Chapter 6. AHRQ Strategic Goals

Goal 1: Safety and Quality of Care

Patient Safety and Reducing Errors in Medicine

The 1999 Institute of Medicine report, To Err is Human: Building a Safer Health System, brought patient safety to the forefront of national attention. It changed the way the public sees this issue, and the statistics cited in the report—44,000 to 98,000 deaths in hospitals each year due to medical error—remain the benchmark for judging the seriousness of the problem.

In November 2004, AHRQ joined the Kaiser Family Foundation and the Harvard School of Public Health to assess consumers' views on medical errors and patient safety. The findings made clear that consumers remain concerned about the problem of medical errors and do not believe that the Nation's quality of care is improving. In fact, four in ten people said that the quality of health care is now worse than in 1999; one in three people said that they or a family member had experienced a medical error. People with chronic health conditions were most likely to report problems in receiving care.

Many challenges exist in the area of patient safety research. First, adverse events that would be of interest to providers and researchers in determining how to make care safer are relatively rare. Thus, there isn't a large pool of these kinds of events to study. Further, in today's very complex, mulit-layered systems responsible for delivering care to patients, it is very difficult to isolate the key components in those systems that need to be changed. In addition, traditional clinical study techniques like randomized trials are hard to achieve, and in fact, these techniques beg the question of what type or level of evidence is needed to judge the effectiveness of patient safety interventions.

Since FY 2001, AHRQ has funded over 225 patient safety and related health information technology projects to help make health care services safer. These projects address four broad sets of tasks needed to achieve that goal:

• Identify medical errors and other threats to patient safety and understand why they occur.
• Advance the knowledge of practices that will effectively reduce or eliminate the occurrence of medical errors and minimize the risk of patient harm.
• Develop, assemble, and widely disseminate information on how to implement patient safety best-practices.
• Enable providers to continually monitor and evaluate threats to patient safety and the progress they are making.

Increasingly, AHRQ's projects have emphasized the development of skills needed to improve patient safety, development of practical tools to facilitate the use of what is now known, and collaboration with public- and private-sector groups to actually implement that knowledge.

Developing Skills to Implement Patient Safety Initiatives

AHRQ has created a Patient Safety Improvement Corps (PSIC), a training program that brings together teams of State officials and private-sector providers to learn and work together and undertake joint patient safety initiatives. The Department of Veterans Affairs has partnered with AHRQ in carrying out the training sessions. During 2004, teams from 20 States and the District of Columbia participated in the second PSIC class, joining teams from 15 States that participated in the inaugural 2003-2004 class. In recruiting for the third class, AHRQ is giving preference to applications from States that thus far have not participated.

Some teams have been successful in developing projects involving a large number of providers. For example, the Georgia team involved 28 hospitals and health systems across the State to develop and adopt strategies to ensure that the correct operative site has been verified before a surgical procedure is begun on a patient.

Another initiative with the Department of Defense (DoD) is built on the recognition that teamwork is a critical aspect of patient safety. Poor team coordination is a major cause of preventable patient harm. In 2004, the DoD and AHRQ began developing a public domain curriculum for training health care professionals to improve teamwork. This curriculum has undergone extensive field testing and will be made available to all health care institutions nationally in the fall of 2005. AHRQ and DoD will be working with CMS and the State Quality Improvement Organizations to set up a national training program in teamwork using the new curriculum. The curriculum will also be available on the AHRQ PSNet Web site (http://psnet.ahrq.gov/).

An important goal is to increase the skill level for analyzing patient safety threats at the hospital level. The most common approach in hospitals is known as Morbidity and Mortality, or M&M, conferences to assess what went wrong in cases where a patient is harmed. The Agency has built upon that approach with a popular Web site, known as the AHRQ Web M&M (http://www.webmm.ahrq.gov/) in which new cases are shared, along with expert commentaries on how to think through such cases, identify problem areas, and formulate potential solutions.

Each month a "spotlight" case is presented, accompanied by a slide set that health professionals can download and use as an educational tool in their own institutions. As a result of continued traffic on the site in 2004, more than 10,000 health care professionals are now ongoing registered users of Web M&M, and there were on average 28,000 visitors to the site each month in 2004. This approach is bringing lessons learned about patient injury and medical error outside the confines of individual hospitals. Users include physicians, nurses, pharmacists, physician assistants, and other allied health professionals.

Communication with patients is an important skill, especially when an error has occurred. One of AHRQ's grantees, the Partnership for Health and Accountability (PHA), which comprises the Georgia Hospital Association (GHA) and Emory University, has developed a video, Discussing Unanticipated Outcomes and Disclosing Medical Errors, to assist providers with effective approaches for disclosing medical errors. The videotape was evaluated, refined, and distributed to all GHA members. Over two dozen workshops were held throughout Georgia to discuss the content of the video and to distribute a questionnaire to ascertain hospital disclosure practices. Distribution of the video is available at no cost through the PHA Web site (http://www.gha.org/pha/).

Developing Tools to Improve Patient Safety

In response to requests by State hospital associations, State data organizations, and others, AHRQ developed a set of indicators that any hospital can run against its hospital discharge data set to evaluate how it is doing in terms of safety and quality. The AHRQ Patient Safety Indicators (PSIs) are being used by a variety of hospitals and other organizations to screen for suspiciously high rates of potentially preventable complications from surgery and medical care, such as complications of anesthesia or postoperative infection.

Because AHRQ's PSIs allow for comparisons between hospitals, they are being used by a variety of organizations for public reporting and private- and public-sector pay-for-performance initiatives and demonstrations, in addition to internal hospital quality improvement. Many State and regional hospital associations, including the Georgia Hospital Association and the Dallas-Fort Worth Hospital Council, have integrated the AHRQ PSIs into their quality improvement programs. A number of Blue Cross plans are using the PSIs to align financial incentives with achievement of specific performance objectives, and some of the indicators are being used by CMS as part of their pay-for-performance demonstration.

Public- and private-sector organizations, such as Premier, Inc., have recognized the importance of measuring organizational conditions that can lead to adverse events and patient harm. To assist in that effort, in 2004 AHRQ collaborated with DoD and Premier, Inc., to develop another tool, the Hospital Survey on Patient Safety Culture. This public domain tool was released recently and is being rapidly adopted across the country. For example, Catholic Health Partners has 70 hospitals in their system. They have fielded the survey and, so far, have received about 3,000 responses. DoD anticipates using the survey in all of its facilities world-wide, and AHRQ has made the survey available on the Agency's patient safety Web site PSNet.

Voluntary Partnerships to Improve Patient Safety

The largest initiative, developed by the Institute for Health Improvement and cosponsored by AHRQ, CMS, and CDC, is the 100,000 Lives Campaign. This campaign was announced in December 2004 and has enlisted more than 2,200 hospitals to commit to implementing changes in care that have been proven to prevent avoidable deaths. The initiative is starting with six interventions: deployment of rapid response teams, delivery of evidence-based care for acute myocardial infarction, prevention of adverse drug events, prevention of central line infections, prevention of surgical site infections, and prevention of ventilator-associated pneumonia.

The goal is to save 100,000 lives annually that otherwise would have been lost without these changes in the delivery of care. In addition to saving lives, the benefits of preventing complications are significant. For example, patients on ventilators are very susceptible to pneumonia because it is easy for bacteria to get into the lungs. If they develop pneumonia, they are likely to spend an extra week in the hospital, and the extra cost of care can easily reach $40,000.

An AHRQ grantee at Johns Hopkins University is paving the way for success of the 100,000 Lives Campaign by working to prevent deaths resulting ventilator associated pneumonia and blood stream infections related to central lines. In 2004, the Hopkins team expanded its hospital partners and is now working with 127 Intensive Care Units (ICUs) in Michigan, 30 in New Jersey, 45 in Maryland, and recently expanded into Rhode Island. Michigan's experience suggests the significance of what can be accomplished. An Associated Press story about the project noted that Michigan hospital officials estimated that they had saved 77 patients' lives: 73 from pneumonia and 4 from blood infections. In addition, a small number of ICUs have actually gone as long as 9 months without one of these two complications. This project has developed implementation tool kits to assist other hospitals in putting these safety improvements into practice.

Using Health Information Technology to Improve Patient Safety

Health information technology (health IT) has been recognized, from the start, as an important part of AHRQ's patient safety agenda. Inadequate information is often a root cause of medical errors. And by contrast, information systems that not only make patient information available, but also support decision-making—like "smart" drug ordering systems—can have a sizeable impact on improving the safety of care.

To help promote the use of health IT to improve patient safety, in 2004 AHRQ announced $139 million in grants and contracts to speed the adoption of a variety of health IT innovations.

In particular, the awards are intended to provide insight into how best to use health IT to reduce medication errors and thereby improve patient safety; increase the use of shared health information between providers, laboratories, pharmacies, and patients; to ensure safer patient transitions between health care settings, including hospitals, doctors' offices, and nursing homes; and reduce duplicative and unnecessary testing.

The $139 million investment in health IT was allocated in the following ways:

• Promoting access to health IT. Over 100 grants were awarded to communities, hospitals, providers, and health care systems to help in all phases of the development and use of health IT. The grants are spread across 38 States, with a special focus on small and rural hospitals and communities. First-year funding is $41 million and will total nearly $96 million over 3 years.
• Developing Statewide and regional networks. Contracts were awarded to five States or their designees to help them develop State-wide networks that are secure, have safeguards to ensure privacy of health information, and make an individuals' health information more available to health care providers. These 5- year contracts are for projects in Colorado, Indiana, Rhode Island, Tennessee, and Utah. Participants include major purchasers of health care, public and private payers, hospitals, ambulatory care facilities, home health care providers, and longterm care providers. First-year funding is $1 million for each State and will total $25 million over the course of the contracts.
• Encouraging adoption of health IT by sharing knowledge. This project supports the creation of the National Health Information Technology Resource Center. The Center will aid grantees and other Federal partners by providing technical assistance, and a focus for collaboration, serving as a repository for best practices, and disseminating needed tools to help providers explore the adoption and use of health IT to improve patient safety and quality of care. The 2-year contract was awarded to NORC, a national organization for research at the University of Chicago. First-year funding is $4 million, with an estimated value of $18.5 million over the course of the contract, which can be renewed for up to 3 years.

Recent Findings on Patient Safety

An AHRQ-funded study used the PSIs to focus on children in hospitals. The researchers examined 5.7 million hospital discharge records for children under age 19 from 27 States, drawn from the 2000 Healthcare Cost and Utilization Project State Inpatient Database. This is one of the first studies to quantify the impact of patient safety events on children in terms of excess hospital stays and charges, as well as the increased risk of death among children due to medical errors. The researchers found:

• There were 51,615 patient safety events involving children in hospitals during 2000. Children up to 1 year old were consistently and significantly more likely to experience many of the events identified by the PSIs than older children, and children whose primary insurance was Medicaid also were more likely to experience several of the PSI events.
• The prevalence of patient safety events resulting in injuries among children also had an impact on the length of stay, charges and the rate of in-hospital deaths. For example, infections resulting from medical care caused a 30-day increase in the average length of stay and resulted in average increased charges of over $121,000 per discharge.
• In total, the combined excess charges for all PSI events are estimated to have exceeded $1 billion. Postoperative respiratory failure increased the rate of deaths in hospitals by as much as 76 percent. The researchers estimate that if all deaths among pediatric patients who experience a medical injury are attributed to those injuries, then the records in their analysis alone account for 4,483 deaths among hospitalized children in the year 2000.

Ongoing Research in Patient Safety

• Improving Primary Care Patient Safety with Handheld DSS. The purpose of this project is to investigate the use of computer-based decision support systems (DSS) as a solution for improving prescribing patterns and improving patient safety. Researchers will:
  • Implement DSS designed to reduce medical errors.
  • Minimize barriers to maximize the probability that the systems will be used.
  • Systematically assess the extent to which potential or perceived barriers actually influence DSS use.
  • Most importantly, assess the impact of DSS on patient safety, targeting prevention of the risks of inappropriate prescribing of medications.
• Improving Medication Safety Across Clinical Settings. Researchers are investigating novel approaches to reporting of errors and adverse events involving inpatients, outpatients, and nursing home patients, as well as pediatric, adult, psychiatric, and frail elder groups. Researchers are testing information technology, engineering, and human factor approaches to preventing errors including:
  • Augmented reporting of and learning from all medical errors by moving from local to system-wide error reporting.
  • Expanded epidemiological knowledge of medication errors in vulnerable patient groups, including the ambulatory pediatric and inpatient psychiatric settings.
  • Development and validation of a tool to rapidly assess the culture of an organization and its attitudes regarding error.
  • Evaluation of novel medication safety interventions.
• Accountability and Health Safety—A State-wide Approach. The purpose of this research project is to evaluate the effectiveness of a State-wide, voluntary, peer review protected, medical error reporting system for hospitals in Georgia. Researchers will use data on errors from the State-wide reporting system, and hospital-level data from a variety of demonstration site hospitals to:
  • Examine the effectiveness of the voluntary reporting system in reducing errors.
  • Test modifications to make the reporting system more efficient and less burdensome for reporters.
  • Develop estimates of the financial costs of medical errors in community-based hospitals.
  Additionally, organizational policy experts will collect qualitative data from health care professionals to assess the usefulness of feedback reports generated by the Statewide reporting system, identify barriers to and incentives for reporting errors and implementing recommended interventions, and determine how these relate to the creation of an organizational culture of safety.

Future Steps

Significant progress has been made since the IOM highlighted the importance of patient safety and the vigorous response by the U.S. Congress and agencies like AHRQ. However, as consumers, themselves, reflected in the AHRQ/Kaiser Family Foundation/Harvard survey, there is still a long way to go.

First, a culture of safety is critical on two levels. Health care professionals need to feel safe to honestly acknowledge errors or "near misses" within the institutions in which they practice. Institutions also need to feel safe to seek help in identifying and resolving organizational and system-based threats to patient safety without retribution.

Second, as a culture of safety develops within an individual institution, it is important to recognize that the number of "reported" errors is likely to rise as previously hidden errors are disclosed. For this reason, an initial rise in the number of reported errors is a sign of success, not failure.

Third, while an increasing number of hospitals are developing the capacity to analyze the causes of medical errors, the ability to conduct these analyses is uneven, both in terms of experience and skill level. One of AHRQ's State Patient Safety Improvement Corps teams determined that, after excluding a large hospital with a proactive patient safety program, most hospitals in their State completed only four root cause analyses per year. State teams that focused on the skills needed to undertake such analyses found that the need for better skill development was significant. Moreover, few institutions have any experience with other pro-active risk assessment methods. Moving to a system in which hospitals routinely undertake analyses of the causes of errors will require significant skill development and technical assistance.

Fourth, knowing the right thing to do to improve the quality and safety of patient care is only the first step. To increase the pace of improvement, the emphasis on implementation research, step-by-step guidance on implementation, and tools to facilitate the use of effective interventions are critical. AHRQ has already begun shifting emphasis within its existing resources to move in this direction.

Fifth, there is a significant amount of information on how to improve the safety of hospital care, but the evidence base is less robust for other settings of care.

Finally, AHRQ will seek ways to make effective use of voluntary collaboratives that bring together health care organizations at different stages of development in the application of effective health care interventions. Collaboratives provide a natural setting for shared learning which accelerates the pace of improvement and innovation. By providing an opportunity to learn from the experiences of organizations at the cutting edge, the health care system can eliminate the inherent delays that occur while each institution reinvents the wheel. This approach also enables AHRQ to better focus its technical assistance and short-term implementation research.

Making Quality Count

Quality health care means doing the right thing, at the right time, in the right way, for the right person, and ultimately, achieving the best possible results. The United States has many of the world's finest health care professionals, academic health care centers, and other institutions. Every day, millions of Americans receive high-quality health care services that help to maintain or restore their health and ability to function. However, far too many do not, and some patients receive substandard care.

Quality problems may be reflected in a wide variation in the use of health care services, underuse of some services, overuse of other services, and even misuse of services, including an unacceptable level of errors. Sometimes patients receive more services than they need or they receive unnecessary services that undermine the quality of their care and needlessly increase costs. At other times they do not receive needed services that have been proven to be effective. For example, one AHRQfunded study found that older patients of high-volume surgeons had lower death rates for some cardiac and cancer surgeries than patients whose surgeons performed these operations less frequently.

There is great potential to improve the quality of health care provided in the United States, and AHRQ is committed to this goal. We are working to maintain what is good about the existing health care system while paying special attention to the areas that need improvement. Improving the quality of care and reducing medical errors are priority areas for the Agency. AHRQ is working to develop and test measures of quality, identify the best ways to collect, compare, and communicate data on quality; and widely disseminate information about effective strategies to improve the quality of care.

Recent Findings on Health Care Quality

• Hypertension and its related problems were draining South Carolina of about $9 billion a year in direct medical costs and indirect costs such as lost productivity. To reduce this burden, the State began a Hypertension Initiative in April 1999 to provide feedback and cardiovascular risk management advice to primary care providers and train hypertension specialists. By monitoring prescribing patterns through a data feedback program, providing evidence-based management approaches through continuing medical education seminars, and applying improved treatment protocols, physicians can have a profound impact on hypertension. According to an update on the program, the initiative has educated over 400 doctors throughout the State on management of hypertension, lipid disorders, and diabetes via a series of continuing medical education programs. Finally, the State has certified 63 hypertension specialists in South Carolina.
• A study of elderly Mexican Americans with diabetes found that one-third (36 percent) inconsistently used their prescribed diabetic medications, and those who were inconsistent in their medication use were more likely to develop kidney problems or die over a 7-year period. Patients who did not have Medicaid or private/HMO health insurance and those who were age 75 or older were much more likely to be inconsistent with treatment. Patients with inconsistent use of medication were more likely than consistent users to report kidney problems. Inconsistent use of medication also increased the risk of death from any cause by 43 percent and diabetes-related deaths by 66 percent over a period of 7 years.
• Few donor kidneys are available for transplantation in patients with kidney failure, also called end-stage renal disease (ESRD). Thus, most of these patients must choose between hemodialysis and peritoneal dialysis, procedures that remove toxins or wastes from the blood that the failed kidney can no longer remove. Patients who undergo hemodialysis usually must go to an outpatient dialysis facility three times a week for 3 to 4 hours each time. There, trained nurses and technicians carry out the prescribed treatment using a dialysis machine. In contrast, peritoneal dialysis is most commonly performed every day at home by the patient after he or she is trained by dialysis facility staff. Peritoneal dialysis can even be done at night while the patient is asleep. Patients receiving peritoneal dialysis were much more likely than those receiving hemodialysis to give excellent ratings of dialysis care overall (85 vs. 56 percent), and they were significantly more likely to give excellent ratings for each specific aspect of care rated.
• Diabetes is the cause of 45 percent of ESRD cases, and a recent study shows that about half of patients in high-risk clinical groups are not receiving angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) to slow the progression of diabetes to kidney failure. The majority of patients (61 percent) received indicated ACE inhibitor or ARB therapy in 2000. An ACE inhibitor or ARB was dispensed to 74 percent of patients with both hypertension and albuminuria, but this treatment was dispensed to only 64 percent of those with hypertension alone and 54 percent of those with albuminuria alone. An ACE inhibitor or ARB was dispensed to 61 percent of whites, 63 percent of blacks, 59 percent of Latinos, and 60 percent of Asians. Among those with albuminuria alone, blacks were significantly less likely than whites to receive either medication (47 vs. 56 percent).
• More effective and convenient antiosteoporosis medications (AOMs) boosted patient visits to the doctor for osteoporosis four-fold between 1994 (1.3 million visits) and 2003 (6.3 million visits). In addition, the proportion of visits in which AOMs were prescribed increased 15 percent from 1988 (82 percent) to 2003 (97 percent). In 1988, bisphosphonates (Fosamax®) were prescribed in 1 percent of osteoporosis visits, but by 2003, they were prescribed during 73 percent of visits. This suggests that doctors rapidly adopted use of the new medications to treat osteoporosis.

Research in Progress on Health Care Quality

• Access to Pediatric Subspecialty Care in the USA. Researchers for this project will:
  • Investigate and depict the practice location of pediatric and adult subspecialists.
  • Explore the relationship between county characteristics and access to pediatric subspecialty care. Ascertain the extent to which adult subspecialists expand access to care for children with rheumatic diseases.
  • Describe the practice patterns of subspecialists, their comfort with treating a variety of pediatric conditions, and the practice, provider, and market characteristics that influence their decisions to treat pediatric patients.
  • Determine the independent effects of selected training, personal, and practice characteristics on the likelihood that an adult subspecialist treats pediatric patients.
• National Trends in Outpatient Quality Indicators. Researchers for this project will:
  • Construct a set of outpatient quality indicators.
  • Assess quality of care at the national level using the selected indicators.
  • Evaluate time trends in these indicators.
  • Determine patient, physician, and organizational predictors of quality of care, with a particular focus on racial/ethnic minorities.
  A set of 27 proposed quality indicators will provide a quantitative assessment of quality and will cover recommended medications, antibiotic use, physician counseling/disease management, diagnostic testing, and medication errors.

Tools for Patients and Health Care Consumers

As part of AHRQ's commitment to enhancing the quality of health care for all Americans, the Agency has played a major role in developing, refining, and disseminating quality measures and related resources. These research-based tools serve two purposes. First they provide consumers with the reliable, evidence-based information they need to choose wisely among health plans, practitioners, and facilities and get the health care that is best for them. Second, they offer providers the validated, comparative data they need to assess strengths and weaknesses in their performance.

CAHPS®

The CAHPS® (formerly the Consumer Assessment of Health Plans) initiative, begun in October 1995, has become the industry standard for obtaining input from consumers about their health plans. CAHPS® is an easy-to-use kit of survey and reporting tools that provides reliable information to help consumers and purchasers assess and choose among health plans, providers, hospitals, and other health facilities. CAHPS® also allows health plans and purchasers to assess and track areas for quality improvement. The overall goal of CAHPS® is to provide an integrated set of carefully tested and standardized survey questionnaires and accompanying report formats that can be used to collect and report meaningful and reliable information from health plan enrollees about their experiences. These materials have been designed for use with all types of health insurance enrollees (Medicaid and Medicare beneficiaries as well as the privately insured) and across the full range of health care delivery systems, from fee-for-service to managed care plans. In addition to a core set of items designed for use with all respondents, some additional questions are targeted for use with certain subgroups such as people with chronic conditions or disabilities, Medicaid and Medicare beneficiaries, and families with children. The information from CAHPS® questionnaires and reports can help consumers and group purchasers compare health plans and make more informed choices.

The CAHPS® II project focuses on further development of surveys for different health care settings and populations, strategies for quality improvement using patient survey data, and testing of new and more effective ways to report quality data to consumers, patients, caregivers, and purchasers. It will also permit translation of the questionnaires and reports into Spanish and other languages.

Other CAHPS Projects

Hospital CAHPS® (HCAHPS). Begun in July 2002, HCAHPS has been developed under a collaborative process sponsored by AHRQ and CMS. It has grown out of a need to assess the experiences of hospital patients and will be implemented nationwide by CMS on a voluntary basis in summer 2005. It is expected that once the survey results are available, they will be included as part of a larger effort already in place where hospitals voluntarily publicly report the results of their performance on 10 quality measures for three medical conditions—acute myocardial infarction, heart failure, and pneumonia.

Ambulatory CAHPS® (ACAHPS). ACAHPS will provide users with a flexible, modular approach to assessing the quality of ambulatory care at different levels of the health care system, including the individual clinician, group practice, and health plan levels. With ACAHPS, users will be able to assess patients' perceptions of care for access, doctor communication, office staff courtesy, helpfulness and respect, shared decisionmaking, coordination/integration, health promotion and education, and customer service.

Nursing Home CAHPS® (NH CAHPS). Jointly sponsored by CMS and AHRQ, this effort supports the development of separate surveys for residents and their families. The survey for residents includes questions about the care they receive in the facility and their quality of life and covers such areas as staff communication, staff helpfulness, and ability to get needed care. The family survey covers communication, staff behavior, facility environment, and care of the resident. It is expected that the resident survey will be used nationwide by CMS in late fall of 2005; CMS plans are still in development for use of the family survey.

In-Center Hemodialysis CAHPS® (ICH CAHPS). As the primary payer for care delivered to patients with end-stage renal disease, CMS has devoted significant resources to gathering and reporting on clinical measures that dialysis facilities and patients can use to monitor and improve the quality of care. CMS requested that AHRQ develop a patient survey to supplement these clinical measures, focusing on hemodialysis patients who receive their care in dialysis facilities. The ICH CAHPS survey represents the first CAHPS® survey to focus exclusively on a very sick and dependent population of patients with chronic illness. Among other topics, it assesses communication with the urologist and dialysis center staff, the facility environment, involvement in care, patient education, and complaints. It is expected that CMS will implement the survey sometime in 2006.

The CAHPS® surveys help create consumer demand for quality improvement:

• Research has shown that when consumers have to change health plans, they use CAHPS information for their choice.
• An estimated 130 million Americans are enrolled in health plans that have CAHPS information: Medicare/Medicaid, Department of Defense Tricare, Federal Government employees, and private insurance plans.
• There is evidence that public reporting of data is incentive for providers to conduct quality improvement.
• CAHPS® is a standard survey and can be used to compare scores between insurers.
• In using HCAHPS and ACAHPS, consumers will be able to compare scores for services received from health care providers and use that information in making decisions about choosing providers and services.

Quality Tools for Clinicians and Purchasers

National Quality Measures Clearinghouse™

The National Quality Measures Clearinghouse™ (NQMC) is a database and Web site for information on specific evidence-based health care quality measures and measure sets. NQMC is sponsored by AHRQ to promote widespread access to quality measures by the health care community and other interested individuals. The NQMC mission is to provide practitioners, health care providers, health plans, integrated delivery systems, purchasers, and others an accessible mechanism for obtaining detailed information on quality measures and to further the dissemination, implementation, and use of measures to inform health care decisions.

In order to be included in the NQMC, measures must satisfy the NQMC inclusion criteria. The NQMC inclusion criteria are available online at http://www.qualitymeasures.ahrq.gov/about/inclusion.aspx.

A brief description of the criteria is as follows:

• The measure(s) must address some aspect of health care quality and relate to one of four domains: access, process, patient experience, or outcome.
• English-language documentation of the measure rationale, numerator, denominator, and data source must be provided.
• Documentation of supporting evidence appropriate for the measure domain must be provided.
• The measure(s) must have been cited in one or more reports in a National Library of Medicine indexed, peer-reviewed journal, applying or evaluating the measure's properties; or the submitter must provide documented peer-reviewed evidence evaluating the reliability and validity of the measure; or the measure must have been developed, adopted, adapted, or endorsed by an organization that promotes rigorous development and use of clinical performance measures.
• The measure(s) must be in current use or currently in widespread testing and must be the most recent version if the measure has been revised.

Measures can be submitted to NQMC on an ongoing basis. Measures are submitted by national, State, and local organizations involved in developing and/or using quality measurement tools. These include health care systems, accreditation organizations, professional associations, research institutions, licensing boards, and other relevant organizations.

In 2004, AHRQ released NQMC tutorials on CD-ROM including a series of informative demonstrations and scenarios on using the NQMC. A new detailed search was also implemented on the NQMC Web site. This feature allows users to filter searches by measures included in the National Healthcare Quality Report and/or the National Healthcare Disparities Report.

QualityTools

The QualityTools Web page (http://www.qualitytools.ahrq.gov/) is a clearinghouse for practical, ready-to-use tools for measuring and improving the quality of health care. Links are provided for health care providers, policymakers, patients and consumers, and payers and purchasers.

Provider page: offers resources to help physicians, hospitals, health systems, and other provider organizations, including guidelines, measures, benchmarking and comparative data, and information on patient safety.

Policymakers page: offers resources to help national, regional, State, or local decisionmakers including guidelines, measures, benchmarking and comparative data, and information on patient safety.

Patients and consumers page: offers resources to help individuals with their health care needs including information on specific diseases and conditions, recommendations for choosing health care services, and tips for staying healthy.

Payers and purchasers page: offers resources to help health plans, administrators, and employer groups, including guidelines, measures, benchmarking and comparative data, and information on patient safety.

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