The quality of health care in the United States presents a paradox. The generally high level of training of U.S. health care practitioners, our extensive biomedical research program, the extent of government funding for health care, and the widespread availability of state-of-the-art diagnostic and treatment technology are the envy of much of the world. Conversely, many studies in recent years have documented serious problems throughout U.S. health care. Overuse, underuse, and misuse of medical care have been found in all types of health care delivery systems and with all types of health care financing.
Tens of millions of Americans reap the benefits of modern medicine each year, while millions of others are exposed to unnecessary risks, are denied opportunities for improved health, or are injured or killed as a result of medical errors.
Quite simply, as good as American health care is, it could be markedly better!
Further, there is good reason to believe that U.S. health care—by far the world's most expensive—could be significantly cheaper if more attention were focused on improving quality. In other industries, higher quality has been consistently associated with lower costs, and it is not clear why health care should be different in this regard.
It is notable that interest in objectively determining the quality of health care in the United States is only of recent origin, and due mainly to concerns about managed care. In examining this issue, however, the most striking finding is how little we really know about the quality of U.S. health care. (Not that it is known better anyplace else.) No national surveillance system exists, nor is there any routine systematic review to determine whether quality is improving. Further, few health care providers utilize information management systems that could inform them about their performances.
Overall, it is highly ironic that we know much more about the quality of automobiles, televisions, and toasters in America than we do about health care, the nation's largest enterprise, accounting for more than $1 trillion in annual expenditures and some 15% of the gross national product.
In response to demands for greater health care accountability, various quality improvement efforts have been launched in the last two decades, and incremental progress has been made. In the aggregate, and despite the good work of many dedicated persons and organizations, health care quality has not progressed to where it can and should be. There continue to be large gaps between the care that people should and actually do receive.
This finding was clearly and unmistakably reported in three independently conducted reviews published in 1998—i.e., by RAND, by the Institute of Medicine's National Roundtable on Health Care Quality, and by the President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry.
THE NATIONAL QUALITY FORUM
A sequel to the 1998 reports that may turn out to be one of the most important efforts, to date, to improve the quality of American health care has been the establishment of The National Forum for Health Care Quality Measurement and Reporting, a private, non-profit, membership organization proposed by the President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry.
The concept of the National Quality Forum arose in response to the strong American sentiment against government regulation and control of health care quality. Specifically, the commission proposed public-private partnership consisting of two new organizations—a private-sector entity they named the National Forum for Health Care Quality Measurement and Reporting (better known now as The National Quality Forum) and a public entity called the Advisory Council for Health Care Quality. The commission envisioned that the advisory council would identify national goals for quality improvement and provide oversight on their accomplishment, while the NQF would devise a national strategy for measuring and reporting health care quality that would advance the identified national aims.
The NQF was officially launched in the fall of 1999, following the work of the Quality Forum Planning Committee that started in June 1998.
With in-kind support from the United Hospital Fund of New York, the planning committee drafted an initial mission statement for the NQF, proposed a governance structure, and sought start-up funding. Funds were obtained from The Robert Wood Johnson Foundation, the California Health Care Foundation, the Horace W. Goldsmith Foundation, and the Commonwealth Fund. I joined the Forum in September 1999.
To date, no action has been taken by the U.S. Congress to establish the proposed Advisory Council for Health Care Quality.
THE FORUM'S MISSION
I see the mission of the Forum, quite simply, as being to improve health care quality; that is, to promote delivery of care known to be effective; to achieve better health outcomes, greater patient functionality, and a higher level of patient safety; and to make health care easier to access and a more satisfying experience. The primary strategy that we will employ to accomplish this mission is to standardize the means by which health care quality is measured and reported and to make health care quality data widely available. This strategy is premised on the philosophy that health care quality data are a public good and, therefore, that health care quality measurements should be publicly disclosed. It is further based on the belief that making reliable, comparative data on health care quality publicly available will motivate providers to improve the quality of care by providing benchmarks; will facilitate competition on the basis of quality; will promote consumer choice on the basis of quality; and will inform public policy. Leveraging health care purchasing decisions according to quality data is also integral to this strategy, and the presence of both public (e.g., Health Care Financing Administration) and private (e.g., Pacific Business Group on Health) purchasers on the Forum's board of directors should facilitate operationalization of this concept.
In pursuing this strategy we do not see the Forum developing quality indicators or measures de novo. There are many research, accreditation, and oversight organizations, as well as commercial interests, already doing this work.
To actualize our agenda we have identified five key strategic goals: (1) developing and implementing a national agenda for measuring and reporting health care quality; (2) standardizing the measures used to report health care quality so that data collection is less arduous for health care providers, and so that the reported data are of greater value; (3) building consumer competence for making choices based on quality-of-care data; (4) enhancing the capability of health care providers to use quality-related data; and (5) increasing the overall demand for health care quality data.
Of note, while each of these goals is important, we believe there is an especially acute need to reduce the burden of reporting for providers while concomitantly increasing the value of the reported data.
We expect to address issues of quality across the entire spectrum of health care, and we will seek to coordinate quality measurement between and among the various levels of service delivery—health plan, hospital, medical group, nursing home, individual practitioner, home care, etc.
In pursuing our mission, we will seek to provide a clear, coordinated, and coherent overarching strategy for health care quality measurement and reporting, and we will strive to ensure that our strategy has a sound theoretical framework that also can be used to guide a proactive research agenda. To help craft such a strategy, we have convened a group of highly respected quality improvement and health care policy experts. This group is known as the Strategic Framework Board (SFB). Its mission, in brief, is to determine the intellectual and theoretical basis for health care quality measurement and reporting, as well as to develop a set of guiding principles and criteria that can be used to inform the choice of measures that the Forum will consider endorsing.
In addition, we believe that we must always ensure that the health care consumer's perspective is clearly heard. In an effort to continuously actualize this, the NQF's board of directors is designed to have a majority of its members representing consumers and purchasers. This important structural precept should facilitate keeping the consumer's perspective ever present.
Finally, in approaching our work, we are absolutely committed to working constructively with the many other parties involved with health care quality measurement and reporting, including especially the Joint Commission on Accreditation of Healthcare Organizations and the National Committee for Quality Assurance. We will continuously strive to make certain that our work is collaborative and helpful to the important efforts these entities already have under way. Indeed, improving health care quality is a matter of great national importance that requires all of us to work together. There is neither time nor resources to pursue any strategy other than one of complete cooperation.