Chapter 6. AHRQ Program Objectives

Goal 1: Safety and Quality

Patient Safety and Reducing Errors in Medicine

The November 1999 report of the Institute of Medicine (IOM), To Err is Human: Building a Safer System, focused attention on the unacceptable number of medical errors occurring in the United States every day. The report brought patient safety to the forefront of our attention and led to unprecedented efforts to find solutions. The report showed that a wide gap exists in the quality of care people receive and the quality of care that we as a Nation are capable of providing. According to the IOM, as many as 44,000 to 98,000 people die in hospitals each year as a result of medical errors. Even using the lower estimate, this would make medical errors the eighth leading cause of death in this country.

Medical errors cause more deaths annually than automobile accidents (43,458), breast cancer (42,297), or AIDS (16,516). An estimated 7,000 people die each year from medication errors alone, about 16 percent more deaths than the number attributable to work-related injuries. Moreover, while errors may be more easily detected in hospitals, they affect every health care setting: day-surgery and outpatient clinics, retail pharmacies, nursing homes, and home care.

Research on medical errors and other patient safety issues is not new to AHRQ. We have recognized for some time that reducing medical errors is critically important for improving the quality of health care. In 1993, the agency published one of the first reports focused on medical errors. This landmark report noted that 78 percent of adverse drug reactions were due to system failures, such as the misreading of handwritten prescriptions. Subsequent studies sponsored by AHRQ have focused on the detection of medical errors, investigation of diagnostic inaccuracies, the relationship between nurse staffing and adverse events, computerized monitoring of adverse drug events, and tools for computer-assisted decisionmaking that can reduce the potential for errors and improve safety.

The IOM's 1999 report also called for the establishment of patient safety reporting systems, including State-based systems for accountability purposes that focus on serious adverse events and no-harm events (near misses). The IOM report also recommended that steps be taken to develop data standards to maximize the usefulness of the data collected, minimize the reporting burden, and allow for comparisons across reporting systems and over time.

To encourage the growth of voluntary, confidential reporting systems so that practitioners and health care organizations can correct problems before serious harm occurs, the report recommends Federal legislation to protect the confidentiality of certain information. Hospitals first, and eventually other places where patients get care, would be responsible for reporting such events to State governments. Currently, about one-third of the States have their own mandatory reporting requirements.

AHRQ has made considerable progress in the area of providing guidance to facilitate State reporting efforts. These efforts include analyses of State-based patient safety reporting systems conducted by the National Academy for State Health Policy and through the work of the HHS Patient Safety Task Force (PSTF). The PSTF consists of AHRQ, the Centers for Disease Control and Prevention, the Food and Drug Administration, and the Centers for Medicare & Medicaid Services. The Task Force's efforts are focused on how to improve adverse event reporting through the systems these agencies presently operate to better coordinate research and analysis efforts and promote collaboration on reducing the occurrence of injuries that result from medical errors.

In carrying out these and other activities, AHRQ identified the need for additional guidance on the standardization and coding of data submitted to patient safety reporting systems. To further advance our knowledge in this area, IOM published a report in November 2003, requested and funded by AHRQ, that provides input on how patient safety can be improved through the establishment of a national health information infrastructure and health care standards. This report also provides input that will assist with other ongoing patient safety improvement programs, including HHS work on a consolidated patient safety database and AHRQ's current patient safety research aimed at identifying how to improve safety and move those findings into practice.

Between FY 2001 and 2003, AHRQ invested $160 million in research grants, contracts, and other projects to reduce medical errors and improve patient safety. This effort represents the Federal Government's largest single investment in research on medical errors. These projects fall into four broad categories:

• Identifying medical errors and the causes of patient injury associated with the delivery of health care.
• Identifying, designing, testing, and evaluating practices that eliminate medical errors and system-related risks and hazards that compromise patient safety.
• Disseminating information, increasing knowledge, and implementing practices that minimize errors.
• Monitoring and evaluating threats to patient safety over time.

The results of this research will identify improvement strategies that work in hospitals, doctors' offices, nursing homes, and other health care settings across the Nation. Also, as mentioned earlier, the work of the HHS Patient Safety Task Force will help in strengthening the reporting, analysis, and sharing of information on adverse patient safety events.

The results of AHRQ's substantial investment in a multi-year effort to reduce medical errors, enhance patient safety, improve quality in all areas of health care, and inform patients about how they can influence the quality of care they receive, are now being incorporated into practice. For example, AHRQ's Center for Education and Research on Therapeutics (CERT) at the University of Arizona Health Science Center developed a unique educational and research tool that contains a list of 72 drugs that can cause life-threatening heart arrhythmia (abnormal heartbeat).

Caregivers around the globe can go to this online resource at www.qtdrugs.org to research specific drugs that might pose a risk to their patients as well as to submit clinical cases of drug-induced arrhythmias to the registry. Researchers are using the information submitted to develop profiles of people most at risk for drug-induced arrhythmias and to develop a genetic test that can identify them in advance of treatment.

In FY 2003, AHRQ continued its research to raise the level of patient safety in U.S. health care. Examples of new AHRQ-supported projects in this area:

• Challenge grants. AHRQ and the HHS Patient Safety Task Force awarded nearly $4 million to fund 13 projects that will assess patient safety risks to patients, devise ways to prevent them, and implement safe practices that show evidence of eliminating or reducing known hazards to patient safety. AHRQ will provide up to 50 percent of the total cost of the grants, while grant recipients are required to provide a minimum of 50 percent of the total costs. Topics being addressed by this research include improving drug safety by linking lab and pharmacy data, blood product transfusion safe practices, pediatric chemotherapy processes risk analysis, statewide efforts to improve care in intensive care units, and technology to improve medication safety in nursing homes.
• Online patient safety journal. The agency launched the AHRQ WebM&M(Morbidity and Mortality Rounds on the Web), the Nation's first Web-based patient safety resource and journal. This monthly peer-reviewed tool showcases patient safety lessons drawn from actual cases involving medical errors. It was developed to educate health care providers about medical errors in a blame-free environment. Every month the site includes five interesting cases of medical errors and patient safety problems—one each in medicine, surgery/anesthesia, obstetrics-gynecology, pediatrics, and other fields such as psychiatry, emergency medicine, and radiology—that are submitted anonymously through the Web site. One of the cases each month is expanded into a "Spotlight Case," an interactive learning module that features readers' polls, quizzes, and other multi-media elements and for which clinicians can receive continuing medical education credits. The remaining four cases each month are followed by a commentary, written by an expert in the relevant clinical or patient safety field. The site also includes a users' forum where readers can post and react to comments that relate to the cases, as well as links to other resources and facts about patient safety, medical errors, and health care quality. Since the launch of the AHRQ WebM&M, thousands of people have become registered users, and there are approximately 19,000-20,000 visitors who come to the site monthly.
• Patient Safety Improvement Corps. AHRQ, in partnership with the Department of Veterans Affairs (VA), is supporting a training program for State health officials and their selected hospital partners—the Patient Safety Improvement Corps. Its purpose is to train teams of State health officials and their selected private or public hospital partners in analyzing reported medical errors, identifying their root causes, and developing and implementing interventions to improve patient safety. The VA's National Center for Patient Safety is conducting the training, which includes participating organizations from the following 15 States: Alaska, Connecticut, Maryland, Massachusetts, Minnesota, Missouri, New York, North Carolina, Oregon, Pennsylvania, Rhode Island, Texas, Utah, Virginia, and Wisconsin.
• National Quality Forum (NQF) report. The NQF released a report, funded in part by AHRQ, that reflects consensus among the NQF's 173 member organizations about the need to put better systems and procedures in place to help prevent medical errors. The member organizations—which include representatives of the Nation's leading health care and consumer groups—endorsed 30 patient safety practices that should be universally used in health care settings to reduce the risk of harm resulting from processes, systems, or environments of care. These patient safety practices include:
  • Informing patients that they are likely to fare better if they have certain high-risk, elective surgeries at facilities that have demonstrated superior outcomes.
  • Specifying explicit protocols for hospitals and nursing homes to ensure adequate nurse staffing.
  • Hiring critical care medicine specialists to manage all patients in hospital intensive care units.
  • Making sure hospital pharmacists are more actively involved in the medication use process.
  • Creating a culture of safety in all health care settings.
• Evidence report on heart failure treatment. According to a new evidence report, Pharmacological Management of Heart Failure and Left Ventricular Systolic Dysfunction: Effect in Female, Black, and Diabetic Patients, and Cost Effectiveness, ACE inhibitors and beta-blockers (drugs used to treat high blood pressure and heart disease by lowering blood pressure and slowing the heart) reduce deaths in a broad range of patients with left ventricular systolic dysfunction, a type of heart failure. This report, developed by AHRQ's Southern California-RAND Evidence-based Practice Center, concluded that while the use of ACE inhibitors and betablockers is cost effective, the value of using these drugs in women with no symptoms or signs of left ventricular systolic dysfunction is uncertain. In addition, based on data from a single study, the beta-blocker bucindolol may be associated with increased mortality in blacks, whereas other beta-blockers provide similar benefits to blacks and whites.

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, nationwide only about 40 percent of the 31 million Americans with diagnosed high blood pressure have their blood pressure adequately controlled. An increase to 68 percent—the level already achieved by the Nation's top health plans—would save an estimated 28,000 lives per year. The loss of life is compounded by the financial costs the Nation pays for these unnecessary gaps in care. Hospitalizations due to avoidable second heart attacks cost the American economy more than $1.6 billion a year.

The research that provided much of the basis for the 2001 report by the Institute of Medicine (IOM), Crossing the Quality Chasm, goes back several decades to early studies on quality of care, most of which were supported by AHRQ and its predecessor agencies. In its report, the IOM pointed out that quality problems occur across all types of cancer care and in all aspects of the process of care. For instance, the IOM report described "underuse of mammography for early cancer detection, lack of adherence to standards for diagnosis, inadequate patient counseling regarding treatment options, and underuse of radiation therapy and adjuvant chemotherapy following surgery."

Poor quality care results in patients who are sicker, have more disabilities, incur higher costs, and have lower confidence in the Nation's health care system. The National Committee for Quality Assurances' State of Health Care Quality Report: 2003 finds that the health care system's failure to treat just five health care conditions— asthma, depression, diabetes, heart disease, and high blood pressure—with the best available care is responsible for nearly 41 million sick days. This translates to the equivalent productivity of more than 173,000 workers and annual costs to American companies of more than $11.5 billion.

There is great potential to improve the quality of health care provided to Americans, 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.

Findings from recent AHRQ-supported research on health care quality:

• Atrial fibrillation tool. Thousands of Medicare patients with atrial fibrillation can benefit from a new quality improvement tool developed with support from AHRQ. Researchers found that their new CHADS2 method for predicting risk of stroke in patients with atrial fibrillation is more accurate than existing methods. CHADS2, which is an acronym for the five factors that increase the risk of stroke— congestive heart failure, hypertension, age, diabetes, and stroke—may be especially helpful for identifying low-risk patients who, by taking aspirin, can avoid the office visits, expense, and side effects associated with the blood thinning drug, warfarin (also sold as Coumadin®), which carries a risk of bleeding.
• Underuse of hip replacement surgery in Hispanic patients. Even when they have insurance, elderly Hispanics undergo far fewer hip replacement operations than non-Hispanic whites of the same ages. A study of people aged 65 or older in Texas, New Mexico, Arizona, and Illinois found that Hispanics were less than one-third as likely as non-Hispanic whites to undergo total hip replacement, an operation that can alleviate pain and improve physical function and quality of life in patients with severe osteoarthritis, a degenerative joint disease. According to the researchers, underuse of hip replacement surgery in the large and growing U.S. Hispanic population could have important consequences for Medicaid because the resulting excess disability could increase long-term custodial costs (i.e., costs associated with a person's daily living activities such as walking assistance or getting in and out of bed).
• End-of-life discussions. Findings from this AHRQ study can be used to improve end-of-life care and promote more effective use of health care resources by encouraging discussions between terminally ill HIV patients and their doctors. Half of all HIV-infected people in the United States—especially blacks, Hispanics, injection drug users, and people with low education—never talk about end-of-life care with their doctors. Such discussions could improve physicians' understanding of the care their patients do and do not want when they are very ill and close to death.
• New severity measure for hospitalized pneumonia patients. Hospitalized pneumonia patients who have abnormal vital signs, mental confusion, or problems with eating or drinking in the 24 hours prior to discharge are more likely than other pneumonia patients not to be able to resume normal activities upon discharge. These patients also face a greater chance of readmission or death. AHRQ-supported researchers at Mount Sinai School of Medicine developed a simple severity-of-illness measure that can be used by clinicians to judge whether it is safe for a patient to be discharged from the hospital. The measure uses information from the five vital signs that are checked several times a day in hospitalized patients—temperature, heart rate, blood pressure, respiratory rate, and oxygen levels in the blood—as well as an assessment of the patient's mental status and ability to eat and drink. Patients in this study who were discharged with two or more unstable factors had a five-fold greater risk of readmission or death. Using this instrument, the researchers found that one-in-five of the participating patients had been "medically unstable" when discharged.

Examples of AHRQ-supported research projects now in progress that focus on improving health care quality:

• Understanding variability in community mammography. This community-based, multicenter study involves a unique collaboration among three geographically distinct breast cancer surveillance programs in the States of Washington, New Hampshire, and Colorado. The investigators are collecting breast cancer outcomes and interpretive data on more than 500,000 mammograms from 91 facilities and 279 radiologists. The goals are to identify reasons for variability in the interpretation of mammograms and determine how the quality of mammography can be improved.
• Otitis media: Parent education to avoid antibiotic use. Acute otitis media (AOM) continues to be a major child health problem. The average child experiences 2.6 AOM episodes per year in the first 2 years of life. The overuse of antibiotics for AOM has led to the emergence of disease-causing organisms (e.g., bacteria) that are resistant to multiple antibiotics, even though research has shown that 80 to 90 percent of children with AOM will recover without antibiotics. This AHRQ-funded study is evaluating the safety, effectiveness, out-of-pocket costs, and acceptability of a course of action consisting of parent education, nonantibiotic therapy, and careful followup of children with mild AOM. The goals are to establish the safety of withholding antibiotics from children with mild AOM and assess the ability to change parents' expectations about universal antibiotic treatment of AOM.
• Evidence-based reminders in home health care. Researchers are comparing the effectiveness of two alternative information-based strategies with the goal of improving provider performance and promoting adherence to evidence-based guidelines among home health care nurses. This study assigns nurses to one of two treatment groups: a basic intervention group or an augmented intervention group. The nurses in the basic intervention group receive "just in time" E-mail reminders highlighting six condition-specific practices they should follow for patients with either heart failure or cancer pain. The nurses in the augmented intervention group receive the same E-mail reminders along with additional information and consulting services from an expert peer. This study addresses a critical need to provide information and resources that can affect delivery of home health care.

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.

In particular, AHRQ has been the driving force behind a set of measures and tools that focus on patients' experiences with health care and services. Under the CAHPS® program, the Agency is funding a public-private team of researchers to develop a comprehensive and evolving family of surveys that ask consumers and patients to evaluate the interpersonal aspects of health care. CAHPS® surveys probe those aspects of care for which consumers and patients are the best and/or only source of information, as well as those that consumers and patients have identified as being important.

The acronym CAHPS® initially stood for the Consumer Assessment of Health Plans Study. However, in the current CAHPS® program—known as CAHPS® II—the products have evolved beyond health plans, so the acronym now stands alone as a registered brand name.

In FY 2003, the results of the widely adopted CAHPS® Health Plan Survey were available to help more than 123 million Americans with their health care benefits decisions. Building on the success of the Health Care Survey, the Agency and the CAHPS® research team (known as the Consortium) began work on "Ambulatory CAHPS®," or A-CAHPS. The goal of this new initiative is to develop an integrated suite of survey instruments that will provide consumers and providers with information on patients' experiences with medical groups, individual clinicians, sites of care, and health plans.

In conceiving the A-CAHPS initiative, AHRQ and the CAHPS® Consortium relied heavily on extensive market research with both users and non-users of CAHPS® products to identify and clarify their information needs. To ensure that the research-based products that arise from this initiative truly do meet the needs of those who will put them into practice, AHRQ also embarked on a long-term process of building bridges with a variety of stakeholders, including associations that represent medical groups, health plans, and individual clinicians.

To expand on the usefulness of CAHPS® products, CAHPS® II calls for an exploration of new uses for information on quality of care from the patients' perspective. Consequently, AHRQ and its partners have been evaluating the usefulness of survey-based information as a quality improvement tool for health care organizations, which can use the standardized data to identify relative strengths and weaknesses in their performance and determine what aspects of interpersonal care they need to improve.

To support this new emphasis, the Agency and members of the CAHPS® team initiated two collaborations with the health care industry:

• Members of the CAHPS® Consortium worked closely with the National Committee for Quality Assurance (NCQA), which uses the CAHPS® Health Plan Survey as part of its public reporting and its accreditation program for health plans. They conducted research with the plans to understand how they are currently using results of the CAHPS® Health Plan Survey and how the survey could be enhanced to make the results more actionable. This research led to the development of a new set of survey items that plans can use to identify areas in need of improvement.
• Other members of the CAHPS® Consortium began a partnership with the Institute for Clinical Systems Improvement and eight primary care and specialty groups in Minnesota. This project is designed to develop and test a survey instrument at the group level that clinicians can use to improve quality of care. One key element of the project is participation in a year-long collaboration to develop and refine practical quality interventions and tools that will contribute to improved performance in the areas measured by this CAHPS® survey.

The results of these projects will be incorporated into the A-CAHPS® initiative.

In addition to finding ways to make CAHPS® surveys more useful in the quality improvement arena, CAHPS® II focuses on assessing the experiences of special populations (such as American Indians) and refining techniques for reporting survey findings and other quality information to consumers. In FY 2003, AHRQ and the CAHPS® Consortium conducted substantial research to identify effective reporting strategies and the challenges posed by different subgroups in the population.

CAHPS® II also includes a requirement for the development, testing, and distribution of effective tools for assessing patients' experiences with levels of the health care system beyond health plans. One example of this work is the ECHO Survey, which assesses patients' perspectives on behavioral health services. This survey was submitted and accepted as a formal CAHPS® survey in FY 2003. In addition, FY 2003 saw significant progress in the development of several other CAHPS® products, all of which benefitted from collaborations with a variety of public and private organizations.

• In coordination with the California HealthCare Foundation and the Pacific Business Group on Health (PBGH), AHRQ and the CAHPS® Consortium put the finishing touches on a new survey that assesses patients' perceptions of the care received from providers in group practices. Building on substantial research and testing, the CAHPS® Group Practice Survey reflects the practical experiences of PBGH with its group-level instrument in California.
• In 2002, CMS requested that AHRQ and its partners develop and test a standardized survey instrument that would enable consumers to assess the quality of inpatient care using consistent criteria across hospitals. The purpose of the Hospital CAHPS® initiative is two-fold: (1) to help consumers and providers make more informed choices among hospitals and (2) to create incentives for hospitals to improve performance.

Working closely with CMS and its partners in the Consortium, AHRQ made substantial strides with Hospital CAHPS® (HCAHPS®) in FY 2003. Specifically, we gathered and assessed existing inpatient surveys, developed a draft survey, conducted cognitive testing with consumers, sought input from various stakeholder groups (including hospitals, data collection vendors, and others), elicited feedback from consumers, received and responded to extensive public comments, and initiated a field test of the draft instrument in three States.

AHRQ and its partners also worked with CMS to develop and test displays of the survey results, which will be published on CMS's public "Medicare Compare" Web site.

• AHRQ and CMS also collaborated in the development of two other survey products. The CAHPS® Nursing Home Survey will consist of two instruments—one for residents and the other for family members—designed to gather their assessments of the health care and services received in nursing homes. In FY 2003, the CAHPS® Consortium finalized the resident instrument and prepared it for field testing.
• The CAHPS® Dialysis Center Survey is being developed to enable patients with end-stage renal disease to assess the facilities where they receive dialysis. In FY 2003, AHRQ and its partners gathered and analyzed existing surveys, elicited guidance and feedback from subject experts and stakeholders, drafted an instrument, and initiated testing.
• Finally, in FY 2003, AHRQ and the CAHPS® Consortium continued their work on a survey module designed to address the needs of people with mobility impairments. This work is being done in collaboration with the National Institute on Disability and Rehabilitation Research, the Centers for Disease Control and Prevention, and the National Rehabilitation Hospital Center for Health and Disability Research. In an effort to analyze different definitions of disability, the team developed a set of items designed to identify people with impairments. This "screener" is being tested as part of the Massachusetts Health Survey.

Making Quality Count for Patients and Consumers

One of AHRQ's most important priorities is translating research into practice. We are constantly working to make sure research findings are put to work to help patients and consumers get the best possible health care. AHRQ and its partners continue to develop and disseminate many products to help patients choose wisely when it comes to their health care.

Projects undertaken in FY 2003 that focus on providing health care quality information that will be useful to patients and consumers:

• AHRQ and the American Academy of Pediatrics (AAP) partnered to promote a new fact sheet called 20 Tips to Help Prevent Medical Errors in Children. It offers evidence-based, practical tips on avoiding medical errors related to prescription medicines, hospital stays, and surgery. AHRQ and AAP will distribute copies of the fact sheet to AAP's 57,000 member pediatricians, as well as to groups representing children and parents.
• AHRQ and the National Council on Patient Information and Education released a new resource, Your Medicine: Play it Safe, to help consumers use prescription medicines safely. This guide makes four recommendations to consumers for getting the best results:
  • Give your doctor or other health care professionals who prescribe your medicine important information about the medicines you're already taking. This includes whether you have medicine allergies, if you have had problems when taking a medicine before, and if you have any other illness or medical conditions like diabetes or high blood pressure.
  • Get the facts about your medicine. For example, read the prescription, know what your medicine is for, and ask questions.
  • Stay with your treatment plan. For instance, take all the antibiotics you were prescribed, and ask your doctor if your prescription needs to be refilled.
  • Keep a record of the medicines, vitamins, and other dietary supplements you take.

AHRQ, the Centers for Medicare & Medicaid Services, the Office of Personnel Management, and the Department of Labor created posters and fact sheets called 5 Steps to Safer Health Care, which offer evidence-based practical tips on the role that patients can play to help improve the safety of the care they receive. The tips address errors related to prescription medicines, laboratory tests, procedures, and surgery.

National Quality Measures Clearinghouse™ and QualityTools

AHRQ launched the new Web-based National Quality Measures Clearinghouse™ (NQMC™) in FY 2003. Currently, the NQMC™ contains more than 300 quality measures. It presents the most current evidence-based quality measures and measure sets available to evaluate and improve the quality of health care.

The site is designed to be a "one-stop shop" for physicians, hospitals, health plans, and others who may be interested in quality measures. Users can search the NQMC™ for measures that target a particular disease/condition, treatment/intervention, age range, sex, vulnerable population, or setting of care. Additionally, users may browse NQMC™ by organization or measure domain. Visitors can compare attributes of two or more quality measures side by side to determine which measures best suit their needs. The site also provides material on how to select, use, apply, and interpret a measure.

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

A brief description of the criteria:

• 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) has 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 provides documented peer-reviewed evidence evaluating the reliability and validity of the measure; or the measure has 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.

The NQMC™ builds on AHRQ's previous initiatives in quality measurement and is linked to an umbrella quality improvement clearinghouse, Quality Tools, which can be found at http://www.qualitytools.ahrq.gov. This new, expanded site comprises over 140 quality, clinical information, and decision tool components for patients, consumers, providers, purchasers, payers and policymakers. QualityTools enables these audiences to find tools to meet their specific needs.

Examples of tools contained in the clearinghouse:

• Clinical recommendations or processes (i.e., guidelines and measures).
• Patient safety practices.
• Benchmarking and comparative data.
• Tools relating to a specific disease or condition.
• Prevention and wellness information.
• Quality improvement initiatives or strategies.
• Information on health care delivery and services.
• Consumer information on patient medication and safety.

QualityTools also features the National Healthcare Quality Report and the National Healthcare Disparities Report and is linked to the National Guideline Clearinghouse™ (NGC), providing users ready access to evidence-based clinical practice guidelines. The NQMC™ and NGC linkage allows users to coordinate their search for quality measures with the original supporting guideline recommendations.

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