Quality Improvement


Performance measurement, quality improvement, and safety—measuring performance is key to identifying problems in the health care system and thus to improving quality. Performance measures should be developed from evidence-based guidelines. Priorities, goals, and standards to guide the development of measures should be national (to ensure standardization) with local implementation (to permit innovation and focus on community needs). Congress advanced the use of standardized performance measures by authorizing a stable source of adequate funding to the National Quality Forum.

In addition, the Affordable Care Act (ACA) requires the Department of Health and Human Services (HHS) to produce a national health care quality strategy, a plan that establishes principles and priorities to help improve care quality nationwide.

Disparities in care—research has documented significant disparities in health care, including preventive services. These disparities persist regardless of income and health insurance status.

Measuring disparities in health care must be an integral component of performance assessment. The National Healthcare Quality and Disparities Report by the Agency for Healthcare Research and Quality (AHRQ) documents the inequities that pervade the US health care system. Without a consistent and uniform method of collecting information on race, ethnicity, sex, age, primary language, socioeconomic status, sexual orientation, and gender identity, we cannot assess where and why disparities exist. For example, enabling access to knowledgeable and sensitive providers as well as recognizing and eliminating treatment barriers that arise from social stigma are important approaches to ensuring equity for the lesbian, gay, bisexual, and transgender community. A first step toward eliminating these disparities is a systematic approach to collecting these data, which would facilitate monitoring health care processes and outcomes for different population groups and help target initiatives to eliminate gaps in care. In addition, it is important to recognize and respond to the goals and preferences of all individuals for their care.

Safety—safety is a critical component of quality and is a core attribute of a well-performing health care system. In the current system, preventable errors needlessly endanger patients. In its landmark 1999 study, To Err Is Human: Building a Safer Health System, the IOM estimated that thousands of Americans die each year in hospitals due to medical errors. A 2013 estimate suggests that the number of US deaths resulting from medical error may be 400,000 per year.

The Patient Safety and Quality Improvement Act of 2005 authorized a system for hospitals, physicians, and other health professionals to voluntarily and confidentially report medical errors to patient safety organizations. AHRQ found that the organization of the health care delivery system and system-level failures are major contributors to medical errors and threats to patient safety. Many experts recommend expanding the Centers for Disease Control and Prevention’s system for tracking health care-acquired infections in order to track other types of patient harm. Others propose a national patient-safety monitoring board to provide regulatory oversight that would help ensure patient safety. An agenda to reduce patient harm should include monitoring, greater transparency, and penalties for failure to address recognized safety issues.

Public reports—the IOM has recommended a “full performance measurement system that is purposeful, comprehensive, efficient, and transparent.” The measures used must reflect evidence-based practice guidelines and reported data must be in a format that is useful for consumers, providers, purchasers, and regulators.

The assessment of resource use and efficiency along with a corresponding quality appraisal of physicians, hospitals, and other providers would offer patients and purchasers useful information about the cost and quality of care, and would provide information about the value of care provided.

Publicly available performance information should drive resources to high performers. Measurement should include a focus on high-priority areas that have been agreed upon by all stakeholders.

Aligning public and private incentives—to reform the entire health care system, it is necessary to implement consistent provider and consumer incentives in both the public and private sectors, not just in one part of the system, such as Medicare.

The ACA has several provisions that address system reform and health care quality. The legislation created the infrastructure for a national strategy to improve health care services and align the related efforts of public and private payers. It established the NQS, a public/private initiative (i.e., not solely a federal effort) with three aims: better care, healthy people and communities, and affordable care.

The NQS calls for a collaboration by public and private health care stakeholders and has six priorities:

  • Make care safer.
  • Ensure patient- and family-centered care.
  • Promote effective communication and coordination.
  • Promote effective prevention of and treatment for the leading causes of mortality, starting with cardiovascular disease.
  • Work with communities to promote healthy living.
  • Implement new delivery models to make care more affordable for individuals, families, employers, and governments.

Beyond establishing the NQS, the ACA also:

  • requires HHS to identify gaps in quality measures and to fund the development of measures to fill these gaps, giving priority to health outcomes, care coordination, shared decisionmaking, efficiency, and health disparities;
  • charged HHS with overseeing a process for collecting and aggregating performance data and developing a framework for the public reporting of performance information;
  • charged AHRQ with conducting research on best practices for quality improvement and with disseminating research findings; and
  • established a mechanism for multi-stakeholder input to HHS prior to rulemaking (i.e., the Measures Application Partnership and the National Priorities Partnership).

In addition, the ACA requires plans that participate in the health insurance exchanges to be accredited and assessed (by entities meeting HHS requirements) on several factors, including clinical and patient experience, consumer access, and appeals. Qualified Health Plans (QHPs) must implement strategies to improve quality and to provide quality and cost information to consumers. HHS must develop a system to rate QHP outcomes through implementation of activities such as quality reporting; effective case management; care coordination; chronic disease management; medication and care compliance initiatives; activities to prevent hospital readmissions, promote patient safety, and reduce medical errors; and wellness programs.

Quality Improvement: Policy

Funding measurement and quality improvement

In this policy: FederalState

States and the federal government should fund the development of quality measures, quality oversight, and technical assistance to help all health professionals and institutions develop the capacity to collect, aggregate, report, and use data to improve the care they deliver.

Congress should advance the use of standardized performance measures by ensuring a stable source of adequate funding for the development and implementation of valid and reliable standardized performance measures.

Consumer representation

In this policy: FederalState

Consumers should be adequately represented at the governance and policymaking levels on all multi-stakeholder entities, such as those advising HHS on health care priorities and goals, measure selection, and other issues for quality improvement and public reporting.


In this policy: FederalState

AARP supports efforts to eliminate preventable medical injuries and accidents from procedural errors or inadequacy. AARP supports:

  • the multifaceted work of the AHRQ to improve quality and safety; and
  • greater transparency regarding safety lapses, including nationwide mandatory reporting to enable states to collect standardized data on adverse events that result in serious injury or death—Congress should provide funds and technical expertise to help states establish or adapt their current reporting systems to collect and analyze the data and follow up with health care practitioners and providers.

The AHRQ should:

  • ensure that information and expertise on best practices for implementation are disseminated;
  • assess the impact of state programs, and analyze aggregate reports from the states to identify persistent safety issues that require more intensive responses;
  • encourage voluntary reporting efforts that include reports of hazards with the potential to cause patient injury as well as cases in which injuries have actually occurred;
  • develop performance standards that focus on patient safety—the standards should require regulators and accreditors to implement meaningful patient safety programs. Public and private health care purchasers should provide incentives to organizations to demonstrate ongoing improvement in patient safety;
  • facilitate action by health care organizations and affiliated professionals to make patient safety a declared priority—organizations should make quality improvement and safety a defined responsibility at the governance level and institute measures, including developing and implementing nonpunitive systems, for reporting errors and proven medication safety practices;
  • develop medical-error data collection methods that are consistent with patients’ legal rights; and
  • encourage states to develop effective systems to protect the public by removing from practice those health care professionals who fail to provide consistently safe and effective care.

Reporting preventable events

In this policy: FederalState

The federal and state governments should require individual providers and health care facilities (including hospitals, nursing homes, rehabilitation centers, medical centers or offices, outpatient dialysis centers, ambulatory surgical centers, urgent care centers, and dental practices) to report the occurrence of any of the serious, preventable adverse events identified by the National Quality Forum’s list of adverse events. Policymakers should require that facility-specific reports be publicly disseminated.

The federal and state governments should prohibit facilities responsible for serious, preventable, reportable adverse events from passing the cost of treating related complications either to the federal government, states, other payers, or patients.

Assessing performance and improving quality

In this policy: FederalState

Measures should focus on high-priority areas identified by the consensus of a multi-stakeholder group that includes adequate consumer representation.

A core set of quality and performance measures in the IOM’s six domains of quality should be developed, at least in part with public funds, and collected from all providers and practitioners across all care settings.

The NQS should serve as the basis for national priority-setting to improve quality, safety, and efficiency.

States and the federal government should identify a consistent and uniform method of collecting information on an individual’s race, ethnicity, sex, age, socioeconomic status, and primary language and require health plans, public and private insurers, and other appropriate entities to collect and use the data to reduce or eliminate inappropriate disparities. These data should be reported to the public.

States and the federal government should identify gaps in access to care and care quality for vulnerable populations, including people with multiple chronic physical and mental illnesses.

States and the federal government should implement measures to assess resource use and efficiency in conjunction with quality so that physicians, hospitals, and other providers are fairly evaluated and patients and purchasers have useful information about the value of care they receive.

Public reports

In this policy: FederalState

All public reports should present information that is grounded in evidence, clinically important, and useful and meaningful to the end-users: consumers, providers, purchasers, and regulators.

The federal government and states should ensure that valid, accurate, objective, and standardized information is available to consumers to help inform their health care decisions.

Information for consumer decisionmaking should include, but not be limited to, data on: treatment options; plan benefits and procedures; plan, provider, and practitioner performance; consumer experience; patient outcomes; and cost.

To the extent possible, such reports should permit consumers to compare the performance of competing types and models of plans, such as health maintenance organizations, preferred-provider organizations, conventional fee-for-service plans, and those with integrated delivery systems, among others. Comparative data on medical groups, physicians, and institutions (including hospitals) also should be provided.

To the extent possible, quality information, including outcomes data, should be paired with information about the cost of care to help consumers and others make informed decisions about where to receive care.

Information should be presented in formats that promote understanding and correct interpretation of data. Processes known to reduce the cognitive and physical difficulty of using information should be employed, and users’ literacy levels should be taken into account when information is developed and reported. Consumer information should be evaluated to assess its usefulness and relevance.

Public education

In this policy: FederalState

Education programs should promote the public’s understanding of the health care system, the need to improve health care quality, the role individual consumers can play in maintaining their health and improving their care, and how they can make the best and most efficient use of health care services.

Governments should encourage the use of shared decision aids in collaborative treatment planning. These decision aids should be made available in multiple languages and at appropriate literacy levels.

To help consumers make informed decisions, information must pair quality, patient outcomes, and cost should be publicly available whenever appropriate and feasible.