2014 Annual Progress Report to Congress: National Strategy for Quality Improvement in Health Care

Submitted by the U.S. Department of Health and Human Services


Contents

Overview of the National Quality Strategy
National Quality Strategy Priorities in Action Across the Nation
Harmonizing Measures for Consistent Reporting and Measurement
The Future of the National Quality Strategy

Figure

Figure: Three Aims and Six Priorities

Executive Summary

Across the Nation, the National Strategy for Quality Improvement in Health Care (National Quality Strategy) brings together Federal Agencies, health care payers, purchasers, providers, consumers, and other partners in pursuit of improved health and health care for all Americans. The National Quality Strategy serves as a framework for aligning stakeholders across the private and public sectors at the Federal, State, and local levels of the six priority areas, and progress on each of the three strategic opportunities.

The initial National Quality Strategy, published in March 2011, established three aims and six priorities for quality improvement, with real implications for the person receiving the care, advocating for a loved one, or becoming healthier as part of a community-wide effort. This year's annual progress report features National Quality Strategy Priorities in Action, which highlights some of the promising and transformative quality improvement programs at the State and local levels and spotlights organizations including many Agencies within the U.S. Department of Health and Human Services, who have adopted the National Quality Strategy as a framework for quality improvement; an analysis of the current state of quality measurement, with consideration for the need for harmonization and alignment; and a preview of the future of the National Quality Strategy Annual Progress Reports.

Figure: Three Aims and Six Priorities

NATIONAL QUALITY STRATEGY’S THREE AIMS 1. BETTER CARE: Improve the overall quality of care, by making health care more patient-centered, reliable, accessible, and safe.  2. HEALTHY PEOPLE/HEALTHY  COMMUNITIES: Improve the health of the U.S. population by supporting proven  interventions to address behavioral, social, and environmental determinants of health in addition to delivering higher-quality care.  3. AFFORDABLE CARE: Reduce the cost of quality health care for individuals, families, employers, and government.  NATIONAL QUALITY STRATEGY’S SIX PRIORITIES:  1. Making care safer by reducing harm caused in the delivery of care. 2. Ensuring that each person and family are engaged as partners in their care. 3. Promoting effective communication and coordination of care. 4. Promoting the most effective prevention and treatment practices for the leading causes of mortality, starting with  cardiovascular disease. 5. Working with communities to promote wide use of best practices to enable healthy living. 6. Making quality care more affordable for individuals, families, employers, and governments by developing and spreading new health care delivery models.

Priorities in Action

The National Quality Strategy's Priorities in Action series captures the vision and motivation of organizations who put the aims and priorities into practice, and who attain tangible results through their efforts. This report highlights a select few communities, health systems, and organizations that show improvement in each priority area, illustrating how their successes demonstrate the potential impact of National Quality Strategy implementation.

Notably, this success includes significant progress in improving safety in health care settings, including a 9 percent decrease in harm experienced by patients in hospitals nationwide in 2012 compared with 2010.A


A U.S. Department of Health and Human Services. “New HHS Data Shows Major Strides Made in Patient Safety, Leading to Improved Care and Savings” May 7, 2014. Accessed August 2014. http://innovation.cms.gov/Files/reports/patient-safety-results.pdf.


Using the National Quality Strategy as a Framework for Quality Improvement

The National Quality Strategy continues to guide nationwide quality improvement efforts. This year's report includes examples of National Quality Strategy implementation from several operating divisions of the U.S. Department of Health and Human Services. A full account of the Department of Health and Human Services' support of National Quality Strategy implementation can be found in the companion Agency-Specific Plans, available on the Working for Quality site.

Several organizations, including the California Department of Health Care Services and multiple U.S. Department of Health and Human Services Agencies, such as the Centers for Medicare & Medicaid Services, used the National Quality Strategy aims and priorities as a foundation to develop their own quality improvement strategies. The Centers for Medicare & Medicaid Services provides care and services for one in three Americans, while one in 10 Americans resides in California; consequently, these organizations' quality strategies have a major impact on the health and health care of Americans and represent a significant step forward in National Quality Strategy implementation.

Harmonizing Measures for Consistent Reporting and Measurement

The current health care quality landscape includes many reporting initiatives and a proliferation of measures to evaluate performance and opportunities for improvement. However, not all measures are useful. Sometimes measures are redundant, diverting resources away from improving care while increasing reporting burden without providing additional, useful information. Simultaneously, detailed measure specifications and methods can vary, creating confusion for payers, providers, patients, and consumers when interpreting performance. The National Quality Strategy calls for an aligned focus on outcomes for children, adolescents, and adults and for the retirement of unnecessary, redundant measures that will reduce the reporting burden and will allow the remaining quality measures to send a stronger signal about where and how better care is achieved.

Across the Nation, stakeholders are responding to the need for coordination and alignment of measures currently in use by pursuing measure harmonization and alignment. The U.S. Department of Health and Human Services convened the Measurement Policy Council to evaluate measures in use across the Department, create consensus around harmonized core measure sets for high-priority areas, and coordinate future measure development. Initiatives such as “Buying Value,” a collaborative of health care purchasers, harness the power of private purchasers to establish an agreed-upon measure set into contracts with payers that encourage pay-for-performance and give visibility to the need for further measure harmonization.

Future of the National Quality Strategy Annual Progress Reports

Future releases of the National Quality Strategy Annual Progress Report will feature updates on how Federal Agencies, States, and the private sector have implemented the National Quality Strategy over the prior year (i.e., what the Nation is doing to advance each priority), and the updated measurement data that tracks the Nation's progress against aims and priorities will be available in the National Healthcare Quality and Disparities Reports, which are published annually by the Agency for Healthcare Research and Quality and in collaboration with Agencies across the U.S. Department of Health and Human Services. This comprehensive update on quality improvement will draw much-needed attention to the state of health and health care quality in the United States, including opportunities for continued improvement and successes achieved.

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Overview of the National Quality Strategy

The Patient Protection and Affordable Care Act directed the Secretary of the U.S. Department of Health and Human Services to “establish a national strategy to improve the delivery of health care services, patient health outcomes, and population health.” The resulting National Strategy for Quality Improvement in Health Care (National Quality Strategy) serves as a resource to identify and prioritize quality improvement efforts, share lessons learned, and monitor the collective success of Federal, State, and private-sector health and health care stakeholders across the country.

Aims and Priorities of the National Quality Strategy

The Agency for Healthcare Research and Quality delivered the National Quality Strategy to Congress in spring 2011 on behalf of the U.S. Department of Health and Human Services. The Strategy defined three aims and six priorities to serve as a vehicle to focus nationwide attention on quality improvement efforts and a common approach to measuring quality.

Annual Report to Congress: Advancing the National Quality Strategy

After the National Quality Strategy outlined the aims and priorities described above, the 2012 Annual Report to Congress established long-term goals and national tracking measures to monitor quality improvement progress. The 2012 report also offered an in-depth look at the implementation activities taking place across the Federal Government.

The Measurement Policy Council reviewed current measures in use by the U.S. Department of Health and Human Services and reached consensus on measures in hospital-acquired conditions, hypertension control, care coordination, patient experience, smoking cessation, HIV/AIDS, perinatal, obesity, and depression.

The 2013 Annual Report to Congress provided updates on overall quality improvement against the national tracking measures and spotlighted the significant collaboration between public and private payers. It also presented private-sector accomplishments in the six priority areas and highlighted ongoing work toward reducing the data collection burden for providers engaged in quality improvement.

This year's Annual Report to Congress provides concrete examples of how diverse organizations at the State, local, and community levels are adopting these priorities to improve health and health care for the communities they serve. This report provides a snapshot of the many programs across the country demonstrating alignment to the National Quality Strategy priorities and the effects of their efforts in improving health and health care across the country.

This 2014 Annual Report to Congress also includes a discussion on the connection between measurement and quality improvement and the continuing efforts both the public and private sectors are making to reduce the reporting burden on providers.

Priorities in Action are programs featured on the National Quality Strategy Working for Quality Web site each month. It features some of the Nation's promising and transformative quality improvement programs, and describes their alignment to the NQS' six priorities. These programs represent private sector, Federal, State, and local efforts.

The National Quality Strategy encourages alignment of health and health care quality programs and performance measures across the country. The past year has seen significant advancements in patient safety research and improvement, adoption of new care delivery models rewarding quality improvement, public-private alignment of data collection and measurement, and a decrease in cost growth across the American health care system.

This report provides an update on the Nation's progress improving quality across six priority areas, while also highlighting local examples of excellence that show what is possible. Further, it details the ongoing work by Federal partners, including the U.S. Department of Health and Human Services (HHS), to support the nationwide effort to achieve the National Quality Strategy's three aims: better care, healthy people/healthy communities, and affordable care.

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National Quality Strategy Priorities in Action Across the Nation

The National Quality Strategy's three aims form the foundation for improving health and health care quality where Americans live, work, and play. Whether this improvement occurs through policy changes, patient and consumer advocacy, provider training, or improvements in technology, the three aims catalyze efforts that have real implications for those on the receiving end. This includes the person receiving the care, the family caregiver advocating for a loved one, or the individual trying to become healthier as part of a community-wide effort. To help capture the effects of these improvements, the Priorities in Action series features some of the promising and transformative quality improvement programs at the Federal, State, and local levels aligned to at least one of the six National Quality Strategy priorities. The Priorities in Action series illustrates the vision and motivation of those who put these programs into practice and who are seeing tangible results from their efforts, as evidenced by the following examples.

Image of Priority in Action 1 LogoReducing The Harm in the Delivery of Care: the Connecticut Hospital Association

The National Quality Strategy asserts that no patients should be harmed by the health care they receive, and all clinicians should be empowered with the best tools and information to deliver safe, effective, quality care. Eliminating infections, injuries, and other harms in health care settings is fundamental to improving quality.

The Connecticut Hospital Association represents more than 140 hospitals and health-related organizations.B through the association, Connecticut hospitals work to reduce the harm in the delivery of care through comprehensive programming aimed at preventing adverse drug events, falls, catheter-associated urinary tract infections, perinatal harm, central line-associated bloodstream infections, pressure ulcers, surgical site infections, venous thromboembolism, ventilator-associated events, and reducing preventable readmissions.

Since 2009, Connecticut hospitals have been participating in the national On the CUSP: Stop BSI Project (Comprehensive Unit-based Safety Program: Stop Bloodstream Infection), funded by the Agency for Healthcare Research and Quality, to eliminate central line-associated bloodstream infections by implementing safety checklists, standardizing processes, identifying and mitigating defects, conducting communication trainings, and improving the culture of safety.C Fourteen Connecticut hospitals participated in the association's CUSP: Stop BSI Project and achieved a reduction in their central line-associated bloodstream infection rates of nearly 50 percent, from 1.99 infections to 1.05 infections per 1,000 central line days.D The Agency for Healthcare Research and Quality's On the CUSP: Stop BSI Project used the Comprehensive Unit-based Safety Program with hospital teams at more than 1,100 adult intensive care units in 44 States over a 4-year period. Hospitals participating in this project nationwide reduced the rate of central line-associated bloodstream infections nationally from 1.903 infections per 1,000 central line days to 1.137 infections per 1,000 central line days, an overall reduction of 40 percent.E

More broadly, there has been a coordinated effort at the national level to eliminate health care-associated infections, including the launch of the U.S. Department of Health and Human Services' National Action Plan to Prevent Healthcare-Associated Infections: Roadmap to Elimination and the Centers for Medicare & Medicaid Services' quality improvement activities to prevent health care-associated infections, and to provide data for Federal initiatives and States such as Connecticut to focus on prevention of health care-associated infections. More recently, these efforts have been enhanced through the Partnership for Patients® initiative and Hospital Engagement Networks. Combined Federal and State efforts have contributed to substantial reductions in some types of healthcare-associated infections, especially central line-associated bloodstream infections. The Nation has also seen significant progress in improving safety in health care settings, including a 9 percent decrease in harm experienced by patients in hospitals in 2012 compared to 2010. The U.S. Department of Health and Human Services has estimated that these improvements resulted in 15,000 deaths avoided in 2011 and 2012 and a reduction of 560,000 patient harms.F


B About the Connecticut Hospital Association. Accessed May 2014 http://www.chime.org/about-cha/
C Connecticut Hospital Association. Connecticut Hospital Association Launches Patient Safety Initiative To Reduce Deadly Infections, April 17, 2009. Accessed May 2014 http://www.cthosp.org/CHA/assets/File/newsroom/pr/041709_CHA_Launches_Pt_Safety_Initiative_CLABSI.pdf 
D Connecticut Hospital Association. First-of-its-Kind Event Highlights Transitions of Care, October 11, 2012. Accessed May 2014 http://www.cthosp.org/CHA/assets/file/newsroom/publications/update/101112.pdf.
E Agency for Healthcare Research and Quality. AHRQ Patient Safety Project Reduces Bloodstream Infections by 40 Percent, September 10, 2012. 
F U.S. Department of Health and Human Services. “New HHS Data Shows Major Strides Made in Patient Safety, Leading to Improved Care and Savings” May 7, 2014. .


Image of Priority in Action 2 LogoEngaging Individuals and Families in Their Care: the Flex Medicare Beneficiary Quality Improvement Program

The National Quality Strategy asserts that high-quality care is not only safe; it is also timely, accessible, and consistent with individual and family preferences and values. Individuals stay healthier when they and their families actively engage in their care, understand their options, and make choices that work for their lifestyles.

In 2010, the Health Resources and Services Administration launched the Flex Medicare Beneficiary Quality Improvement Program, which expands public reporting on quality measures that pertain to rural health care, allowing for clear benchmarking of hospital performance and identification of best practices. This project works to improve patient care and operations in rural, critical-access hospitals by promoting patient engagement. The Health Resources and Services Administration works with the grantee communities to improve the social, economic, and environmental factors affecting individuals and their care. The program provides technical assistance and national benchmarks to participating hospitals to improve health care outcomes in person-centered care.G

The three-phase project emphasizes person-centered care by focusing on improving health care services, processes, and administration. The first phase focused on Medicare Hospital Compare measures with a focus on pneumonia and congestive heart failure. The second phase focused on Medicare Hospital Compare measures in the outpatient setting and Hospital Consumer Health Assessment of Healthcare Providers and Systems (HCAHPS). The third phase focused on care coordination measures, including pharmacist computerized physician order entry systems and emergency department transfer communication. Currently, 94 percent of critical access hospitals located in 45 States voluntarily participate in the program. Hospitals submitting data for the Flex Medicare Beneficiary Quality Improvement Program show performance improvements each reporting quarter. Depending on the region, there have been increases in performance as high as a 10 percent in the measures that appropriately assess health care received in critical-access hospitals. Over the next year, the program will focus on quality improvement initiatives to improve outcomes nationally.H


G Federal Office of Rural Health Policy. FLEX Medicare Beneficiary Quality Improvement Project. Accessed May 2014. http://www.ruralcenter.org/sites/default/files/MBQIP%20Overview%20for%20CAHs.pdf
H Health Resources and Services Administration Office of Rural Health Policy, Accessed May 2014. http://www.hrsa.gov/ruralhealth/.


Image Priorities in Action 3 logo Promoting Effective Communication and Coordination of Care: Oregon Health Care Quality Corporation

Conscious, patient-centered coordination of care improves the person's experience and leads to better long-term health outcomes, as demonstrated by fewer unnecessary hospitalizations, of repeated tests, and conflicting prescriptions as well as clearer discourse between providers and patients about the best course of treatment.

The Oregon Health Care Quality Corporation (Q Corp) is an independent, nonprofit organization dedicated to improving the quality and affordability of health care in Oregon by leading community-level multi-stakeholder collaborations and producing unbiased information. The Oregon Health Care Quality Corporation works with community stakeholders—including consumers, providers, employers, policymakers, and health insurers—to improve the health of all Oregonians and find solutions to Oregon's health care challenges, such as reducing unnecessary emergency department visits.

The Oregon Health Care Quality Corporation collects primary care provider performance data for a number of quality indicators and provides results to providers over a secure portal with local and national benchmarks. These data allow for identification of gaps in care and places where follow-up needs to occur. Providers can identify patients who are not receiving the care they need, allowing them to manage the health of their populations more effectively. The Oregon Health Care Quality Corporation's database currently includes more than 2.6 million, or 75 percent, of publicly and privately insured Oregonians.I This allows the collaborative to have a statewide impact on the communication and coordination of care across Oregon.

Because of its work, combined with the efforts of community members and stakeholders across the State, the Oregon Health Care Quality Corporation's 2013 statewide report noted a decrease in potentially avoidable emergency department visits from the prior year. Avoidable emergency department visits among children as a percentage of total emergency department visits among children dropped from 16.8 percent to 13.9 percent. In the same time period, the percentage of avoidable emergency department visits among adults also decreased from 11.0 percent to 10.1 percent.J


Katrina Kahl, Director of Communications, Oregon Health Corporation. June 2014.
J Oregon Health Care Quality Corporation. Information for a Healthy Oregon: Statewide Report. August 2013.


Image Priorities in Action 4 logoPromoting the Most Effective Prevention and Treatment Practices for the Leading Causes of Mortality: the New York State Health Foundation's Diabetes Campaign: "Reversing the Trend"

To improve quality across all stages of life, the National Quality Strategy focuses on efforts targeting diseases that are responsible for the largest number of American deaths and disabilities.

With nearly 10 percent of New Yorkers—or 1.4 million—afflicted with diabetes, the condition is one of New York State's most pervasive epidemics. Another 4.5 million residents have prediabetes, a condition that puts them at high risk for developing diabetes and its complications. Diabetes accounts for nearly $13 billion a year in health care costs and productivity losses in New York State.K

The New York State Health Foundation's (NYSHealth) ‘Reversing the Trend Diabetes' campaign has helped more than 3,000 physicians achieve the National Committee for Quality Assurance and Bridges to Excellence Diabetes Recognition Certification. Working with statewide associations representing hospitals, community health centers, and private practices, the Foundation has helped to improve diabetes care for more than 600,000 people. To mobilize communities to improve diabetes prevention, screening, and management, it partnered with the Institute for Leadership to establish 200 diabetes prevention and self-management programs across the State. Through this effort, the institute has embedded chronic disease self-management programs into existing health ministry programs in faith-based organizations and subsequently identified more than 8,000 participants who were at risk for diabetes and were not aware of it. Results of the campaign indicate success in diabetes prevention and management: between 2007 and 2011, the percentage of New Yorkers who have diabetes with controlled cholesterol increased from 41 percent to 47 percent, and the percentage with controlled blood pressure rose from 61 percent to 66 percent.L

In 2013, NYSHealth expanded efforts to improve diabetes prevention where New Yorkers live, work, and worship. Currently, NYSHealth is working to expand its network of community organizations, health centers, and health plans.


K New York State Health Foundation. Improving Diabetes Prevention. Accessed May 2014. http://nyshealthfoundation.org/priority-areas/improving-diabetes-prevention.
L New York State Health Foundation. Social Impact Context: Improving Diabetes Prevention. Accessed May 2014. http://nyshealthfoundation.org/priority-areas/improving-diabetes-prevention.


Image Priorities in Action 5 logoWorking with Communities to Promote Best Practices to Enable Healthy Living: the Minnesota Statewide Health Improvement Program

The National Quality Strategy promotes high-quality health care that extends beyond the walls of medical facilities. Access to healthy food, preventive services, and physical exercise are all vital to maintaining overall health and preventing unnecessary and costly medical complications.

The Minnesota Statewide Health Improvement Program (SHIP) addresses the leading causes of premature death and disability through improved nutrition, increased physical activity, and decreased exposure to commercial tobacco products. Working with local governments, communities, schools, businesses, and medical providers across Minnesota, the program builds sustainable, community-level changes and supports local public health and tribal health agencies through grants,gathering science-based best practices in a menu of strategies, and offering technical assistance and evaluation.

The program's most recent annual results demonstrate how each community intervention improved the health and health care of Minnesotans: roughly 14,000 workers benefited from worksite wellness programs; more than 60 communities increased biking and walking in their communities by creating safer crosswalks, sidewalks, and bike paths; and 98 property management companies adopted smoke-free policies across the State. The program worked with farmers across the State to add 11 additional farmers markets to the existing 77 throughout the State. There were 429 schools that incorporated changes into their food policies by supporting school gardens, and 160 schools adopted the “Safe Routes to School” program to make walking and biking to school easier and safer for more than 68,000 students. In addition, 232 schools implemented “Active Classroom” programs to incorporate more physical activity into the school day, affecting 118,000 students.M


M William Burleson, Communications Coordinator, Office of Statewide Health Improvement Initiatives at the Minnesota Department of Health. April 2014.


Image Priorities in Action 6 logoMaking Quality Care More Affordable by Developing and Spreading New Health Care Delivery Models: California Quality Collaborative

The National Quality Strategy states that high-quality health care is useful only when people find it affordable. Moreover, quality improvement often goes hand in hand with cost savings for both payers and consumers.

The California Quality Collaborative is a health care improvement organization composed of approximately 300 purchasers, providers, health plans, and patient advocacy organizations dedicated to improving health care delivery for 7 million Californians.N

Hospitals in the California Quality Collaborative implemented an innovative program called Avoid Readmissions through Collaboration. This program implements hospital-level care and administrative processes that are known to reduce preventable readmissions, such as providing patients with post-discharge self-management skills and deploying a discharge advocate to coordinate discharge with the care team and the patient. Between 2011 and 2013, the 27 participating hospitals reduced preventable readmission rates by 13 percent, avoiding 6,471 hospitalizations and saving more than $62 million.O

The California Quality Collaborative also received a Centers for Medicare & Medicaid Services Health Care Innovation Award to launch the Intensive Outpatient Care Program. For 27,000 high-risk Medicare patients throughout California and Arizona, the program embeds care managers in primary care settings to develop close relationships with patients and help tailor care to each individual's needs. At the same time, it seeks to reduce costs by decreasing emergency room visits, preventable hospitalizations, and complications through intensive care management. By 2015, the collaborative anticipates improving patient experience by 2 to 4 percent; improving patient clinical outcomes, blood pressure, cholesterol, and blood sugar control by 2 percent; and reducing costs by 5 percent through lower avoidable hospitalization rates and fewer emergency department visits.P


N California Quality Collaborative 2013 Annual Report, May 2014 http://www.calquality.org/storage/CQC-Impact-Report-Final.pdf.
O Avoid Readmissions Through Collaboration. “Collaborative Reducing Hospital Readmissions Celebrates Success” May 6, 2014. http://www.avoidreadmissions.com/press/press-release-may-6-2014.html.
http://www.ihs.gov/MedicalPrograms/Diabetes/HomeDocs/Resources/FactSheets/2012/Fact_sheet_AIAN_508c.pdf
R Indian Health Service, “Special Diabetes Program for Indians” May 2012. Accessed May 2014 http://www.ihs.gov/MedicalPrograms/Diabetes/HomeDocs/Resources/FactSheets/2012/Fact_Sheet_SDPI_508c.pdf.
S Yvette Roubideaux, M.D., M.P.H. Indian Health Service. “Tribal Caucus Briefing on the HHS Special Diabetes Program for Indians” March 7, 2012. Accessed May 2014 http://www.ihs.gov/newsroom/includes/themes/newihstheme/display_objects/documents/2012_Speeches/SDPI%20-%203-7.pdf.


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Using the National Quality Strategy as a Framework for Quality Improvement

Both Federal and State agencies are aligning to the National Quality Strategy framework by using the National Quality Strategy aims and priorities as a foundation in the development of their own quality improvement strategies.

State Initiative

California Department of Health Care Services: The California Department of Health Care Services adopted the National Quality Strategy's framework to develop its Strategy for Quality Improvement in Health Care. First published in 2012, California's strategy used the National Quality Strategy as a foundation and tailored its strategy to the needs of the diverse California population and health care delivery system. California's strategy emphasizes high quality and optimal clinical outcomes, and taps into the extensive and broad stakeholder engagement process used to develop the National Quality Strategy. Updated in December 2013, California's strategy establishes clear targets for quality improvement in several priority areas, such as reducing the central line-associated bloodstream infection rates among select neonatal intensive care units. Future iterations will report on the State's success in meeting these targets. To access California's strategy, visit www.dhcs.ca.gov/services/Documents/DHCS_Quality_Strategy_2013.pdf.

U.S. Department of Health and Human Services Initiatives

To support the National Quality Strategy implementation, the U.S. Department of Health and Human Services' Agencies develop Agency-Specific Plans, called for by the Affordable Care Act, which outline objectives, action steps, and performance measures that align with the National Quality Strategy aims and priorities. Narratives of the Agency-Specific Plans are available on the Working for Quality Web Site. Each Agency offers programs that aim to improve quality across all areas of health and health care, as demonstrated in the following examples.

Agency for Healthcare Research and Quality

The Agency for Healthcare Research and Quality has taken a lead in embracing the National Quality Strategy through its mission and priorities. The Agency for Healthcare Research and Quality's mission is to “produce evidence to make health care safer, higher quality, more accessible, equitable, and affordable, and to work with the U.S. Department of Health and Human Services and other partners to make sure that the evidence is understood and used.”

Accordingly, the Agency focuses on four priority areas related to this mission. The first priority area focuses on improving health care quality by accelerating implementation of patient-centered outcomes research, with an initial emphasis on helping small- and medium-sized primary care practices and their patients improve outcomes on cardiovascular risk factors, including blood pressure control, cholesterol management, smoking cessation, and the use of appropriate aspirin therapy for those who need it.

The second priority is making health care safer. The Agency is accelerating patient safety improvements in hospitals through the use of its patient safety tools. It also continues to support the Centers for Medicare & Medicaid Services' Partnership for Patients®, contributing to the Nation's progress in reducing healthcare-associated infections in hospitals and in ambulatory care settings. Additional areas of focus include reducing perinatal patient safety events and examining the impact of communication and resolution programs to improve patient safety and reduce medical liability.

The Agency's third priority area is increasing accessibility. The Agency for Healthcare Research and Quality coordinates closely with the U.S. Department of Health and Human Services' Office of the Assistant Secretary for Planning and Evaluation and the Centers for Medicare & Medicaid Services to provide evidence on the effects of health insurance coverage expansions on the health and financial security of the uninsured, on labor markets, on health care providers, particularly those in the safety net, and on employer and employee decisions with respect to employer-sponsored insurance.

The fourth priority is to improve health care affordability, efficiency, and cost transparency. One way the Agency does is this is by developing and disseminating evidence and tools to measure and enhance the efficiency of health systems. AHRQ analyzes variations in quality and resource use and identifies the factors that differentiate higher-performing from lower-performing systems. In pursuing these priorities, the Agency for Healthcare Research and Quality demonstrates an Agency-specific approach to adopting and implementing the National Quality Strategy.

Substance Abuse and Mental Health Services Administration

Using the National Quality Strategy as a model, the Substance Abuse and Mental Health Services Administration has developed the National Behavioral Health Quality Framework. The National Behavioral Health Quality Framework provides a mechanism to examine and prioritize quality prevention, treatment, and recovery elements at the payer/system/plan, provider/practitioner, and patient/population levels. The Framework is aligned with the National Quality Strategy in that it supports the three broad aims of better care, healthy people/healthy communities, and affordable care. However, it was specifically broadened to include the dissemination of proven interventions and accessible care. The latter concept encompasses the delivery of affordable care, along with other elements of care accessibility, including the impact of health disparities.

The Substance Abuse and Mental Health Services Administration offers the National Behavioral Health Quality Framework as a guiding document for the identification and implementation of key behavioral health quality measures for use in Agency or system funding decisions, monitoring behavioral health of the Nation, and the delivery of behavioral health care. Although many of the measures featured in the Framework are endorsed by the National Quality Forum, the Substance Abuse and Mental Health Services Administration recognizes the importance of looking beyond National Quality Forum endorsement for measures that capture the breadth of behavioral health activities addressed by the Substance Abuse and Mental Health Services Administration and the U.S. Department of Health and Human Services, particularly those for which the evidence base is not mature or areas in which data collection is still evolving.

To the extent possible, measures included in the National Behavioral Health Quality Framework will:

  • Be endorsed by the National Quality Forum or other relevant national quality entity where possible
  • Be relevant to National Quality Strategy and National Behavioral Health Quality Framework priorities
  • Address “high-impact” health conditions
  • Promote alignment with program attributes and across programs, including health and social programs, and across the U.S. Department of Health and Human Services
  • Reflect a mix of measurement types: outcome, process, cost/appropriateness, and structure
  • Apply across patient-centered episodes of care
  • Account for population disparities

In addition to the National Behavioral Health Quality Framework, a second component of the Substance Abuse and Mental Health Services Administration's quality agenda that supports the National Quality Strategy is the National and State Behavioral Health Barometer. The Behavioral Health Barometer presents a set of substance use and mental health indicators as measured through data collection efforts sponsored by the Substance Abuse and Mental Health Services Administration (the National Survey on Drug Use and Health and the National Survey of Substance Abuse Treatment Services), the Centers for Disease Control and Prevention (the Youth Risk Behavior Survey), and the National Institute on Drug Abuse (the Monitoring the Future survey). Also included are data on the use of mental health and substance use treatment services by Medicare enrollees, as reported by the Centers for Medicare & Medicaid Services. This array of indicators provides a unique overview of the Nation's behavioral health at a point in time as well as a mechanism for tracking change and trends over time, which support the three aims of the National Quality Strategy.

Indian Health Service

The U.S. Department of Health and Human Services Indian Health Service works toward achieving the National Quality Strategy's priority to implement the most effective prevention and treatment practices for the leading causes of mortality. The likelihood of American Indians and Alaska Native adults to have diagnosed diabetes is 16.1 percent, which is 2.3 times higher compared with non-Hispanic Whites.Q

In response to the diabetes epidemic in American Indian and Alaska Native people, Congress established the Special Diabetes Program for Indians through the Balanced Budget Act of 1997.R Serving the majority of federally recognized tribes, this program has successfully implemented innovative interventions in 404 Indian Health Service Tribal and Urban Indian Health programs across the Nation to address this widespread health problem. Both scientific literature and community-driven priorities guide the program and have allowed tribal leaders and the Indian Health Service to collectively build one of the most strategic and comprehensive diabetes prevention and treatment programs in the United States.

The Special Diabetes Program for Indians provides the funding for tools, training, support, and clinical data to help the Indian health system make tremendous changes in the diabetes landscape of American Indian and Alaska Native communities. Certain aspects of the program include group classes and individual coaching sessions to inform lifestyle changes. Other features include intensive clinical management, including medical care and patient education strategies, to change risky behaviors and improve clinical outcomes in people with diabetes. Consultants work with individual grantees to improve accountability, introducing them to comprehensive diabetes training tools, clinical tools, and an easily accessible Web site which acts as a central information source for all tools, training, and resources. The Special Diabetes Program for Indians ensures information technology and electronic health records are available for diabetics. Data collection services are available, along with the necessary data infrastructure for diabetes surveillance and care-cost analysis.

Analysis of the Special Diabetes Program for Indians' outcomes illustrates the program's effectiveness. The average blood sugar level for program participants decreased from 9.0 percent in 1996 to 8.0 percent in 2011, as measured by the hemoglobin A1c test (HbA1c) test, a common medical assessment for blood sugar levels. Participants showed an average LDL (low-density lipoprotein) cholesterol decline from 118 mg/dL in 1998 to 94 mg/dL in 2011. Furthermore, the blood pressure of participants has been well controlled: the use of blood pressure-lowering medications increased from 42 percent in 1997 to 72 percent in 2011, resulting in lower average blood pressure readings.S


Q Indian Health Service. “Diabetes in American Indians and Native Alaskans: Facts At-A-Glance” June 2012. Accessed May 2014. http://www.ihs.gov/MedicalPrograms/Diabetes/HomeDocs/Resources/FactSheets/2012/Fact_sheet_AIAN_508c.pdf.
R Indian Health Service, “Special Diabetes Program for Indians” May 2012. Accessed May 2014 http://www.ihs.gov/MedicalPrograms/Diabetes/HomeDocs/Resources/FactSheets/2012/Fact_Sheet_SDPI_508c.pdf.
S Yvette Roubideaux, M.D., M.P.H. Indian Health Service. “Tribal Caucus Briefing on the HHS Special Diabetes Program for Indians” March 7, 2012. Accessed May 2014 http://www.ihs.gov/newsroom/includes/themes/newihstheme/display_objects/documents/2012_Speeches/SDPI%20-%203-7.pdf.


Administration for Community Living

The U.S. Department of Health and Human Services Administration for Community Living advances the National Quality Strategy through health-related long-term support services. Under the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (DD Act) and the Older Americans Act, the Administration for Community Living administers programs protecting the rights of people with disabilities and older adults. The Administration for Community Living works to:

  • Empower people with disabilities and older adults to make informed decisions about their health and independence
  • Actively participates in the design and implementation of policies, programs, and systems that affect their lives
  • Enables people with disabilities and older adults to remain in the community through the provision of long-term services and supports, including support for family caregivers
  • Advocates on behalf of people with disabilities and older adults ensuring their interests are reflected in the design and implementation of Federal policies and programs (e.g., employment, housing, transportation, etc.)

One specific initiative the Administration for Community Living supports is the National Core Indicators™, which works to improve the health and outcomes for people with disabilities and older Americans in communities across the Nation by gathering information about individual health care outcomes on consumers and their families. This information allows States to better understand the outcomes of their services. The program gathers a standard set of performance and outcome measures that track States' performance over time, compare results across States, and establish national benchmarks for certain indicators that measure the quality of life for aging and disabled populations. Currently the tool is being used in 40 States with developmental disabilities systems and is being piloted in three States for aging populations and people with physical disabilities. The National Core Indicators program includes a set of performance indicators that track the performance of public agencies.

Within this Federal–State partnership, the Administration for Community Living provides assistance for training on the survey instruments the National Core Indicator uses as well as support for data analysis. Collected data are used to inform strategic planning, produce legislative reports, and prioritize quality improvement initiatives.

The Centers for Disease Control and Prevention

The Centers for Disease Control and Prevention promotes the most effective prevention and treatment practices for the leading causes of mortality through many of its activities, including its work on the National Diabetes Prevention Program and Million Hearts™. The National Diabetes Prevention Program is an evidence-based lifestyle change intervention for preventing type 2 diabetes in people at risk. The program uses curriculum, lifestyle coaches, and group discussion sessions to teach participants strategies for incorporating physical activity and healthy eating habits into daily life. The program also works with national grantees, State health departments, and other partners to assure quality, reach, and sustainability of the lifestyle change intervention in States. It collaborates with partner organizations and grantees to obtain health insurance coverage for the lifestyle change intervention and increasing awareness of pre-diabetes among the general public. Through its efforts, the National Diabetes Prevention Program has proven to help people cut their risk of developing type 2 diabetes in half.

The Centers for Disease Control and Prevention also supports Million Hearts™, an initiative launched in 2012 to support cardiovascular disease prevention activities across the public and private sectors. The Centers for Disease Control and Prevention's role includes monitoring State reporting on performance measures related to controlling high blood pressure, and creating a dashboard on the Million Hearts™ Web site for tracking national uptake of that measure across quality reporting programs. These activities not only support the National Quality Strategy priority of promoting the most effective prevention and treatment practices, but also provide evidence of alignment around critical, core metrics on prevention efforts.

In addition, the Centers for Disease Control and Prevention addresses the National Quality Strategy's priority to make care safer by reducing harm caused in health care settings through its efforts to track and address healthcare-associated infections and related patient safety threats. The Centers for Disease Control and Prevention contributes to national efforts to prevent healthcare-associated infections by developing guidelines for their prevention and by tracking their incidence and prevalence across the Nation. The Centers for Disease Control and Prevention's National Healthcare Safety Network has more than 12,000 health care facilities participating in all 50 States and is used by Federal and State agencies as well as health care facilities to target prevention and assess impact. In addition, the Centers for Disease Control and Prevention supports health departments and health care facilities with laboratory and prevention expertise to address health care-associated infections and to assist in related outbreak responses.

The Centers for Disease Control and Prevention also measures, validates, interprets, and responds to other adverse events or medical errors data in health care affecting patients and health care personnel, such as antimicrobial resistance; adverse drug events; blood, organ, and tissue safety; and immunization safety. The Centers for Disease Control and Prevention not only identify emerging threats, but also save lives while protecting patients across health care through outbreak detection and control. These efforts collectively contribute to making health care in the United States safer by reducing harm caused in health care settings across the Nation.

The Centers for Medicare & Medicaid Services

The Centers for Medicare & Medicaid Services directly modeled its Quality Strategy after the National Quality Strategy. The Centers for Medicare & Medicaid Services Quality Strategy was published in 2013, and was followed by a public comment period. It pursues and aligns with the three broad aims of the National Quality Strategy and its six priorities, each of which has become a goal in the Centers for Medicare & Medicaid Services Quality Strategy. For example, through programs and initiatives such as Section 1115 Medicaid Waivers, Partnership for Patients®, Hospital Value-Based Purchasing, patient-centered medical homes, Medicare Advantage Quality Bonus Payments, and the End-Stage Renal Disease Quality Incentive Program, the Centers for Medicare & Medicaid Services provides financial incentives that reward providers for adopting best practices that can decrease harm.

In order to engage individuals and families in their care, the Centers for Medicare & Medicaid Services implemented Quality Improvement Organization-led initiatives, such as the Everyone with Diabetes Counts program, which gives each individual beneficiary and family an active role in their care. These are just a few examples of specific elements in the Centers for Medicare & Medicaid Services Quality Strategy that seek to optimize health outcomes and transform health system practices. As the Centers for Medicare & Medicaid Services covers roughly one in three Americans through its programs,T the purposeful alignment of its Quality Strategy with the National Quality Strategy demonstrates a meaningful change to improve health and health care quality within the Federal Government.

The Centers for Medicare & Medicaid Services also focuses on micro-level alignment to the National Quality Strategy in the Medicare and Medicaid Electronic Health Records Incentive Programs. The Medicare and Medicaid Electronic Health Record Incentive Programs (http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Meaningful_Use.html) support the adoption of electronic health records with evidence-based clinical decision support capabilities as the first step to transforming health care practices to provide consistently high-quality care.

In addition, the Centers for Medicare & Medicaid Services aligns with the National Quality Strategy by providing Medicare and Medicaid financial incentives for the “meaningful use” of certified electronic health record technology to improve patient care and care delivery. While this program was mandated by the Health Information Technology for Economic and Clinical Health (HITECH) Act, the Centers for Medicare & Medicaid Services adopted the priorities of the National Quality Strategy as part of the Meaningful Use criteria. The Electronic Health Records Programs follow three stages with increased requirements that must be met by eligible professionals and hospitals at each stage. Eligible professionals and hospitals must meet core criteria, including reporting of clinical quality measures. In Stage 2, eligible professionals and hospitals who participate must submit measures covering no less than three of six National Quality Strategy Priorities. Meeting the Meaningful Use requirements reflects a provider's efforts to transform the way they deliver health care in such a way that supports and affects quality improvement.

The Centers for Medicare & Medicaid Services also developed a set of recommendations to address gaps in the following health related domains: safety, population and public health, efficiency, beneficiary engagement, functional status/well-being, and care coordination. The Centers for Medicare & Medicaid Services continues to include beneficiary-reported outcomes as Meaningful Use objectives. Because of the recommendations to address gaps in health-related domains, Meaningful Use Stage 3 Priorities were re-aligned in order to synchronize with the National Quality Strategy. Meaningful Use objectives under Stage 3 will focus on improving quality, safety, and efficiency through increased beneficiary access to self-management tools, comprehensive patient data through patient-centered health information exchanges, and decision support tools for providers.


T Centers for Medicare & Medicaid Services. “CMS Statistics Reference Booklet.” Jun 4, 2012. Accessed May 2014 http://cms.gov/Research-Statistics-Data-and-Systems/Research/ResearchGenInfo/CMSStatistics.html.


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Harmonizing Measures for Consistent Reporting and Measurement

The current health care measurement landscape includes many reporting initiatives and a proliferation of measures due to the desire of public and private sector stakeholders to develop and track performance of measures in a variety of settings and for myriad conditions. These measurement initiatives and the measures they use are often not coordinated. This lack of coordination of measures is not beneficial to any stakeholder. Numerous measures that are similar, but different in some ways, can be a burden to consumers unfamiliar with the differences between measures, public reporting entities who struggle to display the data in a way that is meaningful, and providers who have to collect disparate data to satisfy a multitude of requirements. At times measures are redundant, diverting resources away from improving care without providing additional useful information. Other times, detailed measure specifications and methods for attributing the performance on a measure to a specific provider vary, creating confusion for payers, providers, patients, and consumers when interpreting performance.

What is the right number of measures and how should we coordinate measures?

Historically, different organizations and programs have created similar measures for different purposes, sometimes with minor variations. In addition, the varying availability of data sources results in similar measures for the same clinical condition or focus area. With 2,170 measures reported as in-use within the U.S. Department of Health and Human Services' programs and 4,144 measures reported to be in-use by public and private parties, there is growing concern about the redundancy of some measures and the reporting burden on providers. The Measurement Policy Council, Centers for Medicare & Medicaid Services, and many other organizations are working to address these concerns by harmonizing and aligning the measures currently in use.

To avoid these problems, measures must provide useful, timely information for all stakeholders, and this can be achieved only through measure alignment and harmonization. Harmonization refers to the standardization of specifications for related measures with the same measure focus (e.g., influenza immunization of patients in hospitals or nursing homes), related measures for the same target population (e.g., eye exam and HbA1c for patients with diabetes), or definitions applicable to many measures (e.g., age designation for children) so that they are uniform or compatible, unless differences are justified. Measure harmonization should be considered when measures are intended to address either the same measure focus—the target process, condition, vent, outcome—or the same target population. Alignment is the union of various measure collectors (e.g., alignment across the Centers for Medicare & Medicaid Services and private payers). Unnecessary, redundant measures should be retired to reduce reporting burden and allow the remaining quality measures to send a stronger signal about where and how better care is achieved.

The National Quality Strategy encourages the harmonization and alignment of measures across the Nation. Through an interagency workgroup, the U.S. Department of Health and Human Services brings together leaders in the field of measurement to review measures and work toward harmonization. The work group, known as the Measurement Policy Council, has met with non-Federal partners to facilitate the discussion of better identification of measure gaps, priorities for new measure development, as well as any instances of a surplus of measures. In turn, these efforts provide insight for recommendations on how best to move towards achieving a set of highly effective measures that minimize measurement burden, while providing all stakeholders with useful information on health and health care.

Measurement Policy Council

Guided by the six priority areas of the National Quality Strategy, the Measurement Policy Council, along with its operational working groups, facilitates interagency coordination and agreement to harmonize and align existing measures in use across the U.S. Department of Health and Human Services.

  • Current Measures: The Measurement Policy Council reviews measures in use across the U.S. Department of Health and Human Services, developing consensus around core sets of measures for given topics, and advocating phasing out all measures except those that are in an agreed upon core set. In analyzing the measures in use across the Department of Health and Human Services, the Measurement Policy Council is able to develop a process for alignment. The council focuses on aligning core sets for the highest impact topic areas, maximizing quality improvement, and minimizing provider burden and confusion. Since its launch, the Measurement Policy Council achieved consensus for alignment in seven high-priority measure topics (see Figure 1, below) and continues working to harmonize activities in other measure areas.
  • Measures Under Development: The Measurement Policy Council and its operational working groups also prioritize and review measures currently under development. They provide a forum for U.S. Department of Health and Human Services divisions to share routinely their measure development plans and progress towards the Measurement Policy Council's aligned measure sets. In 2014, the operational working groups created and pilot-tested Rules for Categorizing Measures according to the National Quality Strategy priorities.
  • Future Measures: The Measurement Policy Council's guiding principles ensure future measures are developed with the highest standards of evidence-based guidelines and promote quality improvement and person- and family-centricity. The Measurement Policy Council sends a strong signal to the field regarding the Department's future measurement development priorities and reinforces a forward-leaning commitment to develop new measures that take advantage of clinical data in new formats, as outlined by the Meaningful Use Incentive Program—such as electronic health records, registries, and patient portals—rather than simply trying to force imperfect, older measures toward new purposes. With reliable data, it is possible to generate actionable knowledge and to measure progress. Establishing a core set of measures can ensure data are useful for multiple purposes. It can also ensure those data are then available to guide ongoing policy and payment reforms that will influence the care process and generate new metrics data, helping to build a learning health system as a whole.

Since its formation, the Measurement Policy Council has reviewed nine measure topic areas and created seven core measure sets, resulting in the recommendation for the retirement of a significant percentage of measures currently in use. The core measure sets were agreed upon through consensus from across the U.S. Department of Health and Human Services and with consideration for other major Federal and private-sector initiatives that influence quality measurement across the Nation, such as the Partnership for Patients® and Million Hearts®. Figure 1 examines the measures reviewed by the Measurement Policy Council by topic area.

Figure 1

Topic Area Number of Measures Reviewed Number of Measures in Recommendations
Hypertension 51 2
Smoking Cessation 63 4
Depression 48 3
Hospital-Acquired Conditions (HACs) 105 9
HIV/AIDS 138 7
Perinatal 86 5
Obesity 76 3

Operational alignment involves a long process that includes awarding grants, reflecting alignment recommendations in Notices of Proposed Rulemaking for public programs that include a quality measurement aspect, and rolling out national surveillance systems. Quality measures are used across programs to evaluate grantees, providers, and patients' health care status; measure alignment must be balanced against preserving the ability to track health systems' progress. New measurement techniques must be incorporated into complex workflows in practice and may require technology not widely available to all providers, especially those that assist certain groups such as older adults and people with disabilities and chronic conditions. However, efforts are underway to standardize data collection and reporting techniques as well as provide incentives for providers to adopt electronic health records.

The process of agreeing upon measures to review—and once reviewed, recommending measures for the inclusion in a core measure set—is complex. Due to the nature of data collection, the abundance of measures continues to be woven into the fabric of many different types of systems and established processes. The multifaceted process takes time, interagency collaboration, and public–private sector engagement.

Non-Federal Sector Efforts to Harmonize Measurement

Several State and private-sector initiatives focus on harmonizing existing measure sets. These diverse organizations approach harmonizing measures from different perspectives; some bring together stakeholders to determine the best performance measures for public reporting while others identify rules for categorizing measures. The National Quality Forum, Buying Value, and the National Academy for State Health Policy demonstrate State and private-sector activities working to harmonize existing measure sets.

National Quality Forum

The National Quality Forum, a key partner of the National Quality Strategy, is an independent nonprofit organization that refines and endorses standards and measures of health care quality through a national consensus-based approach. Through its relationship with the National Quality Forum, the National Quality Strategy engages in several efforts to harmonize measurement for public and private sector partners:

  • National Quality Partners: The National Quality Partners consists of National Quality Forum members who work to translate the goals of the National Quality Strategy into action. These efforts build on the work of t the National Priorities Partnership. The National Quality Forum leverages its multi-stakeholder membership to meet the National Quality Strategy's call for coordinated action and shared goals across the spectrum of health care stakeholders. The National Quality Partners established action teams to identify and disseminate promising practices across stakeholder groups.
  • Measure Applications Partnership: In addition to working with the National Quality Partners, the National Quality Forum convenes the Measure Applications Partnership to address measurement. This public-private partnership provides input to the U.S. Department of Health and Human Services on the selection of performance measures for public reporting and performance-based payment programs. It provides upstream, pre-rulemaking input to the Federal Government on measure selection and brings together stakeholder groups in a unique collaboration that balances the interests of consumers, businesses and purchasers, labor, health plans, clinicians and providers, communities and States, and suppliers. It identifies the best available performance measures for use in specific applications, and encourages alignment of public and private-sector performance measurement efforts. The Measure Applications Partnership also establishes families of measures in order to fill identified gaps and promote alignment. The families of measures relate to the National Quality Strategy priority areas. The families of measures are useful for assessing the same concept at multiple levels of aggregation in the health system. In 2014, the three topics for which the Measure Applications Partnership is developing families of measures are affordability, patient- and family-centered care, and population health.

In 2013, the Measure Applications Partnership reviewed more than 500 measures on the U.S. Department of Health and Human Services' list of Measures Under Consideration for 20 Federal programs covering clinician, hospital, and post-acute care/long-term care. For the upcoming year, the partnership supports the application of 141 measures within Federal programs and supports the direction of another 166 measures, contingent on further development, testing, or endorsement. Further, the Measure Applications Partnership recommends phased removal of 64 measures and the addition of six measures that are not on the Department of Health and Human Services' list of measures under consideration.U

  • Measures Inventory Pipeline and Measure Gap Analysis: Outside of the Measure Applications Partnership, the National Quality Forum plays a key role in providing recommendations on preexisting measures. In conjunction with the Centers for Medicare & Medicaid Services, the National Quality Forum steers measure development toward the highest priority areas and away from measure duplication and redundancy. To avoid unnecessary measure development, the National Quality Forum, with funds from the U.S. Department of Health and Human Services and Centers for Medicare & Medicaid Service, created the Measure Inventory Pipeline to provide a public, virtual space for measure developers to post planned and current measure development. The Pipeline will also help measure developers connect and collaborate with their peers on development ideas, which in turn will promote harmonization and alignment of measures. Together, the National Quality Forum Measure Inventory Pipeline and the Centers for Medicare & Medicaid Services will coordinate a coherent approach to filling the most important measure gaps.

Buying Value

Buying Value is a landmark initiative undertaken by private health purchasers in partnership with Federal partners.V The initiative is designed to encourage and assist private purchasers transitioning from the traditional volume-based purchasing model to a value-based model, emphasizing coordination, patient safety, and care that is proven to work. Working toward this goal will align Buying Value with the National Quality Strategy's aim of making high-quality health care more affordable. Buying Value focuses on aligning private purchasing practices with the Medicare payment reforms, as well as working with State health insurance marketplaces and Medicaid programs.

A report commissioned by the Buying Value initiative analyzed 48 measure sets across 25 different States and three regional collaboratives. The review found little alignment across measure sets, great regional variation in measure specification, and a proliferation of homegrown measures.

In the future, the initiative will launch a national effort to support the use of standardize measures to help purchasers, health plans, States, and regions understand why measure alignment is important. Buying Value recommends communicating with measure stewards when their measures are modified to explain why the modification can be problematic. To facilitate communication between these groups, the initiative intends to develop an interactive database of recommended measures that will serve as a national measures framework. Once the database has been created, the initiative will assist the States themselves about which measures may be most useful based on their needs.

National Academy for State Health Policy

The National Academy for State Health Policy is an independent organization of State health policymakers. The organization provides a forum for working on health care challenges across branches and agencies of State government. In November 2013, the National Academy for State Health Policy convened and facilitated a discussion around measurement among high-level Federal and State leaders. This meeting focused on new opportunities and promising practices for measuring quality under value-based purchasing approaches as well as new Federal opportunities that support quality measurement.

During the event, Federal leaders heard from States on their unique approaches to quality measurement. States continue to explore innovative health care payment structures, such as new reimbursement models to support advanced models of primary care and episode-based or global payments. Many recognize the need to align measures to support the shift toward value-based purchasing. State governments are focused on using harmonized measure sets for public programs such as Medicaid and the Children's Health Insurance Program Reauthorization Act. States are also continuing to identify measure sets for reporting in payment reform programs, such as accountable-care initiatives.

States are incorporating national measure sets into payments linked to value. Some States are building data infrastructure that supports payment reform and drives improvement in quality outcomes. Furthermore, many States are using quality measures to hold large providers and systems accountable. In those States beginning to implement State-based marketplaces, many are planning to drive quality improvement by measuring and displaying plan-level quality ratings in the health insurance marketplaces.

Private-sector efforts continue to promote aspects of National Quality Strategy implementation, such as the work to align measures and reduce provider burden to enable tracking of quality improvement. In addition, the National Quality Strategy will continue to track progress on these outcomes by using agreed-upon national tracking measures that reflect trends in health and health care services over time.


U National Quality Forum. Measure Applications Partnership Pre-Rulemaking Report: Public Comment Draft January 2014. Accessed May 2014. http://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=74433.
V Buying Value, Buying Value in 2014: Public-Private Alignment. Accessed May 2014 http://www.buyingvalue.org/


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The Future of the National Quality Strategy

Over the past year, the influence of the National Quality Strategy has grown. The Priorities in Action series demonstrates how organizations across the Nation are contributing to efforts to improve the quality of health and health care, and each year, more organizations align with the National Quality Strategy working toward this goal. Federal and State agencies are using the National Quality Strategy aims and priorities as a foundation for their own quality improvement strategies. Stakeholders nationwide are working to align and consolidate the measures that providers are required to collect and report on all populations and age groups, including children, adolescents, and adults.

Beginning this year, the National Quality Strategy Annual Progress Report relies on the Agency for Healthcare Research and Quality's National Healthcare Quality and Disparities Reports to highlight performance on the National Quality Strategy aims and priorities. The National Healthcare Quality and Disparities Reports include updated measurement data (tracking the Nation's progress on each priority). This measurement data can be found on the National Healthcare Quality and Disparities site.

Future releases of the National Quality Strategy Annual Progress Report will feature updates on how Federal Agencies, States, and the private sector have implemented the National Quality Strategy over the prior year (i.e., what the Nation is doing to advance each priority), and the updated measurement data that tracks the Nation's progress against aims and priorities will be available in the National Healthcare Quality and Disparities Reports. This comprehensive update on quality improvement will draw much-needed attention to the state of health and health care quality in the United States, including opportunities for continued improvement and successes achieved.

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U.S. Department of Health and Human Services
Current as of September 2014

Page last reviewed November 2016
Page originally created November 2016
Internet Citation: 2014 Annual Progress Report to Congress: National Strategy for Quality Improvement in Health Care. Content last reviewed November 2016. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/workingforquality/reports/2014-annual-report.html