Aiming for the Best: Defining, Measuring, and Promoting Health Care Quality
Most people trace the health care quality movement back to the early 1990s, when organizations like the National Committee for Quality Assurance and the Institute for Healthcare Improvement began their work on standardized performance measurement and reporting. The movement gained more traction in 1999 when the Institute of Medicine published (with Commonwealth Fund support) its seminal report, To Err Is Human: Building a Safer Health System. The report’s finding that some 44,000 to 98,000 people died in hospitals each year from preventable medical errors captured headlines and ushered in a new field of research into more reliable and effective practices. That year, the Agency for Healthcare Policy and Research was renamed the Agency for Healthcare Research and Quality, and the next year the Commonwealth Fund launched its Program on Quality.
One of us (Dr. Audet) was the founding program officer, and between the two of us, we shepherded the program for 13 years.
While most people agreed on the need for improvement, consensus on its targets was elusive; “quality is in the eye of the beholder” was a favorite cliché. Then in 2001, the Institute of Medicine published a second pivotal report, Crossing the Quality Chasm: A New Health System for the 21st Century (also with Commonwealth Fund support), which offered a compelling definition of quality as care that is safe, effective, patient-centered, timely, efficient, and equitable; the institute also identified 10 rules for redesigning the health care system to achieve this vision. These guideposts shaped the Fund’s Program on Quality, which evolved over the next decade to support efforts to make performance data more widely available and useable, develop evidence-based delivery models, and find approaches to incentivize high-quality care.
One of the program’s first contributions was to document the state of health care quality through a series of chartbooks (on the overall quality of care in the U.S., for children and adolescents, and for Medicare beneficiaries), which the Fund’s Commission on a High Performance Health System evolved into the Fund’s family of scorecards on health system performance. Another effort sought to understand physicians’ views on and involvement in quality improvement; “physician resistance” was often cited as a barrier to progress. The Fund conducted the first national survey to learn about physicians’ engagement in activities such as creating patient registries, using data to assess their performance, or redesigning care processes. The results informed numerous national organizations’ policies.
In addition to pervasive quality deficits, concerns were being raised about health care’s rapidly growing costs, making it difficult to have a conversation about one without the other. The Program on Quality became the Program on Quality and Efficiency in 2006 to expand its focus and align with the newly formed Commission on a High Performance Health System.
In 2008, a Medicare Payment Advisory Commission report to Congress found that many rehospitalizations were potentially preventable, spotlighting an opportunity to improve quality while reducing costs. The Centers for Medicare and Medicaid Services began discussions of ways to make some portion of hospitals’ payment contingent on their rehospitalization rates. In partnership with the Institute for Healthcare Improvement, the Fund launched STAAR (STate Action on Avoidable Rehospitalizations), a groundbreaking effort to develop statewide strategies and practical tools.
By the mid-2000s, it was clear that lack of performance data for benchmarking purposes remained a barrier to quality improvement. Existing reporting sites required user fees, were geared toward consumers rather than providers, and/or were not transparent about their methods. The Fund entered into a partnership with IPRO, a quality improvement organization, to develop WhyNotTheBest.org, a free resource for health care professionals to benchmark their performance against their peers and find improvement resources. The site accelerated quality improvement activities in hundreds of hospitals across the country and demonstrated the value of performance benchmarking and transparency at a time when those issues were being debated nationally.
The 2010 passage of the Affordable Care Act made clear that a more systemic approach to quality was needed to deliver on the three-part aim: better care for individuals, better health for populations, and lower costs. Although the ACA is mostly known for having expanded health insurance coverage, many provisions of the law are testing new health care payment and delivery models. The Fund invested in the evaluation of these new models and was among the first to describe the development and impact of accountable care organizations. These activities paved the way for the Program on Quality to join the Program on Health Care Delivery System Reform, with its focus on high-need and low-income populations.
The Fund’s Program on Quality shaped the field today; we are proud to have been along on that journey and look forward to the Fund’s continued work to advance a high-performance health system for all.