measures and draw on some of the same sources of data as other reports, it should be a distinct product tailored to respond to the objectives just outlined. Health United States, produced annually by the Centers for Disease Control and Prevention (CDC) and the National Center for Health Statistics (NCHS), provides an overview of the health status of the American people (National Center for Health Statistics, 2000). The Quality Report will include related in-

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Page 32 formation since the quality of care offered by the health care system can affect health status. America's Children, produced by the Forum on Child and Family Statistics, and HCFA's annual Health Care Financing Review Medicare and Medicaid Statistical Supplement, are examples of documents that focus on specific populations or subpopulations (Federal Interagency Forum on Child and Family Statistics, 2000; Health Care Financing Administration, 1999). In contrast, the Quality Report is concerned with the population of the United States as a whole, although it will also present data for specific subpopulations (for example, by race or ethnicity) as a means of examining equity. In addition, by including information on both the insured and the uninsured, the Quality Report would be more inclusive than current quality reports, which typically include only health plan enrollees. The Quality Report should also be distinguished from Healthy People 2010, produced by the U.S. Department of Health and Human Services (2000). In Healthy People 2010, DHHS sets national goals for improvement in targeted areas of public health, specifically 467 objectives in 28 focus areas ( Box 1.4). One of the focus areas is “access to quality health services.” Others include aspects related to the management of chronic illness that may overlap with measures included in the Quality Report. However, the subject matter of Healthy People 2010 is public health, whereas the Quality Report's is mainly personal health care services. The majority of the Healthy People 2010 objectives refer to social, behavioral, environmental, and other factors that affect health status but generally lie outside the influence of the health care delivery system. The Quality Report should be dynamically linked to the goal-setting processes of the appropriate public- and private-sector actors in the health care arena. It should continually reflect and be used to shape goals for quality improvement by presenting information that is useful to policy makers and others to define clear objectives, assess progress, and define appropriate actions. The Quality Report should differ from other efforts to report on health care quality. A wide range of public- and private-sector organizations have undertaken initiatives to report on health care quality. These include accrediting organizations such as NCQA and JCAHO; national government agencies such as HCFA and AHRQ; state and local government agencies such as the Pennsylvania Health Care Cost Containment Council; and individual health plans, medical groups, and institutions such as hospitals. In addition, national magazines, such as U.S. News and World Report, and state and local publications feature information on the health care quality of plans, providers, and organizations. A large number of “third-party” organizations also provide information on health care quality, often through free or fee-based web sites. These organizations include Health Care Choices, HealthGrades, HealthScope, and WebMD, to name a few (Bates and Gawande, 2000).

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Page 33 BOX 1.4 Healthy People 2010 Focus Areas 1. Access to Quality Health Services 2. Arthritis, Osteoporosis, and Chronic Back Conditions 3. Cancer 4. Chronic Kidney Disease 5. Diabetes 6. Disability and Secondary Conditions 7. Educational and Community-Based Programs 8. Environmental Health 9. Family Planning 10. Food Safety 11. Health Communication 12. Heart Disease and Stroke 13. HIV 14. Immunization and Infectious Diseases 15. Injury and Violence Prevention 16. Maternal, Infant, and Child Health 17. Medical Product Safety 18. Mental Health and Mental Disorders 19. Nutrition and Overweight 20. Occupational Safety and Health 21. Oral Health 22. Physical Activity and Fitness 23. Public Health Infrastructure 24. Respiratory Diseases 25. Sexually Transmitted Diseases 26. Substance Abuse 27. Tobacco Use 28. Vision and Hearing SOURCE: U.S. Department of Health and Human Services, 2000. Many of these reporting initiatives are designed primarily to help consumers choose quality health care plans, providers, and organizations by providing ratings, rankings, and other information. Although the Quality Report should also aim to reach consumers, it should do so to engage and inform them about quality trends, developments, and issues at the more general levels of national and state health care systems. This information may provide useful background and comparisons when it comes to making health care choices. However, assisting consumer choice should not be the primary purpose of the report. The main purpose of the Quality Report should be to inform policy makers and consumers, as well as purchasers and providers, about the state and progress of health care quality in the United States. It should examine the quality of care

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Page 34 provided by the system as a whole and not care delivered in specific health care settings by specific providers. ORGANIZATION OF THE IOM REPORT The remainder of this report builds on the overview of quality presented in this chapter. Chapter 2 introduces the framework for the National Health Care Quality Report. This kind of framework is a tool used to “explain, either graphically or in narrative form, the main things to be studied—the key factors, constructs or variables—and the presumed relationships among them” (Miles and Huberman, 1994:1). The National Health Care Quality Framework presents the categories of measures needed to comprehensively assess the quality of health care in the United States. It forms the basis for the National Health Care Quality Data Set, which contains the measures and data sources used for the Quality Report. Figure 1.1 illustrates the ways in which the committee defined a framework to guide its vision of the Quality Report and, by extension, the ways in which AHRQ could use that framework to guide production of the actual report. On the left-hand side of the figure are listed the different processes involved in creating the report. On the right-hand side are listed the products generated by these processes. First, the process of determining the framework produces categories of measures. These categories suggest the measures that should be selected for the report, or the measure set. Chapter 3 presents a discussion of specific selection criteria used to examine the pool of potential measures and to define the set of measures that will be applied. The measure set that is defined, in turn, guides the process of selecting data sources for the data set, which will support the measure set. Chapter 4 contains a discussion of the National Health Care Quality Data Set, including data from existing surveys and new data collection efforts. The discussion includes criteria that can be used in selecting sources for the data set. The measure set and the data set support the comprehensive approach to measuring quality defined by the framework. A comprehensive approach to measurement is necessary to ensure that major aspects of health care quality are captured. However, the actual report should take a selective approach to communicating about quality, focusing on the most important findings resulting from this comprehensive measurement approach in order to ensure that they receive adequate attention. Chapter 5 contains guidelines on how to choose the findings and measures of quality to be communicated in an annual report or family of reports. Lastly, it includes guidelines on how to promote the Quality Report and how to improve it from year to year.

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Page 35 ~ enlarge ~ FIGURE 1.1 From the National Health Care Quality Framework to the National Health Care Quality Report.

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