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Figure 1. Measuring Health Care Quality. Carolyn M. Clancy, MD Director U.S. Agency for Healthcare Research and Quality for May 2008. Health Care Quality. Figure 5. Varies A LOT ; NOT clearly related to $$ spent Matters – can be measured and improved

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measuring health care quality

Figure 1

Measuring Health Care Quality

Carolyn M. Clancy, MD


U.S. Agency for Healthcare Research and Quality


May 2008

health care quality
Health Care Quality

Figure 5

  • Varies A LOT; NOT clearly related to $$ spent
  • Matters – can be measured and improved
  • Measurement science is evolving:
    • Structure, process and outcomes
    • Broad recognition that patient experience is essential component
  • Strong focus on public reporting
    • Motivates providers to improve
    • Not yet ‘consumer friendly’
70 million americans benefit from quality measurement
70 Million Americans Benefit from Quality Measurement

Figure 6

  • 96% of heart attack victims were prescribed beta-blocker treatment in 2005, up from 62% in 1996*
  • 77.7% of children enrolled in private health plans received all recommended immunizations, up 5% from 72.5% in 2004*
  • Evidence-based guidelines from the American College of Cardiology and the American Heart Association have reduced mortality among patients who have had a heart attack

* National Committee for Quality Assurance

ahrq s national reports on quality and disparities
AHRQ’s National Reportson Quality and Disparities

Figure 7

  • New editions available
    • New efficiency chapter
    • Disability data added
    • More on health literacy
2007 national reports some good news need for improvement
2007 National Reports: Some Good News, Need for Improvement

Figure 8

  • The rate of improvement in quality between 1994 and 2005 was 2.3%, down from 3.1% from 1994-2004
  • More than 60% of the disparities in quality of care have stayed the same or worsened for Blacks, Asians and the poor, and approximately 56% of disparities have not improved for Hispanics
  • For Blacks, Asians, Hispanics and poor populations, about half of the core measures of quality used to track access to care are improving
uninsurance is a major barrier to reducing disparities
Uninsurance is a Major Barrier to Reducing Disparities

Figure 9




  • Uninsured individuals do worse than privately insured individuals on almost 90% of quality measures
  • Uninsured individuals do worse than privately insured individuals on all access measures











2007 National Healthcare Disparities Report, AHRQ

overall scope
Overall Scope

Figure 10

  • Patients receive the proper diagnosis and treatment only about 55% of the time*
  • Overall, disparities in health care quality and access are not getting smaller **
  • Total health care expenditures in 2006 totaled $2.1 trillion (16% of GDP) and are projected to reach $4.1 trillion (19.6% of GDP) by 2016***

* McGlynn E, Asch S, et al. The Quality of Health Care Delivered to Adults in the United States N Engl J Med 2003;348:2635-45.

** AHRQ 2007 National Healthcare Disparities Report

*** National Health Expenditure Accounts


Figure 11


Figure 12

  • The “why” is a systems challenge:
    • The U.S. has extremely talented and qualified health care professionals who have not been trained to work in teams
    • The delivery system is fragmented, so information doesn’t follow patients as they move from hospitals to other sites of care
    • Payment is quality neutral

Light Figure Fragment Craig A. Kraft Washington, DC

there are major opportunities for improvement examples
There Are Major Opportunities for Improvement: Examples

Figure 13

  • Uptake of health information technology, while still relatively slow, is gaining traction
  • Growing focus on comparative effectiveness research
  • HHS Secretary Michael Leavitt’s Value-Driven Health Care Initiative
    • Chartered Value Exchanges
    • National Learning Network

Downtown USA Alejandra Vernon

emerging methods in comparative effectiveness safety
Emerging Methods in Comparative Effectiveness & Safety

Figure 14

  • A series of 23 articles by AHRQ researchers on new approaches in comparative effectiveness methods are compiled in a special October edition of Medical Care
  • A valuable new resource for scientists committed to advancing the comparative effectiveness and safety research
  • The Resource Center in Oregon led the development process, helped draft the document and manage work groups, and handled public comment



Figure 16

Role Of IT In Reducing Medical Errors

Percent who say…

Have you or a family member ever created your own set of medical records to ensure that you and all of your health care providers have all of your medical information?

The coordination among the different health professionals that they see is a problem


They have seen a health care professional and noticed that they did not have all of their medical information


They had to wait or come back for another appointment because the provider did not have all their medical information


Don’t know



Source: Kaiser Family Foundation / Agency for Healthcare Research and Quality / Harvard School of Public Health National Survey on Consumers’ Experiences with Patient Safety and Quality Information, November 2004 (Conducted July 7 – September 5, 2005).


Figure 17

Personal Experience

Did the error have serious health consequences, minor health consequences, or no health consequences at all?

Have you been personally involved in a situation where a preventable medical error was made in your own medical care or that of a family member?

Serious health consequences





Minor health consequences




No health consequences


Don’t Know

Source: Kaiser Family Foundation / Agency for Healthcare Research and Quality / Harvard School of Public Health National Survey on Consumers’ Experiences with Patient Safety and Quality Information, November 2004 (Conducted July 7 – September 5, 2005).

guidelines measures
Guidelines & Measures

Figure 18

More emphasis needs to be placed on what’s most important

We measure

what we can

Identifying what

counts and

determining how

it can be measured

Rather Than

guidelines measures incentives
Guidelines Measures Incentives

Figure 19

“You can get 60% of the improvement from 15% of the change”

Don Berwick

  • Where should the busy primary care practice begin?
  • Where should policy makers target their incentives?

To changes that:

  • Produce the greatest benefit
  • Address the biggest quality gap
  • Can be implemented most easily, cheaply and safely
reconciling guidelines and quality measures
Reconciling Guidelines and Quality Measures

Figure 20

Developing guidelines that address a wide range of needs…

Low-Risk Patients

Higher Risk Patients

challenges in addressing multiple conditions
Challenges in Addressing Multiple Conditions

Figure 21

Interactions between illnesses

Interactions between treatments

Multiple medications

Multiple providers

Tension between therapeutic goals

setting priorities for patients with multiple conditions
Setting Priorities for Patients with Multiple Conditions

Figure 22

  • Address the need for clinicians to set priorities, weighing the benefits and burdens of increasingly complex medical regiments
  • Make sure guidelines keep up with unique issue of treating older and more frail patients
patient centered guidelines
“Patient-Centered” Guidelines

Figure 23

  • If care is to be patient centered, guidelines need to reflect this goal
    • Quality measures must accommodate differences in:
      • Patient values
      • Patient preferences
what level of collaboration is practical
What Level of Collaboration Is Practical?

Figure 24

Globalize the evidence, localize the decision-making

  • Guidelines may need to reflect local values, disease burdens, priorities and resources


  • Information on how to develop clear and practical guidelines
  • Evidence on barriers and facilitators to implementing guidelines
  • Evidence about integration of guidelines in electronic health records
the goal
The Goal

Figure 25

  • Historically, the focus has been on structure
  • In recent years, there has been more interest in process – the right care
  • Tomorrow’s goal? Outcomes and end results
the information exists
The Information Exists

Figure 26

  • Information on topics including guidelines, measures, incentives and outcomes are available for a wide range of uses. Included is information about:
    • Hospitals:
    • Nursing Homes:
    • Health Plans:
    • Various Health Care Organizations:

Hospital Compare

Nursing Home Compare

National Committee for Quality Assurance

Quality Check ®

cbo report on comparative effectiveness
CBO Report on Comparative Effectiveness

Figure 27

Congressional Budget Office Report:

  • Discusses several mechanisms for organizing and funding additional comparative effectiveness research efforts
  • Reviews the different types of research that could be pursued and the likely benefits and costs
  • Considers the potential effects that such research could have on health care spending
reasons for optimism
Reasons for Optimism

Figure 28

  • Multiple stakeholders are working together
    • AQA & HQA established the Quality Alliance Steering Committee to promote quality measurement, transparency and improvement in care
  • There is clear recognition that there should be one set of measures
    • A move is underfoot toward real standardization across agencies and organizations
  • A shared sense of urgency exists on improving patient outcomes, workforce productivity and costs
    • The National Quality Forum is bringing stakeholders together to establish priorities for moving forward
future opportunities
Future Opportunities

Figure 29

  • The primary opportunity involves patients
    • We will not improve chronic illness care without active, informed patients
    • Patients as shoppers
    • Women are key
this is not a political issue it s a practical issue
This is not a Political Issue, It’s a Practical Issue

Figure 30

  • Quality and access are linked
  • Quality will be a major theme of multiple reform proposals
  • Quality is central to getting better value for what we’re spending on health care
21 st century health care
21st Century Health Care

Figure 31

Improving quality by promoting a culture of safety through Value-Driven Health Care

Information-rich, patient-focused enterprises

Information and evidence transform interactions from reactive to proactive (benefits and harms)

Evidence is continually refined as a by-product of care delivery

21st Century Health Care

Actionable information available – to clinicians AND patients – “in real time”

measuring health care quality28
Measuring Health Care Quality

Figure 32

AHRQ Mission

To improve the quality, safety, efficiency, and effectiveness of health care for all Americans

AHRQ Vision

As a result of AHRQ's efforts, American health care will provide services of the highest quality, with the best possible outcomes, at the lowest cost


Figure 33

To learn more about health care quality, visit these websites:

  • Agency for Heathcare Research and Quality,
  • Quality of Care, Reference Library,

  • The Commonwealth Fund,
  • Institute for Healthcare Improvement,
  • National Committee on Quality Assurance,
  • Robert Wood Johnson Foundation,