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Measuring the Quality of Health Care

A Statement by The National Roundtable on Health Care Quality

Division of Health Care Services


Molla S. Donaldson, Editor

Washington, D.C.

The National Academies | 500 Fifth St. N.W. | Washington, D.C. 20001
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--> Measuring the Quality of Health Care A Statement by The National Roundtable on Health Care Quality Division of Health Care Services INSTITUTE OF MEDICINE Molla S. Donaldson, Editor NATIONAL ACADEMY PRESS Washington, D.C. 1999

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--> NATIONAL ACADEMY PRESS 2101 Constitution Avenue, N.W. Washington, DC 20418 NOTICE: The project that is the subject of this statement was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the roundtable responsible for the statement were chosen for their special competencies and with regard for appropriate balance. The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of the appropriate professions in the examination of policy matters pertaining to the health of the public. In this, the Institute acts under both the Academy's 1863 congressional charter responsibility to be an adviser to the federal government and its own initiative in identifying issues of medical care, research, and education. Dr. Kenneth I. Shine is president of the Institute of Medicine. Support for this project was provided by The Agency for Health Care Research and Policy (DHHS), The Commonwealth Fund (a New York City-based private independent foundation), the National Research Council, the Department of Defense (Health Affairs), and Pfizer Inc. The views presented in this statement are those of the members of the National Roundtable on Health Care Quality and are not necessarily those of the funding organizations. International Standard Book Number 0-309-06387-6 Additional copies of Measuring the Quality of Health Care are available for sale from the National Academy Press, 2101 Constitution Avenue, N.W., Box 285, Washington, DC 20055. Call (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area) or visit the NAP's on-line bookstore at This report is available on line at For more information about the Institute of Medicine, visit the IOM home page at Copyright 1999 by the National Academy of Sciences. All rights reserved. Printed in the United States of America. The serpent has been a symbol of long life, healing and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin.

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--> NATIONAL ROUNDTABLE ON HEALTH CARE QUALITY MARK R. CHASSIN (Cochair), Professor and Chairman, Department of Health Policy, The Mount Sinai Medical Center, New York ROBERT W. GALVIN (Cochair), Chairman of Executive Committee, Motorola, Inc., Schaumburg, IL KATHLEEN O. ANGEL, Vice President, Benefits and Worldwide Solutions, U.S. Human Resource Administration, Digital Equipment Corporation, Maynard, MA MARCIA ANGELL, Executive Editor, The New England Journal of Medicine , Boston ROBERT A. BERENSON, Vice President, The Lewin Group, Fairfax, VA ROBERT H. BROOK, Professor of Medicine and Health Services, UCLA Center for Health Sciences, and Vice President and Director, RAND Health, The RAND Corporation, Santa Monica, CA EZRA C. DAVIDSON, JR., Dean, Primary Care, and Professor and Past Chair, Department of Obstetrics and Gynecology, Charles R. Drew University of Medicine and Science ARNOLD EPSTEIN, Chairman, Department of Health Policy and Management, Professor of Medicine and Health Care Policy, Harvard School of Public Health CLIFTON GAUS (until 4/01/97), Administrator, Agency for Health Care Policy and Research, Rockville, MD CHARLENE A. HARRINGTON, Professor and Chair, Department of Social and Behavioral Sciences, School of Nursing, University of California, at San Francisco JOHN K. IGLEHART, Editor, Health Affairs, National Correspondent, New England Journal of Medicine, Potomac, MD BRENT JAMES, Executive Director, Intermountain Health Care, Institute for Health Care Delivery Research, Salt Lake City, UT STEPHEN JOSEPH (until 1/15/97), Assistant Secretary of Defense for Health Affairs, Department of Defense, Washington, DC RHODA KARPATKIN, President, Consumers Union of the United States, Yonkers, NY KENNETH W. KIZER, Under Secretary for Health, Department of Veteran Affairs, Veterans Health Administration, Washington, DC GERALD D. LAUBACH, Former CEO, Pfizer Pharmaceuticals, New York DAVID McK. LAWRENCE, Chairman and Chief Executive Officer, Kaiser Foundation Health Plan, Inc. and Kaiser Foundation Hospitals, Oakland, CA WILLIAM L. ROPER, Dean, School of Public Health, University of North Carolina, Chapel Hill O. DAVID TAUNTON, Private Practice of Endocrinology, Birmingham, AL BRUCE VLADECK (until 9/13/97), Administrator, Health Care Financing Administration, Washington, D.C.

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--> Institute of Medicine Staff MOLLA S. DONALDSON, Project Director KATHLEEN NOLAN, Research Assistant TRACY McKAY, Project Assistant EVELYN SIMEON, Administrative Assistant

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--> Preface and Acknowledgments The National Roundtable on Health Care Quality was established in 1995 by the Institute of Medicine. The Roundtable consists of experts formally appointed through procedures of the National Research Council (NRC) who represent both public and private-sector perspectives and appropriate areas of substantive expertise (not organizations). From the public sector, heads of appropriate Federal agencies serve. It offers a unique, nonadversarial environment to explore ongoing rapid changes in the medical marketplace and the implications of these changes for the quality of health and health care in this nation. The Roundtable has a liaison panel focused on quality of care in managed care organizations. The Roundtable convenes nationally prominent representatives of the private and public sector (regional, state and federal), academia, patients, and the health media to analyze unfolding issues concerning quality, to hold workshops and commission papers on significant topics, and when appropriate, to produce periodic statements for the nation on quality of care matters. By providing a structured opportunity for regular communication and interaction, the Roundtable fosters candid discussion among individuals who represent various sides of a given issue. Biographical sketches of each member of the Roundtable are included at the end of this statement. These authors are expressing their individual views and not necessarily those of the agencies or organizations with which they may be affiliated. In addition to appointed members of the Roundtable, several individuals from government agencies provided special assistance to the Roundtable. They are: from the Agency for Health Care Policy and Research, Lisa Simpson, M.B.,, F.A.A.P., Deputy Administrator; Sandra Robinson, M.S.P.H., Acting Director, Center for Quality Measurement and Improvement; and Irene Fraser, Ph.D., Director, Center for Organization and Delivery Studies. From the Health

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--> Care Financing Administration, Helen Smits, M.D., Deputy Administrator; and Peter Bouxsein, J.D., Acting Director, Office of Clinical Standards and Quality; from the Department of Defense (Health Affairs) Colonels David Schutt and William Strampel, Directors of Quality Management OSD/Clinical Services, and from the Department of Veterans Affairs, Department for Quality Management, Nancy J. Wilson, M.D., M.P.H., all assisted the Roundtable both during its deliberations and by providing helpful information about their agency's work. Although the Roundtable does not provide advice or make recommendations on any specific issue or policy pending before any government agency or other entity, it makes public statements about the state of health and the quality of health care in the nation. Such documents are subject to the formal report review procedures of the National Research Council. The charge to the Roundtable was: To identify important issues related to the quality of health care in the United States, including its measurement, assessment, and improvement. To identify important strengths and weaknesses in the current health care system that affect the quality of health care and options for improvement that might be considered by the public or private sector. To identify issues related to the quality of health care that should be recommended for formal Institute of Medicine studies through the various Boards of the Institute. To identify issues related to the quality of health care that should be clarified by workshops, symposia, invited presentation, or commissioned papers. To provide representation to the Quality Coordinating Committee leading to that committee's peer-reviewed assessment of the quality of health care and resulting in periodic statements, including specific recommendations for action. To identify other roles of the Roundtable consistent with Institute of Medicine and National Research Council policies that would lead to enhanced quality of health care in the United States. The Roundtable met six times in formal plenary sessions between February, 1996 and January, 1998. It invited presentations from experts, convened two conferences, and commissioned papers. Individuals who made presentations at meetings of the Roundtable were: Jo Ivey Boufford, M.D., Dean, Wagner Graduate School of Public Service, New York University; Janet Corrigan, Ph.D., Executive Director, Advisory Commission on Consumer Protection and Quality in the Health Care Industry; James E. Jensen, Director, Office of Congressional and Government Affairs, National Academy of Sciences; Stanley B. Jones, Director, Health Insurance Reform Project George Washington University and Chair, IOM Committee on Choice and Managed Care; Charles, J.D., (then) Majority staff, House Ways and Means Subcommittee on Health; Lawrence Lewin, M.B.A., Chief Executive Officer, The Lewin Group; and Harold S. Luft, Ph.D., Caldwell B. Esselstyn Professor of Health Policy and Economics Director, Institute for Health Policy Studies, University of California, San Francisco.

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--> Based on its deliberations over a two-year period, two major conferences, guest presentations, and commissioned papers, the Roundtable members determined that a statement outlining its conclusions was warranted. The statement presented here has been reviewed by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the NRC's Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the authors and the IOM in making the published statement as sound as possible and to ensure that the statement meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The content of the review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their participation in the review of this statement: Jinnet Fowles, Ph.D., Director, Health Research Center Vice President, Research & Development, Institute for Research and Education, HealthSystem Minnesota; Arnold Milstein, M.D., M.P.H., Managing Director, William M. Mercer, Inc.; Mary O. Mundinger, Dr.P.H., Dean and Centennial Professor in Health Policy, School of Nursing, Columbia University; Robert J. Panzer, M.D., Associate Professor, Division of Medical Informatics, Office of Clinical Practice Evaluation, University of Rochester; Neil Schlackman, M.D., Senior Corporate Medical Director, AETNA U.S. Healthcare; Richard Sharpe, Managing Director, Quality Measurement, Riversite, CT. Although the individuals listed above have provided many constructive comments and suggestions, responsibility for the final content of this statement rests solely with the authoring committee and the IOM. Finally, the Roundtable members wish to thank the IOM staff—Clyde Behney, Deputy Executive Officer; Molla Donaldson, Project Director; Kathleen Nolan, Research Assistant; Tracy McKay, Project Assistant; and Kay Harris, Financial Analyst who provided valuable assistance throughout their work. Organization of this Statement The statement that follows first describes quality of care based on the IOM's 1990 definition and then outlines the burden of harm from poor quality. It then describes major approaches to and recent advances in quality measurement. Finally, it describes some of the challenges facing this field.

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--> Contents     Measuring The Quality Of Health Care   1     Can Quality of Care Be Defined?   3     Terms in the Definition,   3     What Is the Relationship Between Quality and Resource Constraints?   4     Where Do Quality-of-Care Concerns Lie?   5     Too Much Care: Unnecessary or Inappropriate Care,   5     Too Little Care: Underuse of Needed, Effective, and Appropriate Care,   5     Misuse: Shortcomings in Technical and Interpersonal Aspects of Care,   6     The Burden of Poor Quality,   6     What Are the Major Approaches to Quality Measurement?   7     Structural Measures of Quality,   7     Process Measures of Quality,   7     Outcomes Measurement,   8     The Importance of Linking Structure, Process, Outcomes, and Cost,   10     Measurement as a Continuous Process that Serves Multiple Purposes,   10     Advances in Quality Measurement,   11     Applying Research Methods to Address Real-World Quality Problems,   12     Combining Quality Measurement and Improvement to Reduce Adverse Drug Events,   12     Translating Clinical Guidelines into Useful Quality Measures,   12     The Development of Patient-Reported Measures of Quality,   13     Beginnings of Quality Measurement in Integrated Systems,   13

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-->     Amassing and Accessing the Burgeoning Toolkit of Quality Measures,   14     Infrastructure for the Development and Use of Measures,   15     Challenges,   16     Evaluating Measures,   17     Data Systems,   17     The Evidence Base of Medicine and Health Care,   18     Common Definitions and Measurement Methods,   18     Risk Adjustment,   19     Ensuring the Accuracy of Public Reporting,   19     Confidentiality,   19     The Cost of Quality Measurement, Improvement, and Poor Quality,   20     Who Is Responsible for Performance?   21     Concluding Thoughts,   22     References   25     Committee Biographies   27