The federal government plays numerous roles in health care. It funds more than half of U.S. health care spending through various departments, such as the Department of Health and Human Services, the Department of Defense, and the Department of Veterans Affairs, said Carolyn Clancy of the Agency for Healthcare Research and Quality (AHRQ). Parts of the government are responsible for the actual provision of care, while others are responsible for informing health care decision makers. Although multiple factors influence health care quality and safety, policy initiatives must give organizations incentives to improve quality and share their experiences. Therefore, policy can be very helpful in shaping the environment in which care is delivered.

For the past decade, quality improvement has been a movement for health care leaders, but only recently has it become a movement for those on the front line of care delivery. In 2003 the Medicare Modernization Act required hospitals to report on selected measures of health care quality in order to receive their full reimbursements. Since then, the number of measures has grown, and beginning in 2008 hospitals will report on patient experiences of care through the Hospital CAHPS survey, Clancy said.

As recognized throughout the workshop, health care is a local enterprise. To build on this, Clancy introduced President Bush’s four cornerstones of value-driven health care: (1) transparency of quality standards, (2) transparency of price standards, (3) information technology interoperability, and (4) incentives for providing high-quality care. To support the coordination of these cornerstones, regional and local public–private collaborations, or chartered value exchanges, have been developed. In support of this effort, AHRQ is developing a learning network to produce public reports, foster pay for performance, and thereby improve quality. Value exchanges will have some access to data at physician group levels, aggregated to distribute data on physician performance.

Evidence is used in making many types of policy decisions, from product approval to practice guidelines, from program financing to priority setting. But, Clancy asked, can a case be made for strengthening quality improvement research? The field is relatively new and the current evidence base is mixed about what works to improve quality, but it is becoming better understood that different research designs are needed for different methods. Randomized controlled trials are clearly helpful at times, but may not always be the best method. A large opportunity exists to use other methods, such as quasi-experimental methods. Context is also important to

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