whose activities include educational programs for providers and patients, reporting systems, and clearinghouses for best practices in safety (Rosenthal and Booth, 2004).

  • Education and technical assistance—The Institute for Healthcare Improvement has developed many quality improvement programs, including breakthrough series collaboratives, IMPACT networks, forums, and Calls to Action, along with the recently launched 100,000 Lives Campaign. These efforts now reach tens of thousands of people in 50 countries (IHI, 2004). Between 2000 and 2003, the Medicare Quality Improvement Organization Program supported quality improvement projects in all states, often reaching all hospitals, nursing homes, home health agencies, and outpatient physicians in the state, with varying degrees of involvement (AMA, 2000; U.S. DHHS, 2003c).

  • Informed purchasing—Private and public purchasers have launched national initiatives to drive quality through purchasing decisions. The Leapfrog Group and Bridges to Excellence are two large national efforts aimed at encouraging and rewarding quality improvement in both hospital and ambulatory settings (DeBrantes et al., 2003; Galvin and Milstein, 2002). The Consumer-Purchaser Disclosure Project is an alliance of more than 25 consumer, employer, and labor organizations working to ensure that comparative performance data are available in all geographic areas and to all population groups (Consumer-Purchaser Disclosure Project, 2005). Many other purchaser-driven efforts exist at the local and regional levels (Rosenthal et al., 2004).

  • Quality oversight—Major accreditation organizations have strengthened requirements and programs, especially in the area of patient safety (JCAHO, 2004; NCQA, 2000; Wachter, 2004). Professional certification programs, such as those of the Accreditation Council for Graduate Medical Education and the American Board of Medical Specialties, have adopted new standards requiring health professionals to demonstrate quality-related competencies (ACGME, 2002; American Board of Medical Specialties, 2005).

Despite these many worthwhile efforts, major changes in the health care delivery system are difficult to discern. Investment in information technology has expanded, but the pace of penetration and modernization in the overall health care system has been slow. Of the nearly 70 percent of physicians who operate in small practice settings, only 8 percent use electronic prescribing, and fewer than one in four providers use some form of computer-generated treatment reminders (Reed and Grossman, 2004). Pockets of innovation have emerged, with some health systems making sizable investments in electronic health records (EHRs) (Garrido et al., 2005; Health Data Management, 2003; HealthPartners, 2004; NYC Health and

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