2015 Annual Progress Report to Congress: National Strategy for Quality Improvement in Health Care

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


Executive Summary
Priorities in Action
   Making Care Safer
   Person- and Family-Centered Care
   Effective Communication and Care Coordination
   Prevention and Treatment of Leading Causes of Mortality
   Health and Well-Being of All Communities
   Making Quality Care More Affordable


Figure: Three Aims and Six Priorities

Executive Summary

The National Quality Strategy establishes three aims, six priorities, and nine levers for quality improvement that are used by public and private organizations to chart a course for improved health and health care. Five years following passage of the Affordable Care Act, the National Quality Strategy has gained ground. Key measures indicate that health and health care quality are improving, and millions of Americans have gained access to the health care system. These advances are paving the way for delivery system reform goals championed by the U.S. Department of Health and Human Services that will result in better care, smarter spending, and healthier people.

National Quality Strategy Progress

The National Quality Strategy is backed by the data published annually by the National Healthcare Quality and Disparities Report, an Agency for Healthcare Research and Quality publication. The National Healthcare Quality and Disparities Report tracks more than 250 health care process, outcome, and access measures, covering a wide variety of conditions and settings. Across the National Quality Strategy's six priorities, the 2014 report finds that half of the patient safety measures improved, led by a 17 percent reduction in rates of hospital-acquired conditions; person-centered care improved steadily, especially for children; care coordination improved as providers enhanced discharge processes and adopted health information technologies; effective treatment in hospitals improved, as indicated by measures publicly reported by the Centers for Medicare & Medicaid Services on the Hospital Compare Web Site; healthy living improved in about half of the measures followed, led by increased administration of selected adolescent vaccines from 2008 to 2012; and care affordability worsened from 2002 to 2010 and then leveled off.1 After years without improvement, the rate of un-insurance among adults ages 18-64 decreased substantially during the first half of 2014.1 In order to obtain high-quality care, Americans must first gain entry into the health care system, and millions have done so by enrolling in the health care marketplaces that have expanded coverage to 17.6 million people through provisions of the Affordable Care Act, including both Medicaid expansion and Health Insurance Marketplaces.2 As of June 30, 2015, about 9.9 million consumers had effectuated Health Insurance Marketplace coverage, and about 84 percent, or more than 8.3 million consumers, were receiving an advanced premium tax credit to make their premiums more affordable throughout the year.3

1 2014 National Healthcare Quality and Disparities Report. Rockville, MD: Agency for Healthcare Research and Quality; May 2015. AHRQ Pub. No. 15-0007.
2 Health Insurance Coverage and the Affordable Care Act. ASPE Issue Brief. May 5, 2015. http://aspe.hhs.gov/health/reports/2015/uninsured_change/ib_uninsured_change.pdf
3 June 30, 2015 Effectuated Enrollment Snapshot. Centers for Medicare & Medicaid Services. September 8, 2015. https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-09-08.html

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.

Program Alignment to the National Quality Strategy

Program alignment to the National Quality Strategy aims and priorities contributes to progress on key measures. Several important programs within the Centers for Medicare & Medicaid Services are aligned with the National Quality Strategy priorities. Programs such as the Quality Improvement Organizations, Physician Quality Reporting System, Value-Based Purchasing, the Electronic Health Records (EHR) Incentive Programs, and the Quality Rating System all use the National Quality Strategy aims and priorities to drive improvements in the quality of health and health care for all Americans. The Indian Health Service Hospital Consortium adopted the National Quality Strategy as a framework for improvement work in accreditation, credentialing, privileging processes, culture of safety, role of patient advocates, customer service training across the agency, harms reduction through updates and consolidation of infection control policies, and the environment of care in all facilities. More Federal programs and U.S. Department of Health and Human Services Agency-specific initiatives and plans to further implement the National Quality Strategy are available on the Working for Quality site.

National Quality Strategy Progress in Measure Alignment and Harmonization

Another important aspect of the National Quality Strategy is measure alignment and harmonization. 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. The Measurement Policy Council has reviewed nine topics to date: hypertension control, hospital-acquired conditions/patient safety, Hospital Consumer Assessment of Healthcare Providers and Systems, smoking cessation, depression screening, care coordination, HIV/AIDS, perinatal, and obesity/BMI. Seven core measure sets were created as a result, with the recommendation for the retirement of more than 500 measures currently in use. In 2014, the Centers for Medicare & Medicaid Services, along with America's Health Insurance Plans and its member plans' Chief Medical Officers, the National Quality Forum, and national physician organizations, formed a public-private workgroup called the Core Quality Measures Collaborative in order to assemble a set of core quality measures that align to the National Quality Strategy.4 In addition to the work done by the Measurement Policy Council and the Core Quality Measures Collaborative, the Institute of Medicine recently released "Vital Signs: Core Metrics for Health and Health Care Progress." The Core Measure sets selected by the report align to the National Quality Strategy priorities.5

4 Patrick H Conway and the Core Quality Measures Collaborative Workgroup. The Core Quality Measures Collaborative A Rational and Framework for Public-Private Quality Measure Alignment. Health Affairs. June 23, 2015. http://healthaffairs.org/blog/2015/06/23/the-core-quality-measures-collaborative-a-rationale-and-framework-for-public-private-quality-measure-alignment/
5 Vital Signs: Core Metrics for Health and Health Care Progress. Institute of Medicine. April 28, 2015. http://www.iom.edu/~/media/Files/Report%20Files/2015/Vital_Signs/VitalSigns_RB.pdf

Looking Forward: The National Quality Strategy and Delivery System Reform

Implementing payment models that reward and incentivize providers to deliver high-quality, patient-centered care is one of the nine levers of the National Quality Strategy. In January 2015, the U.S. Department of Health and Human Services announced new measureable goals and a clear timeline to move the Medicare program, and the health care system at large, toward paying providers based on the quality rather than the quantity of care they give patients. These recently announced goals reflect the intent of the National Quality Strategy and are part of the Department's broader effort to help move the health care system to one that achieves the goals of better care, smarter spending, and healthier people. The U.S. Department of Health and Human Services set a goal of moving 30 percent of Medicare provider payments to be in alternative payment models tied to how well providers care for their patients, such as Accountable Care Organizations or bundled payment arrangements by the end of 2016, and 50 percent by 2018.6 In addition, the Department set a goal of tying 85 percent of all traditional Medicare fee for service payments to quality or value by 2016 and 90 percent by 2018 through programs such as the Hospital Value-Based Purchasing and the Hospital Readmissions Reduction Program. This is the first time in the history of the Medicare program that the U.S. Department of Health and Human Services has set explicit goals for alternative payment models and value-based payments.

In order to engage the private sector in this effort, the U.S. Department of Health and Human Services launched the Health Care Payment Learning and Action Network ("Network"). Through the Learning and Action Network, the U.S. Department of Health and Human Services is working with private payers, employers, consumers, providers, States and State Medicaid programs, and other partners to expand alternative payment models into their programs. More than 4,000 individual patients, insurers, providers, States, consumer groups, employers and other partners have registered to participate in the Network, and many organizations have set their own goals for rewarding value and quality.

6 Better, Smarter, Healthier: In historic announcement, HHS sets clear goals and timeline for shifting Medicare reimbursements from volume to value. U.S. Department of Health and Human Services, January 26, 2015. http://www.hhs.gov/news/press/2015pres/01/20150126a.html

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Priorities in Action

Federal, State, regional, and local agencies, as well as private sector organizations, continue to demonstrate alignment to the National Quality Strategy by using the aims and priorities as a foundation for many programs and initiatives. The National Quality Strategy's Priorities in Action series, published on the Working for Quality Web site, highlights organizations that put the aims and priorities into practice, and attain tangible results through their efforts.

Priority in Action Making Care SaferMaking Care Safer



The National Quality Strategy identifies patient safety as a key element for delivering high quality health care. Patients should not 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.

Measuring Progress

The 2014 National Health Care Quality and Disparities Reports found that across measures related to patient safety, about half of the measures improved through 2012, with a median improvement of 3.6 percent per year.1 From 2010 to 2013, the overall rate of hospital-acquired conditions declined from 145 to 121 per 1,000 hospital discharges.1 Large declines were also observed in rates of adverse drug events, healthcare-associated infections, and pressure ulcers.1 The rate of central line-associated bloodstream infections improved quickly, at an average annual rate of change above 10 percent per year.1 Lastly, only one measure – postoperative physiologic and metabolic derangements during elective-surgery admissions – worsened over time.1 The general trend in patient safety is a result of Partnership for Patients and other Federal efforts, such as Medicare's Quality Improvement Organizations and the Department's National Action Plan to Prevent Health Care-Associated Infections, as well as the dedication of hospitals, private payers, and patient advocates.

Current Landscape

In recent years, the Partnership for Patients, a major public-private partnership convened by the Centers for Medicare & Medicaid Services, has focused on eliminating a set of hospital-acquired conditions and reducing readmissions. From 2010 to 2013, efforts by initiatives such as the Partnership for Patients and the Hospital Readmission Reduction Program helped achieve an estimated 50,000 fewer patient deaths in hospitals and approximately $12 billion in health care cost savings from a reduction in hospital-acquired conditions.7 In total, hospital patients experienced 1.3 million fewer hospital-acquired conditions over a 3-year period, which translates to a 17 percent decline.7 In addition, clinicians at some hospitals have reduced their early elective deliveries to close to zero, meaning fewer at-risk newborns and fewer admissions to the neonatal intensive care units.8

One such hospital is the Children's Hospital of the University of Pittsburgh Medical Center. It has achieved a significant reduction in adverse events and medication errors through an innovative electronic health record system. In addition to reducing adverse events through their electronic health record program, Children's Hospital entered into a partnership with Rothman Healthcare to develop the first-ever pediatric version of Rothman Index in 2012. The Rothman Index quantifies a patient's condition into a simple graphic format based on vital signs, nursing assessments, and lab results.9 Index graphics are meant to serve as a backup to point-of-care physicians by providing a historical context for patient care by drawing attention to changes in health that may otherwise be difficult to detect when a patient is handed off between multiple physicians and nurses.9 In-house analysis of the data mined from the record enables the hospital to go a step further and make care safer for future patients. An inter-hospital bioinformatics workgroup co-operated with the University of Pittsburgh feeds Children's Hospital data into a machine learning system with the goal of better predicting a patient's rate of readmission as soon as they enter the hospital. In doing so, hospital staff hope to better focus care management resources on those patients who need the most intensive preventive care for readmission.

A recent retrospective study of 16,239 Children's Hospital pediatric admissions between January 2006 and December 2013 compared the use of vital signs, a common indicator of patient condition, to the Pediatric Rothman to identify patients requiring urgent intervention with pediatric Intensive Care Unit transfer. The research, conducted by Children's Hospital clinicians, found that use of vital signs alone led to false-positive identification of serious events almost half of the time (46 percent).10, 11 The Pediatric Rothman Index had a false-positive rate of just 1 percent. The high specificity of the pediatric Rothman Index demonstrates an innovative improvement for patient safety concerns.11

Looking Forward

The trend of improving patient safety should continue as the Centers for Medicare & Medicaid Services continues to tie Medicare payment for hospitals to readmission rates for certain conditions. Under the Hospital Readmissions Reduction Program, Medicare payments to hospitals with excess readmissions are reduced, resulting in rewards for patient safety and care quality.8 The Hospital-Acquired Condition Reduction Program reduces Medicare payments for some hospitals that rank in the worst performing quartile with respect to hospital-acquired conditions. For the Fiscal Year 2015 program, the ranking was based on the hospital's performance on three quality measures (Patient Safety Indicator 90 composite, central-line associated bloodstream infection and catheter associated urinary tract infection).8 Additional safety measures for measures such as surgical site infections and methicillin-resistant Staphylococcus aureus infections have been added for future years. Choosing Wisely® also works to reduce unnecessary care that at times can be harmful. Choosing Wisely promotes conversations between patients and providers that help patients choose care that is supported by evidence, not duplicative of other tests or procedures already received, free from harm, and truly necessary.12

7 Efforts to improve patient safety result in 1.3 million fewer patient harms, 50,000 lives saved and $12 billion in health spending avoided U.S. Department of Health and Human Services. December 3, 2014
8 Better Care, Smarter Spending, Healthier People: Improving Our Health Care Delivery System. Centers for Medicare & Medicaid Services. January 26, 2015 http://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-01-26.html
9 Children's Hospital of Pittsburgh of UPMC Partners with Rothman Healthcare. BusinessWire. February 2012 http://www.businesswire.com/news/home/20120220005166/en/Childrens-Hospit....
10 Peer-Review: Children's Hospital of Pittsburgh of UPMC's Electronic Surveillance Framework Could Significantly Reduce False Positive Diagnosis. PR News Wire. July 15, 2015. http://www.prnewswire.com/news-releases/peer-review-childrens-hospital-o...
8 Better Care, Smarter Spending, Healthier People: Improving Our Health Care Delivery System. Centers for Medicare & Medicaid Services. January 26, 2015 http://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-01-26.html
11 Da Silva, et al. Evaluation of Electronic Medical Record Vital Sign Data Versus a Commercially Available Acuity Score in Predicting Need for Critical Intervention at a Tertiary Children's Hospital. Pediatric Critical Care Medicine. 2015 Sep;16(7):644-51. http://www.ncbi.nlm.nih.gov/pubmed/25901545
12 Choosing Wisely®. Accessed September 14, 2015.

Priority in Action Person- and Family-Centered CarePerson- and Family-Centered Care



The National Quality Strategy emphasizes the need to give individual patients and families an active role in the patient's care. Both public and private sector programs are working to promote this priority.

Measuring Progress

The 2014 National Health Care Quality and Disparities Reports found that Person-Centered Care improved with large gains in patient-provider communication.1 Almost all person- and family-centered care measures tracked in the report improved.1 From 2002 to 2012, the percentage of children whose parents reported poor communication with their child's health provider decreased significantly overall and among every racial, ethnic, and income groups.1 The report also found that when care delivery is not person- and family-centered, patients are more likely to over-utilize health care services.1

Current Landscape

Established by the Agency for Healthcare Research and Quality, the Consumer Assessment of Healthcare Providers and Systems®, a collective effort of public and private research organizations, has led the nation in creating surveys that ask consumers and patients to report on and evaluate their experiences with health care. These surveys are an important tool for advancing the National Quality Strategy's priority of person- and family-centered care.

The National Partnership for Women and Families, a non-profit organization, also has a long history of promoting person- and family-centered care by helping to shape and advance models of care that treat the patient as a whole person and ensure coordination of care, improved communication, patient support and empowerment, and ready access to health care providers and services. They provide stakeholders with case studies, toolkits, site-specific training curricula and other educational resources to educate health professionals about the importance and positive impact of providing care that is patient- and family-centered and partnering with patients and families. The organization also promotes Patient and Family Advisors to serve on Patient and Family Advisory Councils and other work groups and committees to improve the quality, safety and experience of care. As a result of their efforts, the National Partnership for Women and Families is able to engage consumers and providers in person- and family- centered care under the new models of health care delivery and payment, such as Accountable Care Organizations and patient-centered medical home/advanced primary care.

For 30 years, the Colorado Coalition for the Homeless has been working to integrate health care and housing services for people who are homeless based on the principle that managing serious mental illnesses, substance abuse disorders, and chronic medical conditions prevalent among this population requires safe housing. In 2013, the Coalition provided health care services to more than 13,000 homeless individuals and families. Many of the patients the Coalition treats are afflicted with multiple chronic conditions common to those without housing, such as hypertension, diabetes, and asthma. The nonprofit oversaw the development of 1,600 housing units for homeless individuals and families largely in the Denver metropolitan area. Many of those units are specifically for men and women in frail health whose recovery is hindered by lack of consistent access to nutritious food, clean water, and a safe place to rest. The Coalition's efforts, which employ a "Housing First" approach, demonstrated marked improvements in health and substantial cost savings in comparing the health and utilization of health care by participants. Participants in the program demonstrated a significant housing stability: during the 2-year study of 19 participants, 77 percent of participants continued to be housed. The Coalition also found that 50 percent of studied participants showed improvements in their health status: 43 percent showed improvements in their mental health status and 15 percent decreased their substance abuse.13, 14 Coupled with these improvements in outcomes was a significant decline in the cost of care for the studied participants. In comparing the health and emergency services records for a subset of participants in the 24 months before entering the program with the 24 months after, the coalition found utilization of all of these services declined, with an average cost savings of $31,546 per participant.14 Although the numbers in this study were small, it is representative of a transformative, innovative approach to person- and family- centered care.

Looking Forward

This year, the Centers for Medicare & Medicaid Services began to introduce Star Ratings on Hospital Compare, the Agency's public information site, to make it easier for consumers to choose a hospital based on the quality of care delivered. This effort is part of the U.S. Department of Health and Human Services' broader delivery system reform goals to deliver better care, spend health care dollars more wisely, and result in healthier people. The ratings are based on data from the Hospital Consumer Assessment of Healthcare Providers and Systems Survey measures. These new Star Ratings will enable consumers to more quickly and easily assess the patient experience of care and will allow consumers to more easily compare hospitals through increased transparency. The new star ratings support the use of quality measures as a key driver of health care system improvement.15

13 Colorado Coalition for the Homeless: A Model of Supportive Housing. Commonwealth Fund. May 2015 http://www.commonwealthfund.org/publications/newsletters/quality-matters/2014/october-november/case-study
14 Sadowski, L.S. (2009) Effect of a Housing and Case Management Program on Emergency Department Visits and Hospitalizations Among Chronically Ill Homeless Adults. JAMA. http://jama.ama-assn.org/content/301/17/1771.full.pdf.
15 CMS Releases First Ever Hospital Compare Star Ratings. Centers for Medicare & Medicaid Services. April 16, 2015 http://cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2015-Press-releases-items/2015-04-16.html

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Page last reviewed November 2016
Page originally created November 2016
Internet Citation: 2015 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. https://www.ahrq.gov/workingforquality/reports/2015-annual-report.html
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