The National Quality Strategy's six priorities address the range of quality concerns that affect most Americans: making care safer by reducing harm caused in the delivery of care; ensuring that each person and family are engaged as partners in their care; promoting effective communication and coordination of care; promoting the most effective prevention and treatment practices for the leading causes of mortality, starting with cardiovascular disease; working with communities to promote wide use of best practices to enable healthy living; and making quality care more affordable for individuals, families, employers, and governments by developing and spreading new health care delivery models.
In this section, progress on each priority is assessed. Data from the National Healthcare Quality and Disparities Report are examined to assess trends, disparities, and changes in disparities over time. National Quality Strategy Priorities in Action are presented and feature some of the nation's most promising and transformative quality improvement programs. These programs represent private sector, federal, state, and local efforts.
Patient Safety: Making care safer by reducing harm caused in the delivery of care
The National Quality Strategy calls on all stakeholders to promote patient safety. Although health care providers continue to work toward a delivery system focused on high-quality care, hospital-acquired conditions and harmful complications acquired from ambulatory health care delivery remain common. Prevention of medical errors saves lives and lowers costs, goals shared by all stakeholders across the system and a key to achieving the three aims of the National Quality Strategy.
Patient Safety improved substantially, led by a 17% reduction in hospital-acquired conditions between 2010 and 2014. Hospital-acquired conditions have been targeted for improvement by the Centers for Medicare & Medicaid Services (CMS) Partnership for Patients initiative, a major public-private partnership working to improve the quality, safety, and affordability of health care for all Americans and aligned to the National Quality Strategy. Hospital-acquired conditions have also been targeted by AHRQ, which has funded research to demonstrate how care can be made safer, development of tools and training materials to make sure that the research results are understood and used, and development of measures to determine the level of adverse events in hospitals.
A number of public and private efforts, as well as the dedication of practitioners, have contributed to improvement in about 60% of safety measures. These efforts include Medicare's Quality Improvement Organizations, built around the National Quality Strategy's priorities, and HHS' National Action Plan to Prevent Health Care-Associated Infections.
Patient Safety: Distribution of hospital-acquired conditions based on national rates per 1,000 hospital adult discharges, 2010-2014
|Hospital-acquired Condition||Rate per 1,000 Discharges|
|Catheter-Associated Urinary Tract Infections||12.2||11.3||10.6||8.8||7.6|
|Adverse Drug Events||49.5||48.7||41.9||40.3||41.4|
Key: HAC = hospital-acquired condition.
Source: Agency for Healthcare Research and Quality, Medicare Patient Safety Monitoring System, 2010-2014; Centers for Disease Control and Prevention, National Healthcare Safety Network, 2010-2014; and Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project, Nationwide Inpatient Sample, 2010-2011 and State Inpatient Databases 2012-2013 quality analysis files.
- From 2010 to 2014, the overall rate of hospital-acquired conditions declined by 17%, from 145 to 121 per 1,000 hospital discharges.
- Large declines were observed in rates of adverse drug events, catheter-associated urinary tract infections, and pressure ulcers.
Patient Safety Disparities were uncommon; more than 70% of racial, ethnic, and income-related contrasts did not indicate a disparity. However, when present at baseline, only about 30% of disparities grew smaller. Moreover, new disparities appeared in areas that had no disparities before. Disparities in patient safety have not been well studied. However, as improvements in patient safety are made, it is important to ensure that care is made safer for all Americans.
Patient Safety: Obstetric trauma per 1,000 instrument-assisted vaginal deliveries, by race/ethnicity, 2001-2013
|Year||Total||White||Black||Asian or Pacific Islander||Hispanic|
Source: Agency for Healthcare Research and Quality (AHRQ), Healthcare Cost and Utilization Project (HCUP), State Inpatient Databases disparities analysis file, 2001-2013, and AHRQ Quality Indicators, version 4.4.
- From 2001 to 2013, the rate of obstetric trauma associated with instrument-assisted vaginal deliveries fell overall and for all racial/ethnic groups.
- Blacks and Hispanics had lower rates of obstetric trauma associated with instrument-assisted vaginal deliveries than Whites in all years.
- The gap between the Asian or Pacific Islander rate and the White rate was not statistically significant in 2001 but grew larger over time.
The Michigan Health and Hospital Association Keystone Center Hospital Engagement Network aims to reduce preventable hospital-acquired conditions. From 2011 through 2014, nearly 100 hospitals participated in the network and saved more than $40 million in health care costs per year by reducing patient harm.2 Michigan hospitals continue to improve central-line-associated bloodstream infection (CLABSI) and ventilator-associated event rates and are implementing prevention, detection, and treatment strategies to reduce sedation and delirium in the intensive care unit. From 2004 through 2014, there was a reduction in CLABSI of 69%.3
Person- and Family-Centered Care: Ensuring that each person and family is engaged as partners in their care
The National Quality Strategy calls on all stakeholders to promote person- and family-centered care. Person-centered care ensures that each person and family is engaged as partners in their care. It means defining success not just by the resolution of clinical syndromes but also by whether patients achieve their desired outcomes. Care should adapt readily to individual and family circumstances, as well as differing cultures, languages, disabilities, health literacy levels, and social backgrounds.
A study published in 2015 in the Journal of General Internal Medicine examined the implementation of a patient-centered medical home (PCMH) pilot program in 15 small and medium primary care practices in Colorado. Over a 3-year period, the study found that the patient-centered primary care delivered in the PCMH model led to sustained decreases in the number of annual emergency department visits and primary care visits, as well as increased screening for some types of cancer.4
Person-centered care also needs to be integrated outside of medical homes in the fee-for-service settings in which most patients receive care. As outlined in the National Quality Strategy, successful person-centered care entails more than just the successful completion of clinical care; it also means that patients achieve their own desired outcomes.
Person-Centered Care improved quickly, but Person-Centered Care Disparities were common, especially for Hispanics and poor people. As is true for access, disparities by income are larger than disparities by race/ethnicity. Effective and respectful provider-patient communication is at the core of person-centered care. The 2013 enhanced National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care (https://www.thinkculturalhealth.hhs.gov/clas) provides a framework to help organizations deliver services that are responsive to patients' diverse cultural health beliefs and practices, preferred languages, health literacy, and other communication needs.
Such efforts have led to widespread improvements in person-centered care; 80% of measures tracked showed improvement. However, many disparities exist and only about 30% of them are getting smaller over time. We expect an additional decrease in disparities, in part, because of enforcement of Section 1557 of the Affordable Care Act, which prohibits organizations from discriminating on the grounds of race, color, national origin, age, disability, or sex, under any health program or activity, any part of which is receiving federal financial assistance, or under any program or activity that is administered by HHS, including the Health Insurance Marketplaces.
Person-Centered Care: Adults who had a doctor's office or clinic visit in the last 12 months who reported poor communication with health providers, by race/ethnicity and income, 2002-2013
Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2013.
Note: Adults who reported that their health providers sometimes or never listened carefully, explained things clearly, showed respect for what they had to say, or spent enough time with them are considered to have poor communication.
- From 2002 to 2013, the percentage of adults who reported poor communication with their health providers significantly decreased overall and among all racial/ethnic and income groups.
- Hispanics were more likely than Whites to report poor communication in all years; this gap did not change over time.
- Blacks were more likely than Whites to report poor communication in all years except 2006; this gap did not change over time.
- Poor, low-income, and middle-income families were more likely than high-income families to report poor communication in all years. The gap between middle- and high-income families did not change over time while the gaps between poor and high-income families and between low- and high-income families grew larger.
PatientsLikeMe is an online patient community that uses social networking to facilitate communication among people with chronic illnesses. The social network, a leader among similar organizations such as DailyStrength, CareAcross, and CureTogether, has demonstrated that open access to information facilitated by this model has strong potential to nurture patient engagement. A study published in Neurology in 2015 found that PatientsLikeMe usage increased epilepsy self-management and self-efficacy.5 A separate study published in 2015 in the same journal examined the data of site users diagnosed with amyotrophic lateral sclerosis (ALS) and found that small temporary plateaus and reversals in patient status are more common than previously believed and should not be interpreted as an ALS treatment effect.6 By engaging patients with diseases to communicate with others about their symptoms, PatientsLikeMe showed the potential for its patient community to contribute to the conversation around rare diseases and treatments.
Care Coordination: Promoting effective communication and coordination of care
The National Quality Strategy calls on all stakeholders to promote effective communication and coordination of care across the health care system. Navigating today's health care system is complicated. Patients receiving care often interact with many physicians, nurses, medical assistants, or other trained professionals across multiple settings, a situation especially true for the sickest populations. More than two-thirds of Medicare beneficiaries have at least two chronic conditions, and 14% of beneficiaries have more than six chronic conditions. Nearly 50% of beneficiaries with more than six chronic conditions have more than 13 doctor visits per year, and in 2010 accounted for 70% of Medicare hospital readmissions.7
When health care providers coordinate with each other, outcomes improve. Improved coordination decreases medication errors, unnecessary or repetitive diagnostic tests, unnecessary emergency department visits, and preventable hospital admissions and readmissions, all of which together lead to higher quality of care, improved health outcomes, and lower costs. Because delivery of coordinated care necessarily brings together disparate sectors of the health and health care system, improving care coordination offers a potential opportunity for drastically improving care quality that could save $240 billion a year.8
Few quality measures assess the process of coordinating care other than at the time of discharge from a hospital. Most care coordination measures in use examine health care utilization that could have been prevented, in part, by more coordinated care, such as readmissions and avoidable hospitalizations and emergency department visits. Among these measures, improvement in Care Coordination lagged behind other priorities, and Care Coordination Disparities were common.
Effective care coordination requires explicit attention to the many settings in which patients receive care as well as attention to the infrastructure to support information exchange across these sites. The CMS Community-based Transitions Program provides funding to test models for improving care transitions for high-risk Medicare patients by using services to manage patients' transitions effectively.
Care coordination also is facilitated by the meaningful use and interoperability of health information technology. The Health Information Technology for Economic and Clinical Health Act of 2009 gives HHS the authority to establish programs to improve health care quality, safety, and efficiency through the promotion of health information technology, including electronic health records and private and secure electronic health information exchange. For example, certification of a patient-centered longitudinal care plan facilitates documentation of a shared care plan for the entire care team, including the patient and his or her family. Ineffective care coordination can lead to preventable emergency department visits, admissions, and readmissions. Perhaps because concerted attention to improving care coordination is relatively recent, fewer than half of measures have documented improvement.
Care Coordination: People who report that their usual source of care usually asks about prescription medications and treatments from other doctors, by age and income, 2002-2013
Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2013.
- From 2002 to 2013, the percentage of people who reported that their usual source of care usually asked about prescription medications and treatments from other doctors increased overall and among all age and income groups.
- In all years, children were less likely than adults ages 18-44 to have a provider who asks about care from other doctors.
- Before 2010, there were few income-related disparities. Since 2010, people in poor and low-income families have been less likely than people in high-income families to have a provider who asks about care from other doctors. These represent new disparities in care coordination.
An organization focused on improving care coordination is the Lourie Center for Children's Social and Emotional Wellness, which provides coordinated health services to 4,000 children in the Washington, DC, area. The Center's Parent-Child Clinical Services Program, a licensed outpatient mental health clinic, uses a family-centered developmental approach to provide assessment, treatment, and consultation services to families and children that promote healthy development, enhance parenting capacity, and foster positive parent-child relationships. A study published in Attachment & Human Development in January 2016 examined the efficacy of the attachment-based experiential intervention program used in the Center's Parent-Child Clinical Services Program. Despite the small sample size, the authors found strong empirical evidence of positive behavioral change in study participants. This finding holds promise that coordination of mental health care enhances the capacity for changes in functioning and behavior between parents and their children.9
Effective Prevention and Treatment: Promoting the most effective prevention and treatment practices for the leading causes of mortality, starting with cardiovascular disease
The National Quality Strategy calls on all stakeholders to promote effective prevention and treatment of the leading causes of morbidity and mortality. A small number of chronic illnesses affect a large percentage of the population and account for a majority of deaths and health care expenditures in the United States. In particular, heart disease has been the leading cause of death in the United States for decades. It kills nearly one in four Americans and costs $312 billion per year, more than 10% of annual health expenditures.10 Improving the quality of American health care thus demands a focus on the prevention and treatment of cardiovascular disease.
The prevalence of cardiovascular disease risk factors and lack of public awareness compound the problem. According to the Centers for Disease Control and Prevention, in 2012, 29% of American adults had hypertension and another third had prehypertension—both early warning signs of cardiovascular disease—but only 52% of people with hypertension had their condition under control.11 Successful prevention and treatment of cardiovascular disease holds real promise to significantly improve the nation's clinical and economic health. AHRQ is focusing resources in this important area through EvidenceNOW, a grant initiative dedicated to helping thousands of small and medium primary care practices across the country use the latest evidence to improve the heart health of millions of Americans.
Effective Treatment improved, and Effective Treatment Disparities were uncommon, with several getting smaller over time. Since CMS began publicly reporting measures of hospital quality on the Hospital Compare Web site in 2005, these measures dominated the list of effective treatment measures tracked in this report. In the last several reports, many CMS measures achieved overall performance levels of 95% or better and were dropped from the report. The remaining measures of effective treatment have also done well, with about 60% showing improvement. Moreover, disparities are less common than in many other priorities; of these disparities, about 45% were getting smaller over time.
Effective Prevention and Treatment: Hospital patients with heart attack given fibrinolytic medication within 30 minutes of arrival, by race, 2005-2013
Source: Centers for Medicare & Medicaid Services, Medicare Quality Improvement Organization Program, 2005-2013.
- From 2005 to 2013, the percentage of hospital patients with heart attack who received timely fibrinolytic medication, which may reduce the amount of damage to the heart, improved overall and for all racial/ethnic groups.
- From 2005 to 2010, the percentage of hospital patients with heart attack who received timely fibrinolytic medication was lower for Blacks than for Whites. By 2011, this disparity had been eliminated.
An organization working toward improved primary care for patients with common chronic conditions is the Better Health Partnership. The Partnership delivers better and more affordable care in northeast Ohio to address the leading causes of morbidity and mortality. The Partnership currently publishes scores on the quality of care, primarily for diabetes and cardiovascular disease, delivered by more than 700 providers in 68 primary care practices of 9 health systems in Cuyahoga County and other adjacent counties.12
Between 2010 and 2013, the Partnership reduced hospitalizations for patients with diabetes, hypertension, angina, or heart failure by 10%, saving $20 million in health care costs. From 2014 to 2015, the Partnership's practices showed high performance on blood pressure control and cholesterol management measures compared with national averages reported by the National Committee for Quality Assurance.13 The national Million Hearts® initiative includes measures tracking performance on these two conditions; improved performance on these conditions is a key facet of the initiative's goal of preventing 1 million heart attacks and strokes in 5 years through improved heart health care.
Healthy Living: Working with communities to promote wide use of best practices to enable healthy living
The National Quality Strategy calls on all stakeholders to promote the health and well-being of communities across the health care system and beyond. Although the United States spends more per capita on health care than any country in the world, its citizens as a whole are the least healthy in the developed world.14 Nearly 45% of Americans have at least one chronic condition, and chronic conditions are responsible for 70% of the nation's deaths and 75% of health care spending.15
Many illnesses associated with chronic conditions are related to unhealthy lifestyle behaviors, environmental hazards, and poor social supports and can be prevented by increasing access to effective clinical preventive services and promoting community interventions that advance public and population health. Working with communities is critical to ensure that immunizations and early detection and prevention services reach everyone who needs them and to build healthy neighborhoods and support networks.
Public health spending has been shown to be particularly effective for lower income, and often higher need, communities, with 21% to 44% greater health and economic effects in low-income communities compared with the average-income community.16 Increasing public health spending and improving access to preventive care thus holds promise as a cost-efficient way to create healthier communities, reduce the personal and economic burden of chronic illnesses, and improve quality of life while reducing disparities throughout the United States.
Promoting healthy lifestyles that prevent disease and disability is better for people and more efficient than treating conditions after organ damage has been done. Measures of healthy living are long term and difficult to evaluate. As a result, measures of healthy living used in this report focus on receipt of indicated counseling and preventive services rather than actual achievement of a healthy lifestyle. For example, provider counseling about smoking cessation is tracked but the prevalence of smoking is not since the latter is influenced by many factors other than health care.
Among these measures, progress in Healthy Living lagged behind other priorities; with rare exceptions, receipt of recommended clinical preventive services has not increased substantially over the past decade. However, Healthy Living disparities were uncommon, with several getting smaller over time. This may reflect the broad availability of clinical preventive services and lifestyle counseling to most Americans even as large differences in the attainment of healthy lifestyles and environments exist across populations.
Healthy Living: Women ages 50-74 who reported they had a mammogram within the past 2 years, by race/ethnicity, 2000-2013
Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey, 2000-2013.
Note: Rates are age adjusted to the 2000 U.S. standard population.
- From 2000 to 2013, the percentage of women ages 50-74 who reported they had a mammogram within the past 2 years decreased overall, especially for White women.
- Trends for Black and Hispanic women were not statistically significant.
- In most years, Hispanic women were less likely than White women to have a mammogram. However, this gap has narrowed over time.
- Black and White women had similar rates of mammography in all years.
An organization working to improve healthy living is the Minnesota State Health Improvement Program (SHIP). SHIP addresses the two largest causes of chronic disease and premature death in Minnesota and nationally: obesity caused by poor nutrition and insufficient physical activity, and commercial tobacco use. By August 2015, the program increased access to healthy food options and physical activity opportunities for approximately 339,000 students. Minnesota SHIP collaborated with 540 employers on comprehensive workplace wellness initiatives for 62,000 employees, including promotion of healthy eating, active living, and tobacco-free living, and support for breastfeeding.
Working with community-based organizations, Minnesota SHIP created opportunities to make biking and walking easier at 180 sites and increased access to fresh fruits and vegetables at nearly 375 locations. In addition, Minnesota SHIP encouraged smoke-free housing policies at nearly 365 rental properties, protecting 17,000 residents from secondhand smoke. Among public housing properties that implemented smoke-free policies, indoor secondhand smoke exposure was reduced by over 46%.17
Care Affordability: Making quality care more affordable for individuals, families, employers, and governments by developing and spreading new health care delivery models
The National Quality Strategy calls on all stakeholders to make quality care more affordable across the health care system. In 2014, annual health and health care expenditures in the United States reached $3 trillion and accounted for 17.5% of the nation's gross domestic product.18 Health expenditures have historically grown faster than the rest of the economy, leading to an increase in the national debt, a decrease in the funds available for other public investments, and an increase in business and household budgets.
Numerous studies estimate that roughly 30% of health care spending produces little net value to the system in the form of improved health outcomes. Such spending includes unnecessary services, excess administrative costs, and inefficient delivery.19,20 Fee-for-service payment models, which reward providers based on the quantity of services provided rather than the quality of care and patient outcomes, can, in many cases, result in higher costs and poorer outcomes. Reforming the country's current payment and care delivery systems to address these problems presents enormous opportunities to reduce the cost of care and increase both quality of care and population health.
While data are limited for measures related to affordable care, available data show that Care Affordability improved since 2010 when the Affordable Care Act was passed, after worsening from 2002 to 2010. In addition, some Care Affordability Disparities have been getting smaller, including income-related disparities in problems paying medical bills. Since 2010, the Affordable Care Act has made health insurance accessible to millions of Americans with limited financial resources.
Care Affordability: People under age 65 who were in families having problems paying medical bills in the past year, by poverty status and race/ethnicity, 2011-2015 Q1-2
Key: Q = quarter.
Source: Cohen RA, Schiller JS. Problems paying medical bills among persons under age 65: early release of estimates from the National Health Interview Survey, 2011-June 2015. Hyattsville, MD: National Center for Health Statistics; 2015. http://www.cdc.gov/nchs/nhis/releases.htm.
Note: Data only available for 2015 quarters 1 and 2.
- From 2011 to the first half of 2015, the percentage of people under age 65 in families having problems paying medical bills decreased overall and for all poverty status and racial/ethnic groups.
- In all years, people in poor and near-poor families were more likely to have problems paying medical bills than people in families that were not poor. The gaps between people in poor and not poor families and between near-poor and not poor families have narrowed over time.
- In all years, compared with Whites, Blacks and Hispanics were more likely to have problems paying medical bills while Asians were less likely to have problems. None of these gaps were changing over time.
An organization working to reduce the cost of care is the Camden Coalition of Healthcare Providers. The Coalition analyzes health information exchange data to assign high-utilizing patients to a care management team that coordinates visits, reviews medications, and arranges postdischarge primary care and home visits. The first cohort of 36 patients enrolled in the program saw significant decreases in hospital utilization and total cost of care. These patients averaged 62 hospital and emergency department visits per month at an average total cost of $1.2 million before the intervention and averaged 37 hospital and emergency department visits per month at an average total cost of about $500,000 afterward.21 Monthly medical costs per "superutilizer" dropped 56%, from $33,333 to $14,597.22