1) Review the data available in the area of consumer information and protections for those enrolled in health plans and make recommendations for improvements; 2) Review existing and planned work that defines, measures, and promotes the quality of health care and will help build further consensus on approaches to assure and promote quality of care in a changing delivery system; and, 3) Collect and evaluate data on changes in the availability of treatment and services, and make recommendations for improvements.

The following is a summary of the commission's recommendations.

Provide Strong Leadership and Clear Aims for Improvement

The President should provide strong, continuous leadership to develop a broad national consensus on improving the quality of health care in the United States. To do this, the President should: 1) articulate and continue to emphasize a unifying Statement of Purpose for the health care system, 2) work with the Congress and leaders of the public and private sectors to embrace this Statement and 3) initiate collaborative efforts for improving health care. The Commission suggests 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."

Advance Quality Measurement and Reporting

Standardized measures of quality are needed to track the health care industry's progress in reaching the aims established for the Nation and to guide public health planning and policy making. Comparative information on quality also is needed for individual consumers, group purchasers, and others to use in selecting health care providers and health plans. Furthermore, valid and stable quality measures are integral to health plans' and providers' efforts to improve performance, and when standardized, encourage health care organizations to learn from each other through a process of benchmarking.

Despite a growing number of efforts to measure and report on health care quality, useful information is neither uniformly nor widely available. The Commission has identified the following steps critical to the advancement of quality measurement.

1) Core sets of quality measures should be identified for standardized reporting by each sector of the health care industry. These measures should reflect priorities accounting for both national aims for improvement and the information needs of consumers (especially vulnerable populations), purchasers, providers, health organizations, and public health and policy officials. Pertinent measures developed by the research community, quality oversight organizations, health care organizations, and others should be evaluated for potential inclusion in these measures.

2) A framework and capacity for quality measurement and reporting should be developed in tandem with the standardization of quality measures for reporting. Specific functions to be undertaken include:

• Articulating a strategy for measuring and reporting quality;
• Setting quality measurement priorities;
• Building a consensus on measures' validity, utility, and meaningfulness;
• Working through complex and sensitive issues of public disclosure with respect to privacy, confidentiality, and liability;
• Launching a public education and communication campaign; and
• Ensuring there is an ongoing research agenda and capacity for its advancement.

3) All sectors of the health care industry should support the focused development of quality measures that enhance and improve the ability to evaluate and improve health care. Comprehensive sets of quality measures are needed to reflect the full continuum of health care, but measures currently are lacking in a number of important areas. The types of measures that are needed include:

• Measures of aspects of health care that are not well addressed by existing measures, e.g., care for chronic conditions and disabilities, mental health care, and interpersonal aspects of health care;
• A wider range of health outcome measures, including functional outcomes;
• Measures that provide meaningful information about quality at the individual practitioner level; and
• Summary measures that address quality across multiple dimensions.

4). Quality measurement requirements and the detailed specifications for measurement and reporting should be determined through a stable and predictable mechanism. The Commission's specific recommendations on the creation of such a stable and predictable mechanism--a Forum for Health Care Quality Measurement and Reporting--are described in detail in Chapter 5 of the report. This entity should:

• Have the capacity to act in a timely and nimble manner to be flexible and responsive to an evolving health system;
• Involve stakeholders and represent the interests of a wide spectrum of users of quality information;
• Provide for public input and deliberation; and
• Be structured in such a manner to avoid conflicts of interest.

5). Steps should be taken to ensure that comparative information on health care quality is valid, reliable, comprehensible, and widely available in the public domain. Specifically:

• Definitions, data sources, and measurement methods that are used for evaluating quality in specific conceptual areas, e.g. pediatrics, immunization rates, should be uniform and consistent over time;
• Information on quality should be adjusted for risk, when appropriate, prior to public release;
• Information on quality that is released to the general public should be externally audited by an independent entity; and
• Quality measurement findings should be: (a) reported through multiple modes, (b) reported in user friendly language and (c) made available in a manner that is affordable to consumers.

Create Public-Private Partnerships

An Advisory Council for Health Care Quality should be created in the public sector to provide ongoing national leadership to promote and guide continuous improvement of health care quality. The expert Advisory Council would establish national goals and objectives to improve system-wide quality measurement. It also would track and report on the Nation's progress in: 1) achieving its national aims for improvement, 2) undertaking related quality measurement and reporting and 3) implementing the Consumer Bill of Rights and Responsibilities.

A Forum for Health Care Quality Measurement and Reporting should be created in the private sector to improve the efficiency and effectiveness of health care quality measurement and reporting. The Forum would define a comprehensive plan for quality measurement, and reporting and address a wide range of other issues in the private sector as well.

Encourage Action by Group Purchasers

Group purchasers including private employers, union-sponsored multi-employer plans and Federal, State and local governments are a prominent feature of the U.S. employment-based health care marketplace. As intermediaries between their members and the health plans, group purchasers make critical decisions on behalf of their employees or beneficiaries with regared to their health care, such as: 1) what health benefits to purchase; 2) what portion of the care is to be paid by the employee or beneficiary; and 3) the number and types of health plans with which to enter into agreements. To the extent that group purchasers make these decisions with attention to quality as well as cost, they can be a considerable force for quality improvement.

Strengthen the Hand of Consumers

Because consumers are the intended beneficiaries of health care, their needs should be of utmost importance. Economically, consumers are important because they expend the largest single amount of money for health care. Thus, mobilizing the full power of the marketplace to improve health care quality requires that the power of the individual consumer be maximized.

The commission has made five important recommendations to strengthen the consumer's role in obtaining the best possible health care all of which emphasize developing and implementing widespread consumer education strategies about the use of quality-oriented information to select health care including further research addressing the use of information by consumers.

Focus on Vulnerable Populations

Throughout its work, the Commission has been particularly cognizant of the special concerns associated with ensuring quality health care for vulnerable populations. Individuals may be vulnerable to health care quality problems for many underlying reasons including financial circumstances or place of residence, health, age, functional or developmental status, race, ethnicity or gender. In the Consumer Bill of Rights and Responsibilities, the Commission articulated that consumers have the right to considerate, respectful care, free of discrimination. In this section of the report, the Commission extends this work by specifically addressing ways in which the particular needs of vulnerable populations should be accounted for in the design of systems for health care delivery, quality measurement, and payment.

Promote Accountability

While all participants in the health care system must be accountable for improving the quality of health care in the United States, employing the extensive knowledge and expertise of organizations that oversee health care quality across the Nation, States, and local communities - in both the public and private sectors - is essential to quality improvement. The Quality Oversight Organizations (QOOs), e.g., State licensing bodies, private sector accrediting bodies, and Medicare/Medicaid compliance determination bodies, have a long-standing and strong track records of assessing, ensuring, and improving health care quality. Together with group purchasers, the proposed Advisory Council on Health Care Quality, and the Forum for Quality Measurement and Reporting, QOOs can promote greater accountability across the entire health care system, and thereby greater incentives for the improvement of quality.

Reduce Errors and Increase Safety in Health Care

Current systems to reduce or prevent errors in the provision of health care services tend to focus too much on individual practitioners and not enough on system problems. The Commission is recommending steps to improve reporting, focus on determining the causes of errors and prevent their recurrence.

In addition, some Americans are injured as a result of inappropriate denial of health benefits. Thus, the Commission believes that stricter adherence to timely appeals processes can help to reduce the incidence of such injuries. Public and private purchasers should work quickly to improve internal appeals systems and establish an independent system of external appeals consistent with Consumer Bill of Rights and Responsibilities.

Foster Evidence-Based Practice and Innovation

Improving the quality of health care and enhancing Americans' health requires commitment to delivering health care based on sound scientific evidence and continuously innovating new, effective health care practices and preventive approaches (see article on page 11 of the Monitor). The lack of evidence supporting effective health care practices contributes to inappropriate care. Encouraging evidence-based practice, and thereby promoting appropriate, effective health care, requires a robust health care research enterprise, careful assessments of the effectiveness of health care technologies and practices, and approaches to encourage the widespread dissemination of effective health care.

Therefore, the Commission recommends bolstering public and private sector funding of basic, clinical, prevention, and health services research, strengthening the scientific evidence base for health care practices through further collaboration in technology assessment and research targeted to filling gaps in existing knowledge; and encouraging dissemination of innovations that have been demonstrated to be effective. The specific recommendations include:

1) Federal funding for health care research, including basic, clinical, prevention, and health services research, should be increased and the necessary research infrastructure supported.

2) Collaborative arrangements between researchers and public and private sector organizations supporting research should be developed to provide additional funding for research, make patients available for approved clinical trials, and provide training opportunities.

3) Research should be targeted to address areas where the greatest improvements in health and functional status of he population can occur and where gaps in knowledge exist.

4) Public and private sector organizations should pursue greater collaboration in conducting health care technology assessments.

5) More complete and rapid dissemination of effective health care practices should be supported by encouraging public and private organizations to collaboratively share knowledge of innovations, synthesize evidence of effective health care practices, develop practice protocols, disseminate this information, and provide technical assistance to practitioners.

Adapt Organizations for Change

Because the science of health care is changing so fast, health care organizations need to match that pace of change. To do so, the systems of care that surround the relationships between patients and providers must be willing to learn from other industries that have demonstrated success in making complex systems function better in order to improve quality. Much remains to be done in the arena.

Engage the Health Care Workforce

The restructuring of the health care industry and ongoing efforts to improve quality are changing how the work of health care is organized. Many health care workers are taking on new roles and responsibilities in the course of these changes. While understanding the need for change, many workers are asking for more of a voice in the process of change.

The challenge for industry leaders is to harness the tremendous talent, energy, and commitment of the 10 million people work in health care because of its strong sense of mission. To improve the quality of health care, we must build a health care workforce that is dedicated to caring for patients, knowledgeable, well trained, committed to continuous quality improvement, secure in their employability, confident in the safety of their work, fairly compensated, and competent in caring for the wide diversity of the American people.

Invest in Information Systems

Health care information systems of the 21st century must be able to guide internal quality improvement efforts; generate 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 generally are not adequate for these purposes. The health care industry invests a lower share of its revenues in information technology than many other information-intensive industries. Thus, the seven recommendations made in this report are critical if the health care industry is to realize the promise of improved information systems.