Executive Summary

Quality First: Better Health Care for All Americans

Every day, millions of Americans receive high-quality health care that helps to maintain or restore their health and ability to function. Skilled physicians, nurses, and other health care practitioners offer expert compassionate care to people in need. High-caliber hospitals, nursing homes, and other health care institutions provide care to patients in need of acute and chronic care. Academic health centers educate and train new generations of health care practitioners and house many of the finest scientific minds who advance the science of health care. Federal, State, and local governments, private employers, labor unions, and others purchase health care coverage for millions of American families, offering security and peace of mind. And public and private quality oversight organizations work to make sure that the care provided is of the highest quality in the world.

A central goal of quality improvement is to maintain what is good about the existing system while focusing on the areas that require improvement. While most Americans receive high-quality care, too many patients receive substandard care. Quality problems include wide variation in health care services, underuse of some services and overuse of others, and an unacceptable level of errors.

Efforts by leaders of the health care professions, the health care industry, major employers, and State and Federal agencies have significantly improved our ability to identify quality problems and begin to address their causes. What is needed now is a national commitment to quality improvement that begins with the President and the Congress and extends to every level of the health care industry.

In seeking to improve the quality of care for all Americans, we cannot forget that there are more than 41 million Americans who live day to day without the security of health insurance. For them, access to quality care often is severely limited. Addressing this issue is critical to improving the health and functioning of all who live in our communities.

A Clear Statement of Purpose

The first step in this effort should be the establishment of a clear Statement of Purpose for the health care system. The Commission recommends that the President articulate and continue to emphasize the following statement:

The purpose of the health care system must be to continuously reduce the impact and burden of illness, injury, and disability and to improve the health and functioning of the people of the United States.

Evidence of Quality Problems

Several types of quality problems in health care have been documented through peer-reviewed research. They include:

• Avoidable errors. Too many Americans are injured during the course of their treatment, and some die prematurely as a result. For example, a study of injuries to patients treated in hospitals in New York State found that 3.7 percent experienced adverse events, of which 13.6 percent led to death and 2.6 percent to permanent disability, and that about one-fourth of these adverse events were due to negligence.¹ A national study found that from 1983 to 1993, deaths due to medication errors rose more than twofold, with 7,391 deaths attributed to medication errors in 1993 alone.²
• Underutilization of services. Millions of people do not receive necessary care and suffer needless complications that add to health care costs and reduce productivity. For example, a study of Medicare patients with myocardial infarction found that only 21 percent of eligible patients received beta blockers, and that the mortality rate among recipients was 43 percent less than that for nonrecipients.³ An estimated 18,000 people die each year from heart attacks because they did not receive effective interventions.⁴
• Overuse of services. Millions of Americans receive health care services that are unnecessary, increase costs, and often endanger their health. For example, an analysis of hysterectomies performed by seven health plans estimated that one in six was inappropriate.⁵
• Variation in services. There is a continuing pattern of wide variation in health care practice, including regional variations and small-area variations.⁶ This is a clear indicator that the practice of health care has not caught up with the science of health care to ensure evidence-based practice in the United States.

Major Recommendations

In total, the Commission's Final Report to the President includes more than 50 recommendations to advance these core purposes. (A complete summary of those recommendations follows this section.)

Public-Private Partnerships

To focus the entire health care industry on this Statement of Purpose, the Commission recommends the creation of two complementary entities, one public and one private, to provide ongoing national leadership in health care quality improvement.

The Advisory Council for Health Care Quality. A public Advisory Council should identify national aims for improvement and specific objectives for improvement and track the Nation's progress in meeting those aims and objectives. The Advisory Council also should establish goals and objectives for quality measurement and reporting by health care organizations and providers and track industry compliance with the Consumer Bill of Rights and Responsibilities.

The Advisory Council should include representatives of the public and private sectors with expertise in health care quality, patient and consumer needs, the purchasing and delivery of health care services, the management of health plans, research, public health, and the education and training of health care practitioners. The Advisory Council should report annually to the President and Congress on the Nation's progress in improving health care quality.

The Forum for Health Care Quality Measurement and Reporting. A private body of public and private purchasers of health care services, consumers, health plans, health care practitioners, and others should be created to implement a comprehensive plan for measuring health care quality and reporting the results of such measures to the public. The Forum should identify core quality measures for standardized reporting and promote the focused development of enhanced core measures for the future. The Forum should coordinate its efforts with the Advisory Council for Health Care Quality.

National Aims for Improvement

A major component of this national strategy is the establishment of a concise set of core aims for improvements that are accompanied by specific, measurable objectives for improvement throughout the system. The Commission recommends the following initial set of six National Aims for Improvement:

• Reducing the underlying causes of illness, injury, and disability.
• Expanding research on new treatments and evidence of effectiveness.
• Ensuring the appropriate use of health care services.
• Reducing health care errors.
• Increasing patients' participation in their care.
• Addressing oversupply and undersupply of health care resources.

Quality Measurement and Reporting

A key element of improving health care quality is the Nation's ability to measure the quality of care and provide easily understood, comparable information on the performance of the industry. Advances in quality measurement and reporting have enabled us to determine the flaws in the current system. But the absence of a systematic approach to quality measurement has hampered the health care industry's ability to track and sustain quality improvement.

The Commission is recommending a series of steps that should be taken -- primarily by the private sector -- to bring order to the current system of quality measurement while continuing to encourage development and innovation in this important field:

• Core sets of quality measures applicable to each sector of the industry (i.e., health plans, hospitals, nursing homes, individual physician practices, etc.) should be identified for standardized reporting.
• The health care industry should support the focused development of quality measures that enhance the Nation's ability to evaluate and improve health care.
• Steps should be taken to ensure that comparative information on health care quality is valid, reliable, comprehensive, and available in the public domain for use by consumers, purchasers, practitioners, quality oversight organizations, and others.

Strengthening the Market To Improve Quality

The health care market is rapidly transforming itself. Many of these changes bode well for quality improvement, but some may impede that progress. The Nation must harness the positive forces of change and guard against impediments to quality improvement.

Group purchasers. Public and private group purchasers of health care coverage and services must become more active and more coordinated in demanding high-quality services for those they represent. Group purchasers have tremendous influence over the health care industry's ability and willingness to focus on quality improvement. Private employers, in small but increasing numbers, have been pushing for a greater focus on quality, while public purchasers also have been emphasizing quality.

Consumers. Patients and other consumers of health care services need greater access to easily understood information and the ability to exercise greater choice in the health care market. With this assistance, consumers can have much greater influence over the industry's emphasis on quality.

Vulnerable populations. The needs of our most vulnerable citizens -- the poor, the frail elderly, those living with disabilities, the mentally ill, children, and others -- require special attention. To ensure high-quality care for all Americans, the needs of vulnerable citizens must be taken into account in the design of systems for health care delivery, quality measurement, and financing. Attention to the quality of health care for children is especially important given their health and developmental needs and their promise for the future.

Accountability. All participants in the health care industry must be accountable for improving the quality of health care in the United States.

Public and private sector quality oversight organizations have a longstanding and strong track record of leadership in assessing, ensuring, and encouraging improvement in health care. This role should be preserved and extended as a key component in a total system of accountability. In addition, better coordination and focus on shared aims and methods of accountability will increase the impact of existing oversight organizations.

The Commission has proposed a Consumer Bill of Rights and Responsibilities for all Americans. Assurance of such rights will strengthen consumer confidence in the health care industry and help to improve the quality of care that consumers receive. Group purchasers as well as public and private sector quality oversight organizations should work expeditiously to incorporate the provisions of the Consumer Bill of Rights and Responsibilities into their contractual and oversight requirements.

The Commission is pleased that the President has acted to ensure accountability in Federal public programs covering an estimated one-third of Americans and that employers and health plans have voluntarily committed to assure these protections to an additional 60 million Americans. In the year 2000, the Advisory Council should issue a comprehensive evaluation of the extent to which public and private sector leaders have been successful in ensuring compliance.

Reducing errors and increasing safety. Current systems to reduce and prevent errors in health care tend to focus too much on individual practitioners and not enough on system problems. Interested parties should develop a health care error reporting system to identify errors and prevent their recurrence. Internal and external appeals systems should be enhanced to assure speedy and accurate decisions. Policymakers and other stakeholders should engage in a national dialogue regarding current remedies for consumers who are injured as a result of inappropriate health care decisions. Such a dialogue should consider the cost and consequences of both the status quo and any revisions to existing policies.

Building the Capacity To Improve Quality

Improving quality requires commitment at all levels of the health care industry. Health care organizations, professionals, and other participants in the health care system must make quality improvement the driving force of the industry. Recommendations include:

• Research and evidence-based practice. Greater investment is needed in basic, clinical, preventive, and health services research. The continued development and dissemination of evidence-based information can help to guide practitioners' actions and the development and implementation of management policies that can influence practice to improve quality.
• Adapting organizations for change. Health care organizations (i.e., health plans, hospitals, nursing homes, quality oversight organizations, and others) must be flexible enough to change at the same pace as does the science of health care.
• Health care workers. Greater collaborations among health workers, along with better education and training of workers in quality improvement skills, are needed. The estimated 10 million health care workers in the United States can be a powerful tool for improving quality.
• Information systems. The health care industry will need to make a significant investment in health information systems to provide data on the individual and comparative performance of plans, facilities, and practitioners; help improve the coordination of care; advance evidence-based health care; and support continued research and innovation. Existing information systems are not adequate for these purposes.

Addressing the Uninsured

Consumer protection and quality improvement often are meaningless to Americans who cannot obtain health care when they need it. The fact that 41.7 million Americans -- including nearly 10 million children -- currently are uninsured and millions of others are underinsured confounds attempts to improve quality and protect consumers. Most uninsured Americans hold full-time jobs or are the spouses or children of such workers. Others are early retirees who have lost their employer-based coverage but are ineligible for Medicare. Many Americans who are living with disabilities or need help in performing essential activities of daily living have inadequate insurance to cover the costs of their acute and long-term care.

There is strong evidence that uninsured and underinsured individuals have less access to primary and preventive care, integrated social services, and continuity of care. They often are at the greatest risk of receiving care that is substandard and inadequate to their needs.

Ensuring that all Americans receive the care they need has been an elusive goal. But this pressing national concern is too important to ignore. Enactment of the State Child Health Insurance Program is an important first step.

The Commission urges the President, Congress, and all other stakeholders to engage in meaningful and continuing efforts to systematically reduce the number of Americans who are uninsured or underinsured. Such an effort should include specific goals and timetables and should have as its ultimate goal access to affordable, comprehensive health care for all Americans.
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1. Brennan, Troyen, et al. "Incidence of Adverse Events and Negligence in Hospitalized Patients." JAMA 324:370-376, 1991.

2. Phillips, David P., Nicholas Christenfeld, and Laura M. Glynn. "Increase in U.S. Medication-Error Deaths Between 1983 and 1993." Lancet February 28, 1998.

3. Soumerai, Stephen, Thomas McLaughlin, Ellen Hertzmark, et al. "Adverse Outcomes of Underuse of Beta Blockers in Elderly Survivors of Acute Myocardial Infarction." JAMA 277:115-121, 1997.

4. Chassin, Mark R. "Assessing Strategies For Quality Improvement." Health Affairs 16(3):151-161, May/June 1997.

5. Bernstein, S.J., Elizabeth A. McGlynn, Albert L. Siu, et al. "The Appropriateness of Hysterectomy: A Comparison of Care in Seven Health Plans." JAMA 269:2398-2402, 1993.

6. Wennberg, John E., and Megan McAndrew Cooper, eds. The Dartmouth Atlas of Health Care in the United States. (Chicago: American Hospital Publishing, Inc., 1998).

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