The United States has the most expensive health care system in the world. In spite of that, health care is of inconsistent quality and leads to poorer health outcomes relative to other, similar nations; for example, the United States has much higher infant mortality rates.1

There are many types of quality problems. There is overuse, underuse, and misuse of care. For example, for overuse of health care, 30 percent of children receive excessive antibiotics for ear infections, 20 percent to 50 percent of many surgical interventions are unnecessary, and 50 percent of X-rays in back pain patients are unnecessary. Underuse can be seen in data that show that 50 percent of the elderly fail to receive the pneumococcal vaccine. Misuse is illustrated by the 7 percent of hospital patients who experience a serious medication error and the 44,000 to 98,000 Americans who die in hospitals each year due to injuries from care (Berwick, 2004). Other types of waste include administrative waste, process waste, and geographic variation in how health care is delivered. Administrative waste is largely a function of the fragmented health care system and a fragmented public health system. Waste is exacerbated when a fragmented health care system interacts with the broader determinants of health. Administrative waste is one area that demonstrates why one should consider the levels of organization of care along with the processes and outcomes of care when considering areas for quality improvement.

As outlined in the 2007 National Healthcare Quality Report (NHQR) (AHRQ, 2008a), there are also variations in the quality of care delivered across the country. The report also indicates that although health care quality is improving, the rate is slow, and safety is improving at an even slower rate. Progress is not as rapid as it should be.

The 2001 Institute of Medicine (IOM) report, Crossing the Quality Chasm (IOM, 2001) outlined six aims to improve the quality of health care. The six aims are that health care should be safe, effective, patient-centered, timely, efficient, and equitable. These six aims address not only process improvement but improvement that needs to occur at multiple levels within the health care system (see Figure 2-1). It is not enough to change the payment and regulatory environment; health care organizations and teams providing care must be sup-


 Of the infant mortality rates reported for 32 developed countries, the United States had higher infant mortality than 30 other countries, ranking above only the country of Latvia (Nordquist, 2006).

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