In November 2002, the Fund published a call to action for quality improvement, Escape Fire: Lessons for the Future of Health Care, by Donald M. Berwick, M.D., of the Institute for Healthcare Improvement. The essay, which originated as a keynote address, outlined an array of pressing problems — medical errors, confusing and inconsistent information, and lack of personal attention and continuity of care — and sketched an ambitious program for reform.

At the same time, the Fund launched a series of colloquia on quality improvement, beginning with an exploration of the prospects for establishing a compelling "business case" for health care quality improvement in the United States. Berwick was among a distinguished roster of presenters, while workgroups considered the issue from the perspectives of four major stakeholder groups: providers, insurers, private purchasers, and public payers. Proceedings, along with conclusions and recommendations, will be published by the Fund. A colloquium in May 2003 focused on information technologies and featured a presentation by David Blumenthal, M.D., and Jeff Goldsmith, subsequently published in Health Affairs.⁽³⁾ Participants discussed the weakness of the information technology infrastructure in American health care and considered solutions to foster broader and more rapid diffusion.

Berwick also collaborated with Sheila Leatherman to examine the financial implications of quality improvement initiatives for health care organizations. In an article⁽⁴⁾ published in Health Affairs, the coauthors presented four case studies of specific interventions — on management of high-cost pharmaceuticals, diabetes management, tobacco cessation, and wellness programs in the workplace — and explored long-term and short-term costs and benefits for health care providers, purchasers and employers, individual patients, and society. To complement the article, the Fund released detailed electronic versions of the case studies for use by researchers and practitioners. A report⁽⁵⁾ by the Institute of Medicine, supported in part by the Fund, recommended that public programs such as Medicare and Medicaid adjust financial incentives to reward high-quality care.

Value-based purchasing (VBP) in health care refers to a range of activities by which employers and public programs attempt to foster quality improvement through the contracting process or by wielding their power as health care purchasers. David Nash, M.D., and Neil Goldfarb, of Jefferson University, conducted a project to gauge the current state of VBP in the United States. Findings from interviews with key health care leaders and an extensive review of the literature were released in the spring of 2003.^(6) (7) The authors report that while there is little evidence that current VBP initiatives are having an impact, that will change once financial incentives are realigned with the goals of high-quality care and performance measures address the particular concerns of health care purchasers.

Important opportunities to use health care legislation to foster quality improvement are often missed. In a paper⁽⁸⁾ published in Health Affairs in 2002, David Lansky proposes legislative requirements that any new expenditure of federal funds for health benefits be accompanied by public disclosure of performance information regarding quality, effectiveness, and safety. He argues that such disclosure would yield public and institutional benefits.

Measuring and reporting on the performance of physicians is another area of national interest. In October 2002, the Fund cosponsored a discussion of recent developments in the field, convened by the National Committee for Quality Assurance (NCQA) and attended by experts in performance measurement, health services researchers and statisticians, health plan and corporate medical directors, federal administrators, and program staff from leading foundations. One paper presented at the meeting, incorporating recommendations for future research, was recently published,⁽⁹⁾ and others will be issued in the coming year. In a Fund-supported project that builds on the recommendations, Sheldon Greenfield, M.D., and Sherrie Kaplan are constructing measures of physician performance and testing them with physicians, purchasers, and the public.