In America, we are now in the midst of an historic transition in how we seek and receive health care and in how we finance and deliver that care. Some fear that the changes under way will produce long queues for care, limit the availability of effective treatments and technologies, or lessen the personal commitment of health care providers to their patients. As we try to provide adequate access to health care for all Americans and to reduce the future cost of care, we want also to ensure that we preserve and improve the quality of care that the nation now enjoys. By enhancing the quality of health care, we will also gain greater value for our health care expenditures.

Quality-of-care concerns have often been set aside to tackle the seemingly more pressing problems of access and financing. The Council of the Institute of Medicine (IOM) believes that quality-of-care matters must be given the same attention in policy and research as the other problems that have led us to the health care reform path on which the nation is now embarked. In fact, the quality of health care can be measured and quality measurement tools can be used to improve care and to help the health care transition succeed.

For almost 25 years, the IOM has contributed to many pivotal health policy issues. As its 1993 monograph, Assessing Health Care Reform, asserts, leaders in both the public and private sectors must ensure that a reformed health care system delivers high-quality care at an affordable price to all and be ever vigilant to the risks to quality of care that change may bring. Those who are responsible for enacting and enforcing public policy and for determining the future shape of health care in the United States must identify the public agencies and private groups that shall be responsible for overseeing quality measurement and specify to whom those organizations shall be accountable. Such policymakers must also:

• identify the populations for whom quality of care shall be monitored, from individuals and members of health plans to groups with special health needs, communities, and the nation as a whole;
• confront the full range of quality-of-care problems, including overuse and underuse of services as well as deficiencies in the technical and interpersonal aspects of health care;
• stipulate that quality measurement include evaluation of structural elements, processes, and outcomes of care;
• create reliable uniform data systems and collect consistent data from a variety of sources;
• apply and refine tools and techniques of quality measurement and improvement that will help health care reform succeed;
• devise means of providing valid, useful information on health care quality to consumers, providers, payers, and policymakers; and
• promote communication and education among all elements of society about quality of care and the use of quality measures.

Concerns about quality of care are no excuse to delay or thwart health reform. They are a compelling reason to confront quality matters with the same vigor and sophistication as will be directed at issues of access and cost.

Improving the quality of health and health care requires attention to the processes and outcomes of health services rendered to individuals, with adequate adjustments for the different disease, risk-factor, and personal characteristics of those individuals. It also demands consideration of these same elements of process, outcome, and risk adjustment for those with special health care needs and for populations.

Preventive care, promotion of healthful lifestyles, and broader public health activities are critical components of good health. For example, 10- to 24-year-olds, as a group, are likely to gain much more in improved health and survival from preventive and public-health-oriented actions than from traditional illness care. A separate paper will address the key role that public health could play in a reformed health system through population-based services, links with the medical care system to ensure the provision of quality health care to all, and public policies related to environmental health and other areas.

The IOM has demonstrated that many barriers to better health are related to socioeconomic, educational, cultural, and behavioral factors. At times these elements extend far beyond health care or health promotion and disease prevention in the usual sense. In this White Paper, however, the IOM emphasizes the central role that assessing and improving the quality of health care services have in achieving value for health care expenditures.