Transforming Health Care Quality
This AHRQ-funded report from the Institute of Medicine (IOM) documents disturbing shortfalls in the quality of health care in the United States. In 2001, an IOM report recommended the systematic identification of priority areas for quality improvement. This new IOM report outlines guiding principles, criteria, and a list of 20 priority areas for improvement.
As next steps, the report recommends that AHRQ work with other public- and private-sector organizations to continuously assess progress in making improvements in the 20 areas by developing and improving data collection and measurement systems, reviewing the evidence base and deciding on updated priorities every 3 to 5 years, and disseminating the results of quality improvement strategies, among other responsibilities.
This summary highlights the IOM report; the full report can be purchased from IOM at www.nap.edu/catalog/10593.html.
Select to download print version of the summary (PDF File, 180 KB). PDF Help.
Contents
Summary
Study Purpose and Scope
Guiding Principles
Criteria
Final List of Priority Areas
Process for Identifying Priority Areas
Next Steps
References
Summary
This report follows several studies spearheaded by the Institute of Medicine (IOM) and other
groups that document disturbing shortfalls in the quality of health care in the United States. The
following statement prepared for the National Roundtable on Health Care Quality captures the
magnitude and scope of the problem:
"Serious and widespread quality problems exist throughout American medicine.... [They]
occur in small and large communities alike, in all parts of the country and with approximately
equal frequency in managed care and fee-for-service systems of care. Very large numbers of
Americans are harmed as a result" (Chassin and Galvin, 1998:1000).
Likewise, two subsequent IOM studies—To Err is Human: Building a Safer Health System (Institute
of Medicine, 2000) and Crossing the Quality Chasm: A New Health System for the 21st Century
(Institute of Medicine, 2001a)—focus national attention on patient safety concerns surrounding the
high incidence of medical errors and sizable gaps in health care quality, respectively.
In addition to the IOM, many others have assumed leadership roles in the movement to address
and improve health care safety and quality. These efforts have included both large-scale national
initiatives, such as the President's Advisory Commission on Consumer Protection and Quality in the
Health Care Industry (1998) and Healthy People 2010 (United States Department of Health and
Human Services, 2000), and private efforts such as the work of the RAND Corporation, which
resulted in a call for mandatory tracking and reporting of health care quality (Schuster et al., 1998).
The newly released chart book from the Commonwealth Fund, which examines the current status of
quality of health care in the United States,
confirms that quality problems persist
(Leatherman and McCarthy, 2002):
Problems such as those cited above have
now been noted so frequently that we risk
becoming desensitized even as we pursue
change. Our technical lexicon of performance
improvements and system interventions can
obscure the stark reality that we invest billions
in research to find appropriate treatments
(National Institutes of Health, 2002), we spend
more than $1 trillion on health care annually
(Heffler et al., 2002), we have extraordinary
knowledge and capacity to deliver the best care
in the world, but we repeatedly fail to translate
that knowledge and capacity into clinical
practice.
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Study Purpose and Scope
The IOM's Quality Chasm report sets forth
a bold strategy for achieving substantial
improvement in health care quality during the
coming decade (Institute of Medicine, 2001a).
As a crucial first step in making the nation's
health care system more responsive to the needs
of patients and more cable of delivering
science-based care, the Quality Chasm report
recommends the systematic identification of
priority areas for quality improvement. The
idea behind this strategy was to have various
groups at different levels focus on improving
care in a limited set of priority areas, with the
hope that their collective efforts would help
move the nation forward toward achieving
better quality health care for all Americans.
In
response, the Department of Health and Human
Services (DHHS) contracted with the IOM to
form a committee whose charge was threefold:
- To select criteria for screening potential priority areas.
- To develop a process for applying those criteria.
- To generate a list of approximately 15 to 20 candidate areas.
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Guiding Principles
Systems Approach
Behind each of the priority areas
recommended in this report is a patient who
may be receiving poor quality care. This is due
not to a lack of effective treatments, but to
inadequate health care delivery systems that fail
to implement these treatments. For this reason,
the committee considered quality to be a
systems property, recognizing that although the
health care workforce is trying hard to deliver
the best care, those efforts are doomed to failure
with today's outmoded and poorly designed
systems. The committee did not concentrate on
ways of improving the efficacy of existing best practice
treatments through either biomedical
research or technological innovation, but rather
on ways to improve the delivery of those
treatments. Indeed the goal of the study was to
identify priority areas that presented the greatest
opportunity to narrow the gap between what the
health care system is routinely doing now and
what we know to be best medical practice.
Scope and Framework
The Quality Chasm report proposes that
chronic conditions serve as the focal point for
the priority areas, given that a limited number of
chronic conditions account for the majority of
the nation's health care burden and resource use
(Hoffman et al., 1996; Institute of Medicine,
2001a; Partnership for Solutions, 2001; The
Robert Wood Johnson Foundation, 2001).
Chronic conditions do represent a substantial
number of the priority areas on the final list
presented in this report; however, this
committee was constituted and charged to go
beyond a disease-based approach. Therefore,
the committee decided to recommend priority
areas that would be representative of the entire
spectrum of health care, rather than being
limited to one important segment.
Given this broader perspective, the
committee decided a framework would be
useful in helping to identify potential candidates
for the priority areas. The committee built upon
the framework originally developed by the
Foundation for Accountability and subsequently
incorporated into the National Health Care
Quality Report (Foundation for Accountability,
1997a, 1997b; Institute of Medicine, 2001b).
This consumer-oriented framework
encompasses four domains of care (terms in parentheses are the clinical terms corresponding to each of these stages):
- Staying healthy (preventive care).
- Getting better (acute care).
- Living with illness/disability (chronic care).
- Coping with end of life (palliative care).
In response to the Quality Chasm
report's ardent appeal for systems change, the
committee supplemented these four categories
with a fifth—cross-cutting systems
interventions—to address vitally important
areas, such as coordination of care, that cut
across specific conditions and domains.
Like all frameworks, that employed by the
committee has advantages as well as limitations.
The committee found its framework to be useful
for initially identifying candidate areas and then
later in the process for checking the balance of
the final portfolio of recommended priority
areas. However, one of the framework's
limitations was that it tended to result in placing
conditions into rigid categories, whereas health
care for many of the priority areas involves
services in all five categories.
Figure 1
presents the committee's initial framework for
determining priority areas. The overlapping
circles represent the interrelatedness of the five
categories.
Recommendation 1
The committee
recommends that the priority areas
collectively:
- Represent the U.S. population's
health care needs across the
lifespan, in multiple health care
settings involving many types of
health care professionals.
- Extend across the full spectrum of
health care, from keeping people
well and maximizing overall health;
to providing treatment to cure
people of disease and health
problems as often as possible; to
assisting people who become
chronically ill to live longer, more
productive and comfortable lives; to
providing dignified care at the end
of life that is respectful of the values
and preferences of individuals and
their families.
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Evidence-Based Approach
The committee developed its
recommendations using an evidence-based
approach. Particularly for estimates of disease
burden, the committee relied on quantitative
data from national datasets to compare the
burden of disease as regards prevalence,
disability, and costs across priority areas.
At the same time, the committee recognized
that the existing evidence base could provide
only partial guidance for fulfilling its charge.
Specifically, there was little quantitative data
available for comparing the costs and outcomes
of quality improvement programs across
different priority areas.
For this purpose, the
committee supplemented quantitative data with
qualitative data and case studies of successful
examples of system change. These sources
were used to study whether, for a condition
posing a high health burden, there was evidence
that quality improvement could substantially
improve care. Here, the committee used
evidence to examine the potential benefits of
system change, rather than to generate
numerical rankings for particular priority areas.
To ensure a stronger evidence base in the future,
the committee has recommended strategic
investment in research on effective
interventions that can improve the quality of
care in a number of the priority areas and the
development of accompanying standardized
measures.
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Criteria
The committee used three closely related
criteria—impact, improvability, and
inclusiveness—in selecting the priority areas.
Recommendation 2 The committee
recommends use of the following criteria
for identifying priority areas:
- Impact—the extent of the burden—
disability, mortality, and economic
costs—imposed by a condition,
including effects on patients,
families, communities, and societies.
- Improvability—the extent of the gap
between current practice and
evidence-based best practice and the
likelihood that the gap can be closed
and conditions improved through
change in an area; and the
opportunity to achieve dramatic
improvements in the six national
quality aims identified in the Quality
Chasm report (safety, effectiveness,
patient-centeredness, timeliness,
efficiency and equity).
- Inclusiveness—the relevance of an
area to a broad range of individuals
with regard to age, gender,
socioeconomic status, and ethnicity/
race (equity); the generalizability of
associated quality improvement
strategies to many types of
conditions and illnesses across the
spectrum of health care
(representativeness); and the
breadth of change effected through
such strategies across a range of
health care settings and providers
(reach).
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Final List of Priority Areas
The committee's selection process yielded a
final set of 20 priority areas for improvement in
health care quality. Improving the delivery of
care in any of these areas would enable
stakeholders at the national, State, and local
levels to begin setting a course for quality health
care while addressing unacceptable disparities
in care for all Americans.
The committee made
no attempt to rank order the priority areas
selected. The first two listed—care coordination
and self-management/health literacy—are cross-cutting
areas in which improvements would
benefit a broad array of patients. The 17 that
follow represent the continuum of care across
the life span and are relevant to preventive care,
inpatient/surgical care, chronic conditions, end-of-life care, and behavioral health, as well as to
care for children and adolescents (select for details). Finally, obesity is included as an
"emerging area" that does not at this point
satisfy the selection criteria as fully as the other
19 priority areas. An emerging area is one of high burden (impact) that affects a broad range of individuals (inclusiveness) and for which
the evidence base for effective interventions (improvability) is still forming.
Recommendation 3 The committee
recommends that DHHS, along with
other public and private entities, focus on
the following priority areas for
transforming health care:
- Care coordination (cross-cutting).
- Self-management/health literacy
(cross-cutting).
- Asthma—appropriate treatment for
persons with mild/moderate
persistent asthma.
- Cancer screening that is evidence based
—focus on colorectal and
cervical cancer.
- Children with special health care
needs.1
- Diabetes—focus on appropriate
management of early disease.
- End of life with advanced organ
system failure—focus on congestive
heart failure and chronic
obstructive pulmonary disease.
- Frailty associated with old age—
preventing falls and pressure ulcers,
maximizing function, and
developing advanced care plans.
- Hypertension—focus on
appropriate management of early
disease.
- Immunization—children and adults.
- Ischemic heart disease—prevention,
reduction of recurring events, and
optimization of functional capacity.
- Major depression—screening and
treatment.
- Medication management—
preventing medication errors and
overuse of antibiotics.
- Nosocomial infections—prevention
and surveillance.
- Pain control in advanced cancer.
- Pregnancy and childbirth—
appropriate prenatal and
intrapartum care.
- Severe and persistent mental
illness—focus on treatment in the
public sector.
- Stroke—early intervention and
rehabilitation.
- Tobacco dependence treatment in
adults.
- Obesity (emerging area).
1 The Maternal and Child Health Bureau defines this population as "those (children) who have or are at increased risk for a
chronic physical, developmental, behavioral or emotional condition and who also require health and related services of a
type or amount beyond that required by children generally" (McPherson et al., 1998:138).
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Process for Identifying Priority Areas
In response to its charge, the committee
developed a process for determining priority
areas (go to Figure 2). This process was
refined according to the committee's experience
in selecting the priority areas recommended in
this report, and is suggested as a model for
future priority-setting efforts. The steps in the
process can be summarized as follows:
- Determine a framework for the priority areas.
- Identify candidate areas.
- Establish criteria for selecting the final priority areas.
- Categorize candidate areas within the framework.
- Apply impact and inclusiveness criteria to the candidates.
- Apply criteria of improvability and inclusiveness to the preliminary set of areas obtained in step 5.
- Identify priority areas; reassess and approve.
- Implement strategies for improving care in the priority areas, measure the impact of implementation, and review/update the list of areas.
Throughout the process, public input should be
solicited from multiple sources.
Following is a detailed description of each
of the above steps. This description
encompasses both the process initially
formulated by the committee and modifications
that emerged as a result of the committee's
deliberations.
Determine Framework
The framework used by the committee's
has been discussed and is detailed in Chapter
1 of the full report.
Identify Candidates
In developing an initial candidate list, the
committee drew on a variety of sources. These
included:
- The collective knowledge and broad expertise of its members.
- Feedback received from presenters and the public at a workshop held in May 2002.
- Work done by other groups in the area of the burden of chronic conditions/diseases and by organizations that have already established lists of priority conditions/areas to meet their specific needs.
Using all these resources, the
committee settled on a list of approximately 60
candidate priority areas to screen by means of
the process outlined above. Selecting just 60
candidates for the first cut was extremely
difficult, as there are hundreds of diseases,
preventive services, and health care system
failures that might be included. The remaining
steps in the process were then applied to narrow
this list still further to the 20 areas
recommended by the committee.
Establish Criteria
The criteria used by the committee were
cited above and are discussed in depth in
Chapter 2 of the full report.
Categorize Candidates Within the
Framework
Once a pool of candidate areas had been
established, they were organized within the
categories of the framework. For example,
using the committee's initial framework,
diabetes was placed under chronic care, tobacco
dependency treatment under preventive care,
pain control under palliative care, antibiotic
overuse under acute care, and care coordination
under cross-cutting systems interventions.
Apply Criteria to Candidates
After identifying a list of candidate priority
areas and organizing them within the
framework, the committee applied the selection
criteria to each area, being particularly sensitive
to the impact on disadvantaged populations. All
three criteria were applied in a single step when
the committee performed this selection process.
On the basis of its experience, however, the
committee recommends a two-step process for
future efforts: one should screen for impact
first, then for improvability, and throughout the
process, particular attention should be paid to
inclusiveness.
This two-step approach would
identify more clearly for consumers,
practitioners, and researchers the rationale for
including some areas and not others. It would
elucidate, for example, which areas did not meet
the impact criterion and which met this criterion
but not that of improvability. Such clarification
could help shape future work in the areas
involved. Moreover, future applications of this
approach to update the priority areas might well
involve richer data analysis and more extensive
feedback from the public and health
professionals.
Identify Priority Areas
The priority areas selected by the committee
were listed under Recommendation 3 and
are discussed in more detail in Chapter 3 of the full report.
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Next Steps
With the priority areas having been
identified, the final step in the process is to
implement strategies for improving care in the
priority areas, measure the impact of
implementation, and periodically review/update
the list of areas. Impact should be measured
using methods that are standardized and can
permit comparison across these diverse areas of
quality improvement. The assessment must
include measures of the degree to which the
system has been transformed and of the clinical
impact on patient care.
As such changes are
effected, the list of priority areas should be
reviewed and updated—optimally every 3 to 5
years. Other areas may need to be added to the
list as the result of new data on impact or the
development of new treatment interventions.
Likewise, if strategies for improvement are
effective, it may be possible to remove some
areas from the list.
Recommendation 4 The committee
recommends that the Agency for
Healthcare Research and Quality
(AHRQ), in collaboration with other
private and public organizations, be
responsible for continuous assessment of
progress and updating of the list of
priority areas. These responsibilities
should include:
- Developing and improving data
collection and measurement systems
for assessing the effectiveness of
quality improvement efforts.
- Supporting the development and
dissemination of valid, accurate, and
reliable standardized measures of
quality.
- Measuring key attributes and
outcomes and making this
information available to the public.
- Revising the selection criteria and
the list of priority areas.
- Reviewing the evidence base and
results, and deciding on updated
priorities every 3 to 5 years.
- Assessing changes in the attributes
of society that affect health and
health care and could alter the
priority of various areas.
- Disseminating the results of
strategies for quality improvement
in the priority areas.
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Throughout this study, the committee often
encountered a lack of reliable measures to use in
assessing improvability for the priority areas
under consideration. Available datasets,
although useful, were also limited in that they
were unable to provide information on health
status and health functioning because of their
disease—and procedure-based orientation. In
addition, it was difficult to compare many
quality improvement efforts because of a lack of
standardization in the way outcomes were
measured.
Thus, the committee concluded that
particular attention should be focused on
enhancing survey data and developing new
strategies for collecting, collating, and
disseminating quality improvement data. Those
conducting quality improvement studies should
be encouraged to include a core set of measures
that would allow comparability across different
conditions, just as consensus standards have
been developed for conducting and reporting
cost-effectiveness analyses (Gold, 1996; Russell
et al., 1996; Siegel et al., 1996; Weinstein et al.,
1996). Only with such standardized approaches
will it be possible to use findings from quality
improvement studies for future efforts at
priority setting.
Recommendation 5 The committee
recommends that data collection in the
priority areas:
- Go beyond the usual reliance on
disease- and procedure-based
information to include data on the
health and functioning of the U.S.
population.
- Cover relevant demographic and
regional groups, as well as the
population as a whole, with
particular emphasis on identifying
disparities in care.
- Be consistent within and across
categories to ensure accurate
assessment and comparison of
quality enhancement efforts.
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If AHRQ is to spearhead this undertaking,
appropriate funds must be allocated for the
purpose. National experts should be convened
to develop action plans in the priority areas, and
this should be done expeditiously so as to
sustain momentum and ensure the timeliness of
the committee's recommendations.
Recommendation 6 The committee
recommends that the Congress and the
Administration provide the necessary
support for the ongoing process of
monitoring progress in the priority areas
and updating the list of areas. This
support should encompass:
- The administrative costs borne by
AHRQ.
- The costs of developing and
implementing data collection
mechanisms and improving the
capacity to measure results.
- The costs of investing strategically
in research aimed at developing new
scientific evidence on interventions
that improve the quality of care and
at creating additional accurate,
valid, and reliable standardized
measures of quality. Such research
is especially critical in areas of high
importance in which either the
scientific evidence for effective
interventions is lacking, or current
measures of quality are inadequate.
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The list of priority areas identified by the
committee is intended to serve as a starting
point for transforming the nation's health care
system. Many of the leading causes of death are
on this list. Just five of the conditions
included—heart disease, cancer, stroke, chronic
obstructive pulmonary disease, and diabetes—account for approximately 1.5 million deaths
annually and represent 63 percent of total deaths
in the United States (Minino and Smith, 2001).2
If redesigning systems of care resulted in
merely a 5 percent mortality improvement in
these areas alone, nearly 75,000 premature
deaths could potentially be averted.
Although AHRQ's role in monitoring
progress and updating the list of areas will be
critical, the health care system will be changed
only through the individual and organized
actions of patients, families, doctors, nurses,
other health professionals, and administrators;
no national body or collaboration can
accomplish the task alone. The priority areas
deliberately encompass a wide range of health
care issues in which improvement is needed for
overall system change. However, the priorities
are also specific enough that individuals and
organizations can choose areas on which to
focus their improvement efforts, helping to
guarantee that all Americans will receive the
quality health care they deserve.
2 Heart disease (ischemic heart disease and hypertension), 537,088; cancer, 551,833; stroke, 166,028; chronic obstructive
pulmonary disease, 123,550; diabetes, 68,662. Total = 1,447,161; total deaths all causes = 2,404,598.
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Current as of January 2003
Internet Citation:
Priority Areas for National Action: Transforming Health Care Quality. Summary of Institute of Medicine report. January 2003. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/qual/iompriorities.htm