Envisioning the National Health Care Quality Report Committee on the National Quality Report on Health Care Delivery Margarita P. Hurtado, Elaine K. Swift, and Janet M. Corrigan, Editors Board on Health Care Services INSTITUTE OF MEDICINE NATIONAL ACADEMY PRESS Washington, D.C. NATIONAL ACADEMY PRESS • 2101 Constitution Avenue, N.W. • Washington, DC 20418 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. Support for this project was provided by the Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services (Contract No.282-99-0045, Task Order No. 2). Addi- tional support was provided by the Commonwealth Fund, a New York City-based private, indepen- dent foundation. The views presented in this report are those of the Institute of Medicine Committee on the National Quality Report on Health Care Delivery and are not necessarily those of the funding agencies. International Standard Book Number 0-309-07343-X Additional copies of this report are available for sale from the National Academy Press, 2101 Constitution Avenue, N.W., Box 285, Washington, D.C. 20055. Call (800) 624-6242 or (202) 334- 3313 (in the Washington metropolitan area), or visit the NAP’s home page at www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at www. iom.edu. Copyright 2001 by the National Academy of Sciences. All rights reserved. Printed in the United States of America. The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the In- stitute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin. “Knowing is not enough; we must apply. Willing is not enough; we must do.” —Goethe INSTITUTE OF MEDICINE Shaping the Future for Health The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal gov- ernment on scientific and technical matters. Dr. Bruce M. Alberts is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of out- standing engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. William A. Wulf is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Kenneth I. Shine is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engi- neering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Bruce M. Alberts and Dr. William A. Wulf are chairman and vice chairman, respectively, of the National Research Council. COMMITTEE ON THE NATIONAL QUALITY REPORT ON HEALTH CARE DELIVERY WILLIAM L. ROPER (Chair), Dean, School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina ARNOLD M. EPSTEIN (Vice Chair), John H. Foster Professor and Chair, Department of Health Policy and Management, Harvard School of Public Health, Boston, Massachusetts BECKY J. CHERNEY, President and CEO, Central Florida Health Care Coalition, Orlando, Florida DAVID C. CLASSEN, Associate Professor of Medicine, University of Utah and Vice President, First Consulting Group, Salt Lake City, Utah ∗ JOHN M. COLMERS, Executive Director, Maryland Health Care Commission, Baltimore, Maryland ALAIN ENTHOVEN, Marriner S. Eccles Professor of Public and Private Management, Graduate School of Business, Stanford University, Stanford, California JOSÉ J. ESCARCE, Senior Natural Scientist, The RAND Corporation, Santa Monica, California SHELDON GREENFIELD, Director, Primary Care Outcomes Research Institute, New England Medical Center, Boston, Massachusetts JUDITH HIBBARD, Professor, Department of Planning, Public Policy and Management, University of Oregon, Eugene, Oregon HAROLD S. LUFT, Director and Caldwell B. Esselstyn Professor of Health Policy and Health Economics, The Institute of Health Policy Studies, University of California, San Francisco, California ∗∗ ELIZABETH A. McGLYNN, Senior Researcher, Health Sciences Program, RAND Corporation, Santa Monica, California ∗∗∗ SCOTT C. RATZAN, Executive Director of Health Communication Technology and Educational Innovation, Academy for Educational Development, Washington, D.C. MARK D. SMITH, President and CEO, California Healthcare Foundation, Oakland, California WILLIAM W. STEAD, Associate Vice Chancellor for Health Affairs and Director, Informatics Center, Vanderbilt University Medical Center, Nashville, Tennessee ALAN M. ZASLAVSKY, Associate Professor of Statistics, Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts ∗ As of November 2000, Program Officer, Milbank Memorial Fund. ∗∗ Served until July 2000. ∗∗∗ As of July 2000, Senior Technical Advisor and Population Leadership Fellow, Center for Population, Health, and Nutrition, U.S. Agency for International Development. v Study Staff MARGARITA P. HURTADO, Study Director ELAINE K. SWIFT, Scholar-in-Residence JANET M. CORRIGAN, Director, Board on Health Care Services RACHEL FRIEDMAN, Senior Project Assistant Auxiliary Staff MIKE EDINGTON, Managing Editor JENNIFER CANGCO, Financial Advisor Copy Editor FLORENCE POILLON Consultants CHRISTINA BETHELL, The Foundation for Accountability ROBERT H. BROOK, The RAND Corporation and the UCLA Center for Health Sciences MARSHA GOLD, Mathematica Policy Research MARK McCLELLAN, Stanford University ELIZABETH A. McGLYNN, The RAND Corporation PAUL G. SHEKELLE, The RAND Corporation and the Greater Los Angeles Veterans Affairs Healthcare System vi REVIEWERS The report was reviewed by individuals chosen for their diverse perspec- tives and technical expertise in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments to assist the authors and the Institute of Medicine in making the published report as sound as possible and to ensure that the report meets institutional standards for objectiv- ity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. The committee wishes to thank the following individuals for their re- view of this report: Lu Ann Aday, University of Texas, Houston Health Science Center Ann Arvin, Stanford University School of Medicine Donald M. Berwick, Institute for Healthcare Improvement Morris F. Collen, Kaiser Permanente Medical Center Colleen Conway-Welch, Vanderbilt University, School of Nursing Robert A. Greenes, Brigham and Women’s Hospital E.A. Hammel, University of California, Berkeley, Department of Demography Pamela H. Mitchell, University of Washington, School of Nursing Patricia Riley, National Academy for State Health Policy Patricia Salber, General Motors Corporation, Health Care Initiatives Shoshanna Sofaer, Baruch College, School of Public Affairs Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by Richard Bonnie, John S. Battle Pro- fessor of Law and Director of the Institute of Law, Psychiatry, and Public Policy at the University of Virginia, who was responsible for making certain that an independent examination of this report was carried out in accordance with in- stitutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and institution. vii Preface After several decades of close attention to the cost of health care and to the uneven access to this care across the United States, we are now beginning to seri- ously examine health care quality. A wide range of individual studies suggests that the quality of the health care we receive is often less than optimal, if not downright poor. Yet we lack information that would allow us to systematically examine how we are doing, to determine which aspects of our health care are better or worse, and to assess whether the quality of our care is improving over time. To help fill these knowledge gaps, the Institute of Medicine (IOM) was asked by the Agency for Healthcare Research and Quality (AHRQ) to undertake a planning effort for a “national quality report on health care delivery.” In the 1999 legislation that reauthorized and renamed the agency, Congress mandated that such a report be developed and published annually starting in 2003. Specifically, the IOM and the committee appointed to conduct this study were asked to take a long-term view and to suggest how best to measure the overall quality of health care in the nation. We were to develop a format that would allow both policy makers and the general public to make year-to-year comparisons of how the health care system is doing, allowing them to determine just how much the quality of care varies or diverges from desired levels when these are specified. Furthermore, our effort is supposed to encompass the spec- trum of health care settings, not just the inpatient hospital environment. Eventu- ally, it is also supposed to allow for state- or regional-level measures, as well as ix