President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry

Executive Summary

Quality First: Better Health Care for All Americans

Every day, millions of Americans receive high-quality health care that helps to maintain or restore their health and ability to function. Skilled physicians, nurses, and other health care practitioners offer expert compassionate care to people in need. High-caliber hospitals, nursing homes, and other health care institutions provide care to patients in need of acute and chronic care. Academic health centers educate and train new generations of health care practitioners and house many of the finest scientific minds who advance the science of health care. Federal, State, and local governments, private employers, labor unions, and others purchase health care coverage for millions of American families, offering security and peace of mind. And public and private quality oversight organizations work to make sure that the care provided is of the highest quality in the world.

A central goal of quality improvement is to maintain what is good about the existing system while focusing on the areas that require improvement. While most Americans receive high-quality care, too many patients receive substandard care. Quality problems include wide variation in health care services, underuse of some services and overuse of others, and an unacceptable level of errors.

Efforts by leaders of the health care professions, the health care industry, major employers, and State and Federal agencies have significantly improved our ability to identify quality problems and begin to address their causes. What is needed now is a national commitment to quality improvement that begins with the President and the Congress and extends to every level of the health care industry.

In seeking to improve the quality of care for all Americans, we cannot forget that there are more than 41 million Americans who live day to day without the security of health insurance. For them, access to quality care often is severely limited. Addressing this issue is critical to improving the health and functioning of all who live in our communities.

A Clear Statement of Purpose

The first step in this effort should be the establishment of a clear Statement of Purpose for the health care system. The Commission recommends that the President articulate and continue to emphasize the following statement:

Evidence of Quality Problems

Several types of quality problems in health care have been documented through peer-reviewed research. They include:

Major Recommendations

In total, the Commission's Final Report to the President includes more than 50 recommendations to advance these core purposes. (A complete summary of those recommendations follows this section.)

Public-Private Partnerships

To focus the entire health care industry on this Statement of Purpose, the Commission recommends the creation of two complementary entities, one public and one private, to provide ongoing national leadership in health care quality improvement.

National Aims for Improvement

A major component of this national strategy is the establishment of a concise set of core aims for improvements that are accompanied by specific, measurable objectives for improvement throughout the system. The Commission recommends the following initial set of six National Aims for Improvement:

Quality Measurement and Reporting

A key element of improving health care quality is the Nation's ability to measure the quality of care and provide easily understood, comparable information on the performance of the industry. Advances in quality measurement and reporting have enabled us to determine the flaws in the current system. But the absence of a systematic approach to quality measurement has hampered the health care industry's ability to track and sustain quality improvement.

The Commission is recommending a series of steps that should be taken -- primarily by the private sector -- to bring order to the current system of quality measurement while continuing to encourage development and innovation in this important field:

Strengthening the Market To Improve Quality

The health care market is rapidly transforming itself. Many of these changes bode well for quality improvement, but some may impede that progress. The Nation must harness the positive forces of change and guard against impediments to quality improvement.

Building the Capacity To Improve Quality

Improving quality requires commitment at all levels of the health care industry. Health care organizations, professionals, and other participants in the health care system must make quality improvement the driving force of the industry. Recommendations include:

Addressing the Uninsured

Consumer protection and quality improvement often are meaningless to Americans who cannot obtain health care when they need it. The fact that 41.7 million Americans -- including nearly 10 million children -- currently are uninsured and millions of others are underinsured confounds attempts to improve quality and protect consumers. Most uninsured Americans hold full-time jobs or are the spouses or children of such workers. Others are early retirees who have lost their employer-based coverage but are ineligible for Medicare. Many Americans who are living with disabilities or need help in performing essential activities of daily living have inadequate insurance to cover the costs of their acute and long-term care.

There is strong evidence that uninsured and underinsured individuals have less access to primary and preventive care, integrated social services, and continuity of care. They often are at the greatest risk of receiving care that is substandard and inadequate to their needs.

Ensuring that all Americans receive the care they need has been an elusive goal. But this pressing national concern is too important to ignore. Enactment of the State Child Health Insurance Program is an important first step.

The Commission urges the President, Congress, and all other stakeholders to engage in meaningful and continuing efforts to systematically reduce the number of Americans who are uninsured or underinsured. Such an effort should include specific goals and timetables and should have as its ultimate goal access to affordable, comprehensive health care for all Americans.

  1. Brennan, Troyen, et al. "Incidence of Adverse Events and Negligence in Hospitalized Patients." JAMA 324:370-376, 1991.

  2. Phillips, David P., Nicholas Christenfeld, and Laura M. Glynn. "Increase in U.S. Medication-Error Deaths Between 1983 and 1993." Lancet February 28, 1998.

  3. Soumerai, Stephen, Thomas McLaughlin, Ellen Hertzmark, et al. "Adverse Outcomes of Underuse of Beta Blockers in Elderly Survivors of Acute Myocardial Infarction." JAMA 277:115-121, 1997.

  4. Chassin, Mark R. "Assessing Strategies For Quality Improvement." Health Affairs 16(3):151-161, May/June 1997.

  5. Bernstein, S.J., Elizabeth A. McGlynn, Albert L. Siu, et al. "The Appropriateness of Hysterectomy: A Comparison of Care in Seven Health Plans." JAMA 269:2398-2402, 1993.

  6. Wennberg, John E., and Megan McAndrew Cooper, eds. The Dartmouth Atlas of Health Care in the United States. (Chicago: American Hospital Publishing, Inc., 1998).

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Last Revised: Monday, June 15, 1998