The original conceptual framework put forth in the 2001 Envisioning the National Healthcare Quality Report highlighted four components of health care quality: (1) safety, (2) effectiveness, (3) patient-centeredness, and (4) timeliness. These components corresponded to four of the six aims of quality health care set forth in the 2001 IOM report Crossing the Quality Chasm: A New Health System for the 21st Century (see Box 3-1). At the time, measurement of efficiency was considered underdeveloped and thus omitted from the framework. The component of equitable care was deemed a crosscutting dimension (see Appendix C for the framework originally adopted by AHRQ for the NHQR and NHDR).

Envisioning the National Healthcare Quality Report recommended that the performance measures presented in the NHQR be framed in consumer categories (i.e., in terms of “staying healthy, getting better, living with illness or disability, and coping with end-of-life care”) (IOM, 2001b, p. 6). Subsequently, AHRQ found it more useful to frame the presentation of data by clinical stages of care (i.e., prevention, acute treatment, management) because that is the context in which most measures are currently developed. Although AHRQ’s clinical stages of care are less patient-focused than the consumer categories, the committee agrees that the clinical stages of care are easily understood by patients as well as the policy makers, health care professionals, and researchers to whom the information in the NHQR and NHDR is primarily directed. Moreover, although data in the reports are not presented by the consumer categories, AHRQ indicated that these categories are implicitly considered when identifying potential measures for inclusion in its full measure set.1

Envisioning the National Healthcare Quality Report acknowledges that the conceptual framework should be dynamic in nature in order to adjust to “changes in conceptualization of quality or significant changes in the nature of the U.S. health care system” (IOM, 2001b, p. 42). Indeed, since the development of the original conceptual framework, new areas for health care performance measurement have emerged, as have attributes of what constitutes high-quality care, thus leading the Future Directions committee to update the framework.


The six quality aims expressed in the 2001 IOM Crossing the Quality Chasm report (see Box 3-1) have become the basic vernacular for discussing health care quality improvement and disparities elimination. Many other organizations, ranging from providers to health plans to quality improvement organizations, have used the six aims to organize their own measurement or reporting efforts. For example, Aetna’s High Performance Provider Initiatives and Hudson River Health Care (a safety net clinical setting) track performance measurement based on these aims (Aetna, 2008; Hudson River Healthcare, 2009). Because continuity is important to preserve and because the original conceptual framework for the national healthcare reports stems from the IOM’s six aims, the committee decided to build on the pre-existing framework rather than propose an entirely new one. The framework remains applicable to both the NHQR and NHDR.

The Future Directions committee looked to prominent organizations and collaboratives engaged in health care quality improvement and disparities elimination for their informed perspectives on the latest advancements in and concerns about the current state of health care. Sources included the Healthy People 2020 Consortium, the National Quality Forum (NQF), the Institute for Healthcare Improvement, the Centers for Medicare and Medicaid Services (CMS), the HHS Office of Minority Health, the Kaiser Family Foundation, the World Health Organization (WHO), the Robert Wood Johnson Foundation, the Health Care Quality Indicators Project of the Organisation for Economic Co-operation and Development (OECD), The Commonwealth Fund’s Commission on a High Performance Health System, the Quality Alliance Steering Committee, the National Committee for Quality Assurance, the Out of Many One Health Data Task Force, and the AQA alliance.


Personal communication, Future Directions committee chair’s site visit to AHRQ, April 30, 2009.

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