and further development and updating of the strategy, which it has continued to do.
At the federal level, the National Quality Strategy has guided the development of HHS programs, regulations, and strategic plans for new initiatives, in addition to serving as a mechanism for evaluating the full range of federal health efforts. The first‐year strategy did not include HHS‐specific plans, goals, benchmarks, and standardized quality metrics, but AHRQ developed these through collaboration with the participating agencies and private‐sector consultations. The 2015 Strategy speaks to the following six evolving priorities that inform the advancement of efforts to keep patients safe (http://www.ahrq.gov/workingforquality/nqs/overview.htm):
Making care safer by reducing harm caused in the delivery of care.
Ensuring that each person and family members are engaged as partners in their care.
Promoting effective communication and coordination of care.
Promoting the most effective prevention and treatment practices for the leading causes of mortality, starting with cardiovascular disease.
Working with communities to promote wide use of best practices to enable healthy living.
Making quality care more affordable for individuals, families, employers, and governments by developing and spreading new health care delivery models.
AHRQ integrated the National Quality Strategy with the National Healthcare Quality and Disparities Report in 2015. The ACA originally called for the establishment of an Interagency Working Group on Health Care Quality (IWG), composed of senior officials representing 24 federal agencies with major responsibility for health care quality and quality improvement. The working group’s function has been to provide a platform for collaboration, cooperation, and consultation among relevant agencies regarding quality initiatives as a means to ensure alignment and coordination across federal efforts and with the private sector for more than 250 structure, process, and outcomes measures. As of 2018, the IWG continued to meet to provide guidance and oversight to the collective quality efforts, and currently includes nine of the federal agencies (https://www.ahrq.gov/research/findings/nhqrdr/nhqdr18/index.html).
Access to care logically relates to the outcomes of care individuals and populations receive. The 2019 National Healthcare Quality and Disparities Report identified that from 2000 to 2018, while more than 50% of access measures showed improvement, 25% of access measures did not show improvement, and 20% of access measures showed worsening conditions. Directly related to quality, this same report identified that 14 of 29 person‐centered care measures showed improvement, 50% of patient safety measures displayed improvement, and almost 60% of healthy living measures showed improvement; 40% of effective treatment measures showed improvement, as did 40% of care coordination measures and care affordability measures (https://www.ahrq.gov/research/findings/nhqrdr/nhqdr19/index.html).
In analyzing these results, the report points out that state‐level data reflect wide variation in quality, dependent upon both state and region. It also noted that even if overall a state performed well on certain measures of quality, there may be wide variation within the state or from community to community, caused by great disparities in health care access or reflected in specific areas of quality. These variations can be documented by using the query process for the Annual Report (https://nhqrnet.ahrq.gov/inhqrdr/data/query). From a nursing perspective, many of these measures can be seen as a reflection of nursing practice, both positive and negative.
Building the Momentum for Quality
The inclusion of such far‐reaching provisions related to quality and safety in the ACA has been made possible largely because of the efforts over several decades of health care industry stakeholders who worked to identify the barriers and build multiple supportive alliances, leading to addressing the issues through policies at every level. As by‐products, professionals in the health care industry became educated about quality principles, and consumer awareness of the complexities of health care systems was raised. The following sections describe how powerful such efforts have become.
National Quality Forum: A Strategic Model
In the early 2000s, following the Institute of Medicine (IOM) reports on medical errors and the quality chasm (Institute of Medicine 2000, 2001), the National Quality Forum (NQF), a new private nonprofit entity, became central to the establishment of standards and policy relative to health care quality. NQF grew out of the Presidential Advisory Commission on Consumer Protection and Quality in the Health Care Industry convened in 1996. The Advisory Commission was one of many ways in which entities concerned about the eroding quality of care began to consider how they might drive improvement. Ultimately, the Commission recommended the creation of a private‐sector entity, which then became the NQF. The expanding role of NQF over the next two decades is an instructive example of the collective efforts of many entities, whether professions, consumers, insurers, or others, working to shape and implement national policy, including the National Quality Strategy.
NQF’s overall purpose is to provide key leadership for a national health care quality measurement and reporting system. Its mission is focused on three themes: (a) build consensus on priorities and goals for health care quality; (b) play a major role in the endorsement of national consensus standards; and (c) use its collective membership to promote attainment of these standards in the delivery of care to consumers. From inception, the CMS, the Office of Personnel Management, and the AHRQ have been part of NQF. In addition, standard‐setting bodies like the Joint Commission, the National Commission for Quality Assurance, the IOM, the National Institutes of Health, and Physician Consortium for Performance Improvement (PCPI)–American Medical Association (AMA) have had key liaison roles as well. Currently, there are nearly 450 NQF organizational members.
The development and expansion of NQF have included input from nurses with representation from organizational membership in NQF from its inception and continuing to the present. The American Nurses Association (ANA) was the first NQF nursing organization member, with others following suit over the next 20 years. As many as 23 entities representing nursing have been NQF members at various times, and nursing has held a seat on the NQF Executive Board in the past.
The NQF employs three strategies to collectively move quality as a national priority as well in driving performance improvement. These three strategies have been used by other coalitions and individual professions as well: (a) convening experts across the industry to define quality by developing standards and measures; (b) gathering information from measurement of performance through data reporting and analysis; and (c) identifying gaps in performance, information about which is then provided back to providers, institutions, and others to initiate performance improvement and public reporting. In addition, NQF, like other collective efforts, places ongoing focus on dissemination of tools and educational activities that promote health care improvement in the United States.
The expansiveness of the NQF structure has provided many touch points for nursing to influence its direction. Calls for endorsement of standards or measures require formal comment and ballot‐type voting. Calls for nominations to work groups based on content expertise or representation allow for formally nominating nursing leaders who can speak on behalf of quality through a nursing lens. Nursing leaders have had opportunities to serve in leadership roles within committees and work groups to react to the work of colleagues from other disciplines, and to inform, persuade, or dissent as needed, in the shaping of policy. And nurses have been instrumental in the development
