sector providers. Each of these government programs has pursued a variety of quality measurement and improvement activities as an integral part of its quality management activities (see Table 3-3).

The VHA program stands apart from most health care programs, both public and private, in its commitment to building the strong organizational supports necessary to provide safe and effective care. In the late 1970s, VHA recognized the important role of clinical decision-support systems in improving quality. During the 1980s and 1990s, VHA created the Veterans Health Information Systems and Technology Architecture (VistA), a computerized patient records system that now extends throughout all 1,100 VHA facilities (including 172 hospitals) in the United States (Institute of Medicine, 2001c). Since 1997, VHA has taken steps to make the automated clinical information more accessible and meaningful at the point of care (see Chapter 5).

VistA serves as the foundation for an extensive program of quality measurement and improvement and clinical decision support, including ongoing benchmarking across a wide range of preventive, acute, and chronic care quality measures; automated entry of medication orders; a notification system that alerts clinicians about clinically significant events identified through the use of integrated laboratory, radiology, pharmacy, progress notes, and other data; a clinical reminder system to promote evidence-based practice; and use of bar codes for medication administration and verification of blood type prior to transfusion.

The DOD TRICARE program conducts numerous quality measurement and improvement projects, including ones that use the HEDIS measurement set and beneficiary surveys such as CAHPS. In recent years, DOD has made progress in developing a computerized clinical information system (see Chapter 5). IHS has emphasized improving diabetes care across the various regions using a standardized measurement set.


Important efforts have been made in recent years to coordinate the quality enhancement activities of the various government health care programs. AHRQ has played a central role in many of these efforts. Its contribution to the development of CAHPS and other standardized tools and techniques for quality measurement and improvement is noteworthy. CAHPS is now used by DOD TRICARE, state Medicaid agencies, private-sector purchasers (e.g., Ford Motor Company, Vermont Employer’s Health Care Alliance), Federal Employees Health Benefit Program (FEHBP), and accrediting bodies (e.g., NCQA) (Agency for Healthcare Research and Quality, 2000). To facilitate widespread use and public disclosure of comparative results, AHRQ established a National CAHPS

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