(e.g., transportation assistance, case management); and to ensure that demographic, clinical, and health care utilization information is used to monitor trends in the spectrum of HIV-related illnesses and the local epidemic (U.S. Congress, 2000a).

The second provision in the reauthorization of RWCA directed the Institute of Medicine (IOM) to study two aspects of quality assessment:

1. “The availability and utility of health outcomes measures and data for HIV primary care and support services and the extent to which those measures and data could be used to measure the quality of such funded services” (Ryan White CARE Act. 42 U.S.C. § 300ff-11 [2003]).

2. “Other factors determined to be relevant to assessing an individual’s or community’s ability to gain and sustain access to quality HIV services” (Ryan White CARE Act. 42 U.S.C. § 300ff-11 [2003]).

The focus on quality in the most recent reauthorization reflects several national trends in quality improvement and accountability. First, the health sector has seen growing interest in measuring and improving quality (IOM 2000, 2001a).^2,3 In addition, numerous reports have identified a gap between care that should be provided based on available professional knowledge and technology and the care that patients actually receive (Advisory Commission on Consumer Protection and Quality in the Health Care Industry, 1988; IOM and NRC, 1999; IOM, 2000, 2001b). Significant disparities have also been identified in the quality of care for persons living with HIV disease (Cunningham et al., 1999; Shapiro et al., 1999; Stein et al., 2000). As a result, quality measurement and improvement efforts have become a central focus of the Health Resources and Services Administration HIV/AIDS Bureau (HRSA/HAB) and RWCA grantees.

Another major trend in quality improvement and accountability is the fact that federal policy and funding decisions are increasingly being based on performance indicators. The passage of the Government Performance Results Act (GPRA)⁴ in 1993 and other legislation⁵ emphasized accountability across federal government sectors and programs by requiring all federal programs to establish measurable performance goals