safety, timeliness, effectiveness, efficiency, equity, and patient-centeredness. Crossing the Quality Chasm emphasized the shift in health care from acute to chronic care, noting that “chronic conditions are now the leading cause of illness, disability, and death; they affect almost half the population and account for the majority of health care expenditures” (IOM, 2001).

A later series of IOM reports (IOM, 2006a, 2006b, 2006c) proposed a rigorous, systematic, and quantifiable approach for using the above six aims to promote quality measurement in the health care system. These studies offered strategies for evaluating the performance of managed care organizations, health plans or programs, and hospitals, as well as individual practitioners, and made suggestions for how these measures could be used to induce changes in practice through financial rewards or penalties. Some progress has been made—primarily in the area of patient safety among adults (Leape and Berwick, 2005)—but nearly a decade later, significant gaps in quality persist.

Several IOM reports have reviewed an array of public- and private-sector initiatives aimed at improving health care quality (IOM, 2006a, 2006b, 2006c). These studies have focused primarily on the quality of adult health care. They reflect a bias toward the need for quality measures that can help improve the management of complex, chronic conditions, as well as health care services that are commonly associated with hospitalization or require intensive procedures or interactions with multiple health care providers.

The initial IOM health care quality framework was augmented by a later approach that called attention to adapting quality measures to a patient-centered focus, emphasizing the stages of an individual’s health status: preventive services (“staying healthy”), acute treatment (“getting better”), chronic conditions (“living with illness”), and end-of-life care.


Concern about the quality of care, particularly chronic care, gave rise to efforts to assess the effectiveness of care for the chronically ill. The National Quality Forum (NQF) is a private-sector standards-setting organization whose efforts center on the evaluation and endorsement of standardized performance measures. Since its establishment in 1999, NQF has endorsed more than 500 measures covering all aspects of care (i.e., ambulatory, hospital and facility, and palliative care). However, measures relevant to or developed specifically for children and adolescents failed to receive early attention. This was the result of NQF’s initial focus on high-need and high-cost conditions (largely in response to its private health plan funders’ priorities). This approach inevitably created a focus on adults, since this population has the highest prevalence of chronic conditions.

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