time. Nonetheless, patients and families should and do care about outcomes and processes at this level. The committee therefore proposes that such measures be developed, used, and reported to drive shared accountability throughout the health care system. In addition, participation is required from policy makers at all levels if the health care delivery system is to improve. Adoption of systems-level measures should help American communities become more aware of their met and unmet health care needs, and over time could induce innovations and relationships among care providers that could lead to better performance.

The ultimate measures of the performance of American health care would assess the nation’s effectiveness in meeting the needs of communities. Few American communities organize their health care as a communitywide system. By measuring and tracking systems-level performance at the community level, however, it may ultimately be possible to assess the national consequences of policy and financing environments as a whole. For assessment of performance at the level of the community as a whole, federal agencies such as the Centers for Disease Control and Prevention can offer guidance. In addition, the state-level reports produced by AHRQ in the context of the National Healthcare Quality and Disparities Reports are good first steps in community-level performance measurement (AHRQ, 2003).

A commitment to systems-level performance measurement will require both scientific innovation and new loci of responsibility for measurement itself, as well as the taking of action in accordance with measurement results. Below the committee proposes a uniform set of hospitalwide measures and measures across the continuum of chronic disease care as the starting point for this effort.

Shared Accountability

Improved performance on many of the measures proposed by the committee can be achieved only through the collaborative efforts of multiple providers and multiple care settings. The committee believes the NQCB should include and report on measures—such as care transitions and longitudinal outcomes and costs—that reflect the performance of multiple providers who should, ideally, collaborate to improve the quality of care. As discussed earlier, the committee also believes that measures should be diffused to different levels of the delivery system, including the community. For example, performance measures for racial, ethnic, or socioeconomic groups (such as the uninsured) should be collected and reported at multiple levels. Analysis of these data would force discussion of the underlying reasons for disparities and the opportunities available to multiple stakeholders for addressing these issues. This notion of shared accountability will have substantial impacts on payment-based incentive policies and will be further



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