Researching, Measuring, and Monitoring the Quality of Health Care

There are hundreds of agencies, institutions, and organizations dedicated to researching, quantifying (measuring), monitoring, and improving health in the United States. Some are federally funded public entities such as the many institutes and agencies governed by the U.S. Department of Health and Human Services (HHS). Others are professional societies and organizations that develop standards of care, represent the views and interests of health care providers, and ensure the quality of health care facilities such as the American Medical Association and the Joint Commission on Accreditation of Healthcare Organizations. Still other voluntary health organizations, such as the American Heart Association, the American Cancer Society, and the March of Dimes, promote research and education about prevention and treatment of specific diseases.

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

The HHS is the nation's lead agency for ensuring the health of Americans by planning, operating, and funding delivery of essential human services, especially for society's most vulnerable populations. According to the HHS, in “HHS: What We Do'' (March 2008, http://www.hhs.gov/about/whatwedo.html/), it consists of more than three hundred programs that are operated by eleven divisions, including eight agencies in the U.S. Public Health Service and three human services agencies. It is the largest grant-making agency in the federal government, funding several thousand grants each year as well as the HHS Medicare program, the nation's largest health insurer, which processes more than one billion claims per year. For fiscal year (FY) 2009, the HHS had a budget of $736.8 billion, which is a net increase of $29 billion from FY 2008. (See Table 4.1.)

HHS Milestones

The HHS notes in “Historical Highlights'' (June 19, 2005, http://www.hhs.gov/about/hhshist.html) that it began with the 1798 opening of the first Marine Hospital in Boston to care for sick and injured merchant seamen. Under President Abraham Lincoln (1809–1865) the agency that would become the U.S. Food and Drug Administration was established in 1862. The National Institutes of Health (NIH) dates back to 1887 and later became part of the Public Health Service. The 1935 enactment of the Social Security Act spurred the development of the Federal Security Agency in 1939 to direct programs in health, human services, insurance, and education. In 1946 the Communicable Disease Center, which would become the Centers for Disease Control and Prevention (CDC), was established, and nineteen years later, in 1965, Medicare (a federal health insurance program for older adults and people with disabilities) and Medicaid (state and federal health insurance for low-income people) were enacted to improve access to health care for older, disabled, and low-income Americans. That same year the Head Start program was developed to provide education, health, and social services to preschoolage children.

In 1970 the National Health Service Corps was established to help meet the health care needs of underserved areas and populations. The following year the National Cancer Act became law, which established cancer research as a national research priority. In 1984 the human immunodeficiency virus (HIV), the virus that causes the acquired immunodeficiency syndrome (AIDS), was identified by the Public Health Service and French research scientists. The National Organ Transplant Act became law in 1984, and in 1990 the Human Genome Project was initiated.

During 1994 NIH-funded research isolated the genes responsible for inherited breast cancer, colon cancer, and the most frequently occurring type of kidney cancer. In 1998 efforts were launched to eliminate racial and ethnic disparities (differences) in health, and in 2000 the human genome sequencing was published. In 2001 the Health Care Financing Administration was replaced by the Centers for Medicaid and Medicare Services, and the HHS responded to the first reported cases of bioterrorism—the 2001 anthrax attacks—and developed new strategies to prevent and detect threats of bioterrorism.

According to the Office of Management and Budget (2008, http://www.whitehouse.gov/omb/budget/fy2009/hhs.html), significant initiatives funded in the FY 2009 budget include the efforts to expand access to quality health care; prepare for the possibility of a pandemic influenza outbreak; protect the U.S population against the threat of bioterrorism; improve public health through science that protects food supplies and research that delivers new advances toward the cures in the future; and continue to address the health and human service needs of low-income children, vulnerable populations, and all Americans.

HHS Agencies and Institutes Provide Comprehensive Health and Social Services

Besides the CDC and the NIH, the HHS explains in U.S. Department of Health and Human Services Budget in Brief, Fiscal Year 2009 (2008, http://www.hhs.gov/budget/09budget/2009BudgetInBrief.pdf) that the following agencies research, plan, direct, oversee, administer, and provide health care services:

• The Administration on Aging (AoA) provides services aimed at helping older Americans retain their independence. The AoA develops policies that support older adults and directs programs that provide transportation, in-home services, and other health and social services. For FY 2009 the AoA planned for a budget of $1.4 billion and 120 employees.
• The Administration for Children and Families (ACF) provides services for families and children in need, administers Head Start, and works with state foster care and adoption programs. The ACF planned to run about 60 programs with a budget of $45.6 billion and 1,299 employees for FY 2009.
• The Agency for Healthcare Research and Quality (AHRQ) researches access to health care, quality of care, and efforts to control health care costs. It also looks at the safety of health care services and ways to prevent medical errors. Figure 4.1 shows how the AHRQ researches health system problems by performing a continuous process of needs assessment, gaining knowledge, interpreting and communicating information, and evaluating the effects of this process on the health problem. Figure 4.2 shows the process that transforms new information about health care issues into actions to improve access, costs, outcomes (how patients fare as a result of the care they have received), and quality. For FY 2009 the AHRQ planned for a budget of $326 million and 300 employees. The AHRQ budgeted $77 million for patient safety; of this total, $45 million was invested in information technology to improve patient safety in ambulatory care settings.
• The Agency for Toxic Substances and Disease Registry (ATSDR) seeks to prevent exposure to hazardous waste. The agency's FY 2009 budget of $73 million represented a decrease of $1 million from FY 2008.
• The Centers for Medicare and Medicaid Services (CMS) administer programs that provide health insurance for about ninety-two million Americans who are either aged sixty-five and older or in financial need. It also operates the State Children's Health Insurance Program, which covers about ten million uninsured children, and regulates all laboratory testing, except testing performed for research purposes, in the United States. For FY 2009 the CMS planned for a $711.2 billion budget. Figure 4.3 shows the allocation of the CMS budget—roughly two-thirds (64%) was devoted to Medicare, one-third (34%)toMedicaid,and1%eachtotheStateChildren's Health Insurance Plan and administration.
• The U.S. Food and Drug Administration (FDA) acts to ensure the safety and efficacy of dietary supplements, pharmaceutical drugs, and medical devices and monitors food safety and purity. The FDA planned for a budget of $2.4 billion in FY 2009 and 10,596 employees. The FDA budget included $287 million to protect the United States against the threat of an influenza pandemic (a worldwide epidemic), ensure the safety and security of the food supply, and provide other bio-defense activities.
• The Health Resources and Services Administration (HRSA) provides services for medically underserved populations such as migrant workers, the homeless, and public housing residents. The HRSA oversees the nation's organ transplant program, directs efforts to improve maternal and child health, and delivers services to people with AIDS through the Ryan White CARE Act. In FY 2009 it planned to have 1,516 employees and a budget of $5.9 billion.
• The Indian Health Service (IHS) serves nearly 560 tribes through a network of 46 hospitals, 309 health stations, and 324 health centers. In FY 2009 the IHS planned to employ 15,131 workers and have a budget of $4.3 billion.
• The General Departmental Management provides the HHS's leadership and oversees the fifteen operating divisions of the HHS. It also advises the president about health, welfare, human service, and income security issues. In FY 2009 it was allotted 1,515 employees and a budget of $380 million.
• The Program Support Center (PSC) administers operations, financial management, and human resources for the HHS as well as for fourteen other executive departments and twenty federal agencies. The PSC staff of 1,249 processes grant payments, provides personnel and payroll services for HHS employees, and performs accounting, management, information technology, and telecommunication services.
• The Substance Abuse and Mental Health Services Administration (SAMHSA) seeks to improve access to, and availability of, substance abuse prevention and treatment programs as well as other mental health services. The SAMHSA was budgeted $3.2 billion in FY 2009 and had 528 employees.

HHS agencies work with state, local, and tribal governments as well as with public and private organizations to coordinate and deliver a wide range of services including:

• Conducting preventive health services such as surveillance to detect outbreaks of disease and immunization programs through efforts directed by the CDC and the NIH
• Ensuring food, drug, and cosmetic safety through efforts of the FDA
• Improving maternal and child health and preschool education in programs such as Head Start, which served more than one million children in 2007, according to the National Head Start Association (2007, http://www.nhsa.org/about/index.htm)
• Preventing child abuse, domestic violence, and substance abuse, as well as funding substance abuse treatment through programs directed by the ACF
• Ensuring the delivery of health care services to more than 1.9 million Native Americans and Alaskan Natives through the IHS, a network of hospitals, health centers, and other programs and facilities
• Administering Medicare and Medicaid via the CMS
• Providing financial assistance and support services for low-income and older Americans, such as home-delivered meals (Meals on Wheels)coordinated by the AoA

SUBSTANTIAL BUDGET HELPS HHS TO ACHIEVE ITS OBJECTIVES . Table 4.2 displays how the FY 2009 HHS budget was allocated and provides comparisons between 2007, 2008, and 2009 outlays. The FY 2009 budget is a net increase of $29 billion over the FY 2008 budget and aims to provide funds to help reform the health care marketplace and foster affordable choices in the health care system. It provides funds to advance the adoption of information technologies and electronic health records. The budget is also intended to increase access to care, strengthen emergency preparedness, and improve public health by intensifying prevention programs to reduce the occurrence of diabetes, asthma, and obesity. HHS agencies also continue to closely examine their expenditures to determine where they can achieve savings while continuing to provide public health activities to the nation.

U.S. PUBLIC HEALTH SERVICE COMMISSIONED CORPS . The U.S. Public Health Service Commissioned Corps (June 10, 2008, http://www.usphs.gov/aboutus/history.aspx) was originally the uniformed service component of the early Marine Hospital Service, which adopted a military model for a group of career health professionals who traveled from one marine hospital to another as their services were needed. It also assisted the Marine Hospital Service to prevent infectious diseases from entering the country by examining newly arrived immigrants and directing state quarantine (the period and place where people suspected of having contagious diseases are detained and isolated) functions. A law enacted in 1889 established this group as the Commissioned Corps, and throughout the twentieth century the corps grew to include a wide range of health professionals. Besides physicians, the corps employed nurses, dentists, research scientists, planners, pharmacists, sanitarians, engineers, and other public health professionals.

By 1912 the Marine Hospital Service was renamed the Public Health Service (PHS) to reflect its broader scope of activities. The PHS is now part of the HHS. PHS-commissioned officers played important roles in disease prevention and detection, acted to ensure food and drug safety, conducted research, provided medical care to underserved groups such as Native Americans and Alaskan Natives, and assisted in disaster relief programs. As one of the seven uniformed services in the United States (the other six are the U.S. Navy, U.S. Army, U.S. Marine Corps, U.S. Air Force, U.S. Coast Guard, and the National Oceanic and Atmospheric Administration Commissioned Corps), the PHS Commissioned Corps continues to perform all these functions and identifies environmental threats to health and safety, promotes healthy lifestyles for Americans, and is involved with international agencies to help address global health problems.

In 2008 the PHS Commissioned Corps numbered approximately six thousand health professionals. These people report to the U.S. surgeon general, who holds the rank of vice admiral in the PHS. Corps officers work in PHS agencies and at other agencies including the U.S. Bureau of Prisons, the U.S. Coast Guard, the Environmental Protection Agency, and the Commission on Mental Health of the District of Columbia. The surgeon general is the physician appointed by the U.S. president to serve in a medical leadership position in the nation for a four-year term of office. The surgeon general reports to the assistant secretary for health, and the Office of the Surgeon General (March 19, 2008, http://www.surgeongeneral.gov/aboutoffice.html) is part of the Office of Public Health and Science. Seventeen surgeons general have served since the 1870s. Since October 2007, Rear Admiral Steven K. Galson (1958–) has served as the acting surgeon general.

CENTERS FOR DISEASE CONTROL AND PREVENTION

The CDC is the primary HHS agency responsible for ensuring the health and safety of the nation's citizens in the United States and abroad. The CDC's responsibilities include researching and monitoring health, detecting and investigating health problems, researching and instituting prevention programs, developing health policies, ensuring environmental health and safety, and offering education and training.

The CDC (May 23, 2007, http://www.cdc.gov/about/resources/facts.htm) states that it employs over 14,000 people in 170 disciplines and in 40 countries. Besides research scientists, physicians, nurses, and other health practitioners, the CDC employs epidemiologists, who study disease in populations as opposed to individuals. Epidemiologists measure disease occurrences, such as incidence and prevalence of disease, and work with clinical researchers to answer questions about causation (how particular diseases arise and the factors that contribute to their development), whether new treatments are effective, and how to prevent specific diseases.

The CDC (January 24, 2008, http://www.cdc.gov/about/organization/research.htm) is home to twelve national centers and various institutes and offices. Among the best known are the National Center for Health Statistics, which collects vital statistics, and the National Institute for Occupational Safety and Health, which seeks to prevent workplace injuries and accidents through research and prevention. Julie Gerberding (1955–) was named the director of the CDC in 2002.

CDC Actions to Protect the Health of the Nation

The CDC is part of the first response to natural disasters, outbreaks of disease, and other public health emergencies. In the agency's role as part of an interagency National Influenza Pandemic Preparedness Task Force organized in May 2005 by the U.S. secretary of health and human services, the CDC is monitoring outbreaks and planning responses to the emerging threat of avian influenza, commonly called bird flu. Figure 4.4 shows the distribution of nations with confirmed cases of H5N1 avian influenza as of April 2008. Other examples of CDC initiatives are identification and education about effective strategies for preventing school and domestic violence as well as programs to promote a healthy diet and increase physical activity to prevent overweight and obesity.

Examples of CDC efforts to educate and communicate vital health information are its publications Morbidity and Mortality Weekly Report and the Emerging Infectious Disease Journal, which alert the medical community to the presence of health risks, outbreaks, and preventive measures. Besides providing vital statistics (births, deaths, and related health data), the CDC monitors Americans' health using surveys to measure the frequency of behaviors that increase health risk, such as smoking, substance abuse, and physical inactivity, and compiles data about the use of health care resources such as inpatient hospitalization rates and visits to hospital emergency departments.

The CDC partnerswithnational, state, local, public, and private agencies and organizations to deliver services. Examples of these collaborative efforts include the global battle against HIV/AIDS by way of the Leadership and Investment in Fighting an Epidemic initiative and the CDC Coordinating Center for Health Information and Service, which was created to improve public health through increased efficiencies and to foster stronger collaboration between the CDC and international health foundations, health care practitioners, community and philanthropic organizations, schools and universities, nonprofit and voluntary organizations, and state and local public health departments.

NATIONAL INSTITUTES OF HEALTH

The NIH (February 15, 2008, http://www.nih.gov/about/history.htm), which began as a one-room laboratory in 1887, is the world's premier medical research center. The NIH conducts research in its own facilities and supports research in universities, medical schools, and hospitals throughout and outside the United States. The NIH trains research scientists and other investigators and serves to communicate medical and health information to professional and consumer audiences.

The NIH (July 9, 2008, http://www.nih.gov/about/organization.htm) is composed of twenty-seven centers and institutes and is housed in more than seventy-five buildings on a three-hundred-acre campus in Bethesda, Maryland. Among the better-known centers and institutes are the National Cancer Institute, the National Human Genome Research Institute, the National Institute of Mental Health, and the National Center for Complementary and Alternative Medicine.

The NIH explains in “Facts at a Glance'' (January 9, 2006, http://clinicalcenter.nih.gov/about/welcome/fact.shtml) that patients arrive at the NIH Warren Grant Magnuson Clinical Center in Bethesda to participate in clinical research trials. About seven thousand patients per year are treated as inpatients here, and an additional one hundred thousand receive outpatient treatment. The National Library of Medicine—which produces the Index Medicus, a monthly listing of articles from the world's top medical journals, and maintains MEDLINE, a comprehensive medical bibliographic database—is in the NIH Lister Hill Center.

The NIH budget was $29.5 billion in FY 2009. Figure 4.5 shows how NIH funding has increased by more than $9 billion since 2001. The NIH (January 12, 2006, http://science.education.nih.gov/supplements/nih1/Genetic/about/about-nih.htm) works to achieve its ambitious research objectives “to acquire new knowledge to help prevent, detect, diagnose, and treat disease and disability, from the rarest genetic disorder to the common cold'' by investing in promising biomedical research. The NIH makes grants and contracts to support research and training in every state in the country, at more than two thousand institutions. The NIH allocated more than half (52.7%) of its FY 2009 budget to research project grants and nearly one-quarter to intramural research (10.6%), support research centers (10.1%), and research training (2.7%). (See Figure 4.6.)

Establishing Research Priorities

By law, all twenty-seven institutes of the NIH must be funded, and each institute must allocate its funding to specific areas and aspects of research within its domain. About half of each institute's budget is dedicated to supporting the best research proposals presented, in terms of their potential to contribute to advances that will combat the diseases the institute is charged with researching. Some of the other criteria used to determine research priorities include:

• Public health need—the NIH responds to health problems and diseases based on their incidence (the rate of development of a disease in a group during a given period), severity, and the costs associated with them. Examples of other measures used to weigh and assess need are the mortality rate (the number of deaths caused by disease), the morbidity rate (the degree of disability caused by disease), the economic and social consequences of the disease, and whether rapid action is required to control the spread of the disease.
• Rigorous peer review—proposals are scrutinized by accomplished researchers to determine their potential to return on the investment of resources.
• Flexibility and expansiveness—NIH experience demonstrates that important findings for commonly occurring diseases may come from research about rarer ones. The NIH attempts to fund the broadest possible array of research opportunities to stimulate creative solutions to pressing problems.
• Commitment to human resources and technology—the NIH invests in people, equipment, and even some construction projects in the pursuit of scientific advancements.

Because not even the most gifted scientists can accurately predict the next critical discovery or stride in biomedical research, the NIH must analyze each research opportunity in terms of competition for the same resources, public interests, scientific merit, and the potential to build on current knowledge. Figure 4.7 shows all the stakeholders whose interests and opinions are considered when NIH resource allocation and grant funding decisions are made.

NIH Achievements

The HHS notes in U.S. Department of Health and Human Services Budget in Brief, Fiscal Year 2009 that in FY 2009 the NIH had 17,254 employees. The NIH recruits and attracts the most capable research scientists in the world. In fact, the NIH states in “The NIH Almanac— Nobel Laureates'' (June 9, 2008, http://www.nih.gov/ about/almanac/nobel/index.htm#scientists) that 115 scientists who conducted NIH research or were supported by NIH grants have received Nobel Prizes. Five Nobel winners made their prize-winning discoveries in NIH laboratories.

Equally important, NIH research has contributed to great improvements in the health of the nation. The following are some of the NIH's (June 19, 2007, http://www.nih.gov/about/NIHoverview.html) achievements:

• Death rates from heart disease and stroke fell by 40% and 51%, respectively, between 1975 and 2000.
• The overall five-year survival rate for childhood cancers rose to nearly 80% during the 1990s from under 60% in the 1970s.
• The number of AIDS-related deaths fell by about 70% between 1995 and 2001.
• Sudden infant death syndrome rates fell by more than 50% between 1994 and 2000.
• Infectious diseases—such as rubella, whooping cough, and pneumococcal pneumonia—that once killed and disabled millions of people are now prevented by vaccines.
• The sequencing of the human genome set a new course for developing ways to diagnose and treat diseases such as cancer, Parkinson's Disease, and Alzheimer's Disease, as well as rare diseases.
• In response to the anthrax attacks of 2001, the NIH launched and expanded research to prevent, detect, diagnose, and treat diseases caused by potential bioterrorism agents.
• New and improved imaging techniques let scientists painlessly look inside the body and detect disease in its earliest stages when it is often most effectively treated.
• Researchers aggressively pursue ways to make effective vaccines for deadly diseases such as HIV/AIDS, tuberculosis, malaria, and potential agents of bioterrorism.
• Progress in understanding the immune system may lead to new ways to treat and cure diabetes, arthritis, asthma and allergies.
• New, more precise ways to treat cancer are emerging, such as drugs that zero in on abnormal proteins in cancer cells.
• Novel research methods are being developed that can identify the causes of outbreaks, such as Severe Acute Respiratory Syndrome, in weeks rather than months or years.

Elias A. Zerhouni, the director of the NIH, explains in NIH: A Vision for the Future (March 6, 2007, http://www.nih.gov/about/director/budgetrequest/fy2008budge thearings.pdf) that NIH scientists have initiated and expanded the scope of their medical research and report significant findings resulting from new and ongoing research projects. Zerhouni indicates that some of these important initiatives and findings are:

• 2007 was the second consecutive year during which cancer deaths in the United States declined.
• Large-scale HIV vaccine trials are under way and new vaccine targets have been identified.
• A vaccine for the human papillomavirus (which infects more than 80% of fifteen- to fifty-year-old women and can cause cervical cancer) was approved by the FDA and is the first vaccine to protect against cancer.
• Researchers developed ways to “personalize'' anticoagulant therapy—drug therapy that regulates bleeding and clotting to reduce the risk of heart attack and stroke.

ACCREDITATION

Accreditation of health care providers (facilities and organizations) provides consumers, payers, and other stake-holders with the assurance that accredited facilities and organizations have been certified as meeting or exceeding predetermined standards. Accreditation refers to both the process during which the quality of care delivered is measured and the resulting official endorsement that quality standards have been met. Besides promoting accreditation to health care consumers and other purchasers of care such as employer groups, accreditation assists health care facilities and organizations to recruit and retain qualified staff, increase organizational efficiencies to reduce costs, identify ways to improve service delivery, and reduce liability insurance premiums.

Joint Commission on Accreditation of Healthcare Organizations

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO; 2008, http://www.jointcommission.org/NewsRoom/faqs.htm) surveys and accredits more than fifteen thousand health care organizations and programs throughout the United States. The JCAHO is a not-for-profit organization and is headquartered in Oakbrook Terrace, Illinois, with a satellite office in Washington, D.C. The JCAHO (2008, http://www.jointcommission.org/AboutUs/CareerOpportunities/default.htm) has more than one thousand surveyors—physicians, nurses, pharmacists, hospital and health care organization administrators, and other health professionals—who are qualified and trained to evaluate specific aspects of health care quality.

Working closely with medical and other professional societies, purchasers of health care services, and management experts as well as other accrediting organizations, the JCAHO develops the standards that health care organizations are expected to meet. Besides developing benchmarks and standards of organizational quality, the JCAHO is credited with promoting improvement in infection control, safety, and patients' rights.

THE JCAHO GROWS TO BECOME THE PREEMINENT ACCREDITING BODY . In “A Journey through the History of the Joint Commission'' (2008, http://www.jointcommission.org/AboutUs/joint_commission_history.htm), the JCAHO explains that early efforts to standardize and evaluate care delivered in hospitals began in 1913 by the American College of Surgeons, a group that thirty-eight years later would start the present-day Joint Commission on Accreditation of Health-care Organizations, originally dubbed the Joint Commission on Accreditation of Hospitals (JCAH) in 1951. In 1966 the JCAH began to offer accreditation to long-term care facilities, and in 1972 the Social Security Act was amended to require the HHS secretary to validate JCAH findings and include them in the HHS annual report to Congress. In subsequent years the JCAH's mandate was expanded to include a variety of other health care facilities, and in 1987 it was renamed the Joint Commission on Accreditation of Healthcare Organizations.

In 1992 the JCAHO instituted a requirement that accredited hospitals prohibit smoking in the hospital, and in 1993 it began performing random, surprise surveys (unannounced site visits) on 5% of accredited organizations. The JCAHO also moved to emphasize performance improvement standards, revising its policies on medical errors and instituting a hotline for complaints about quality of care.

In 1999 the JCAHO required hospitals to begin collecting and reporting data about the care they provide for five specific diagnoses: acute myocardial infarction (heart attack), congestive heart failure, pneumonia, pregnancy and related medical conditions, and surgical procedures and complications. The JCAHO calls these diagnoses “core measure data'' and uses these data to compare facilities and assess the quality of service delivered. In 2002 the JCAHO moved to make its recommendations more easily understood by consumers so they could make informed choices about health care providers.

In 2006 the JCAHO shifted to an unannounced survey program—meaning that organizations receive no advanced notice of their survey date. Before this policy change, the leaders of the nation's more than forty-five hundred Medicare-participating hospitals had ample notice and time to prepare for JCAHO visits and inspections. The policy change was intended to shift hospitals' orientation from preparing for the next JCAHO survey to preparing for the next patient, and requires hospitals to conduct an annual periodic performance review using their own internal evaluators to assess their own level of standards compliance. The hospitals must then communicate the results of their audits to the JCAHO.

This policy change, presumably implemented to improve hospital vigilance about safety, care, and quality, coincided with another, seemingly contradictory JCAHO policy change, which allows hospitals to accumulate a higher number of deficiencies (patient care lapses and other violations) before sanctions are imposed on them. The JCAHO defends this practice by explaining that it would rather identify more problems and have hospitals resolve them than deny hospitals accreditation. Charles Ornstein and Tracy Weber report in “Hospitals' Watch-dog Raises Violation Threshold'' (Los Angeles Times, April 6, 2006) that Dennis S. O'Leary, the JCAHO president, said the commission made the changes because it found that too many decent hospitals were being referred for punishment and that he expected that the number of hospitals sanctioned in 2006 would actually increase from years past.

In 2008 Amy Wilson-Stronks et al. of the JCAHO published One Size Does Not Fit All: Meeting the Health Care Needs of Diverse Populations (http://www.jointcommission.org/NR/rdonlyres/88C2C901-6E4E-4570-95D8-B49BD7F756CF/0/HLCOneSizeFinal.pdf), a report that exhorts health care organizations to assess and enhance their capacity to meet patients' unique cultural and language needs to better accommodate specific populations.

National Committee for Quality Assurance

The National Committee for Quality Assurance (NCQA) is another well-respected accrediting organization that focuses its attention on the managed care industry. The NCQA began surveying and accrediting managed care organizations (MCOs) in 1991. By 2008 most health maintenance organizations (HMOs) in the United States had been reviewed by the NCQA, and thirty states required licensed health maintenance organizations to report Health Plan Employer Data and Information Set (HEDIS) information or undergo NCQA accreditation. In addition, the NCQA indicates in The State of Health Care Quality 2007 (2007, http://www.ncqa.org/Portals/0/Publications/Resource%20Library/SOHC/SOHC_07.pdf) that 141 PPOs voluntarily submitted HEDIS data to the NCQA in 2007. This represented a 76% increase from 2005, during which 80 PPOs reported.

When an MCO undergoes an NCQA survey, it is assessed by more than sixty different standards, each focusing on a specific aspect of health plan operations. The standards address access and service, the qualifications of providers, the organization's commitment to prevention programs and health maintenance, the quality of care delivered to members when they are ill or injured, and the organization's approach for helping members manage chronic diseases such as diabetes, heart disease, and asthma.

To ensure fair comparisons between managed health care plans and to track their progress and improvement over time, the NCQA considers more than sixty HEDIS measures that look at health care delivery issues such as:

• Management of asthma and effective use of medication
• Controlling hypertension (high blood pressure)
• Effective and appropriate use of antidepressant medications
• The frequency and consistency with which smokers are counseled to quit
• Rates of breast cancer screening
• The frequency and consistency with which beta blocker (drug treatment) is used following heart attack
• Rates of immunization among children and teens

The NCQA combines HEDIS data with national and regional benchmarks of quality in a national database called the Quality Compass. This national database enables employers and health care consumers to compare health plans to one another and make choices about coverage based on quality and value rather than simply on price and participating providers (physicians, hospitals, and other providers that offer services to the managed care plan members).

The NCQA issues health plan report cards that rate HMOs and MCOs, and health care consumers and other stakeholders can access them at the NCQA Web site. After the NCQA review, the MCOs may be granted the NCQA's full accreditation for three years, indicating a level of excellence that exceeds NCQA standards. Those that need some improvement are granted one-year accreditation with recommendations about areas that need improvement, and those MCOs that meet some but not all NCQA standards may be denied accreditation or granted provisional accreditation.

In 2007 the NCQA reported that health care quality had improved dramatically for the sixth consecutive year—participating health plans' performance on nearly every measure was better than the previous year's results. Furthermore, care improved regardless of payer—private employer, Medicare, or Medicaid—among health plans that measure and report quality results.

The NCQA documents in State of Health Care Quality 2007 how improved performance saves lives. For example, successful efforts to control high blood pressure, manage cholesterol levels after patients have suffered heart attacks, and ensure that patients receive proper medication have helped prevent second heart attacks and saved the lives of thousands of Americans. Other notable gains in quality include improved immunization rates among children and teens—80% had been immunized, which was an increase of two percentage points from the previous year; adults over age fifty were more likely to have received colon cancer screening; and rates of appropriate treatment for adults suffering from acute bronchitis and rheumatoid arthritis also rose.

Accreditation Association for Ambulatory Health Care

Another accrediting organization, the Accreditation Association for Ambulatory Health Care (AAAHC), was formed in 1979 and focuses exclusively on ambulatory (outpatient) facilities and programs. Outpatient clinics, group practices, college health services, occupational medicine clinics, and ambulatory surgery centers are among the organizations that are evaluated by the AAAHC. The AAAHC accreditation process involves a self-assessment by the organization seeking accreditation and a survey conducted by AAAHC surveyors who are all practicing professionals. The AAAHC grants accreditation for periods ranging from six months to three years.

In 2002 the AAAHC and the JCAHO signed a collaborative accreditation agreement that permits ambulatory health care organizations to use their AAAHC accreditation to satisfy JCAHO requirements. In June 2002 the CMS granted the AAAHC authority to review health plans that provide coverage for Medicare beneficiaries. HMOs, PPOs, and ambulatory surgery centers are now considered Medicare-certified on their receipt of accreditation from the AAAHC.

During 2003 and 2004 several states, including Florida, California, and Ohio, approved the AAAHC to conduct accreditation of office-based surgical centers, primary care practices, and freestanding radiology centers such as magnetic resonance imaging services. By 2008 the AAAHC (http://www.aaahc.org/eweb/dynamicpage.aspx?site=aaahc_site&webcode=about_aaahc) was accrediting over thirty-eight hundred organizations.

National Quality Forum

In 2006 two other national quality organizations, the National Quality Forum and the National Committee on Quality Health Care, merged to become a new organization, also named the National Quality Forum (NQF). The NQF is a private, not-for-profit membership organization created to develop and implement a national strategy for health care quality measurement and reporting. Its mission is to improve U.S. health care through the endorsement of consensus-based national standards for measurement and public reporting of health care performance data that provide meaningful information about whether care is safe, timely, beneficial, patient centered, equitable, and efficient.

PROFESSIONAL SOCIETIES

There are professional and membership organizations and societies for all health professionals, such as physicians, nurses, psychologists, and hospital administrators, as well as for institutional health care providers, such as hospitals, managed care plans, and medical groups. These professional organizations represent the interests and concerns of their members, advocate on their behalf, and frequently compile data and publish information about working conditions, licensing, accreditation, compensation, and scientific advancements of interest to members.

American Medical Association

The American Medical Association (AMA) is a powerful voice for U.S. physicians' interests. The AMA concerns itself with a wide range of health-related issues including medical ethics, medical education, physician and patient advocacy, and development of national health policy. The AMA publishes the highly regarded Journal of the American Medical Association and the AMNews, as well as journals in ten specialty areas called Archives Journals.

Founded in 1847, the AMA has worked to upgrade medical education by expanding medical school curricula and establishing standards for licensing and accreditation of practitioners and postgraduate training programs. Recent activities of the AMA are advocating for legislation to improve patient safety, opposing Medicare physician-payment cuts to ensure that older adults have access to needed medical care, and encouraging film producers, media companies, and the Motion Picture Association of America to eliminate tobacco products and their use in youth-rated films.

American Nurses Association

The American Nurses Association (ANA; 2008, http://www.nursingworld.org/FunctionalMenuCategories/AboutANA.aspx) is a professional organization that represents more than 2.9 million registered nurses (RNs) and promotes high standards of nursing practice and education as well as the roles and responsibilities of nurses in the workplace and the community. On behalf of its members, the ANA works to protect patients' rights, lobbies to advocate for nurses' interests, champions workplace safety, and provides career and continuing education opportunities. The ANA publishes the American Journal of Nursing and actively seeks to improve the public image of nurses among health professionals and the community at large.

American Hospital Association

The American Hospital Association (AHA; 2006, http://www.aha.org/aha/about/index.html) represents nearly five thousand hospitals, health care systems, networks, and other health care providers and thirty-seven thousand individual members. Originally established as a membership organization for hospital superintendents in 1898, the AHA eventually expanded its mission to address all facets of hospital care and quality. Besides national advocacy activities and participation in the development of health policy, the AHA oversees research and pilot programs to improve health service delivery. It also gathers and disseminates hospital and other related health care data, publishes information of interest to its members, and sponsors educational opportunities for health care managers and administrators.

VOLUNTARY HEALTH ORGANIZATIONS

American Heart Association

The American Heart Association's mission is to decrease disability and death from cardiovascular diseases and stroke. The association's national headquarters is in Dallas, Texas, and twelve regional affiliate offices serve the balance of the United States. More than twenty-two million volunteers and supporters were involved with association programs and activities during 2008.

The American Heart Association (2008, http://www.americanheart.org/presenter.jhtml?identifier=10860) was started by a group of physicians and social workers in New York City in 1915. The early efforts of this group, called the Association for the Prevention and Relief of Heart Disease, were to educate physicians and the general public about heart disease. The first fund-raising efforts were launched in 1948 during a radio broadcast, and since then the association has raised millions of dollars to fund research, education, and treatment programs.

Besides research, fund-raising, and generating public awareness about reducing the risk of developing heart disease, the American Heart Association has published many best-selling cookbooks featuring heart-healthy recipes and meal planning ideas. The association is also considered one of the world's most trusted authorities about heart health among physicians and scientists. It publishes five print journals and one online professional journal, including Circulation, Stroke, Hypertension, and Atherosclerosis, Thrombosis, and Vascular Biology.

American Cancer Society

The American Cancer Society (ACS) is headquartered in Atlanta, Georgia, and has more than thirty-four hundred offices across the country. The ACS's (2008, http://www.cancer.org/docroot/AA/content/AA_1_1_ACS_Mission_Statements.asp) mission is “eliminating cancer as a major health problem by preventing cancer, saving lives, and diminishing suffering from cancer, through research, education, advocacy, and service.”

The ACS is the biggest source of private, not-for-profit funding for cancer research—second only to the federal government. In “ACS Fact Sheet'' (March 4, 2008, http://www.cancer.org/docroot/AA/content/AA_1_2_ACS_Fact _Sheet.asp), the ACS states that by 2008 it had invested more than $3 billion in cancer research at leading centers throughout the United States and funded forty-two Nobel Prize winners early in their careers. It also supports epidemiological research to provide cancer surveillance information about occurrence rates, risk factors, mortality, and availability of treatment services. The ACS publishes an array of patient information brochures and four clinical journals for health professionals: Cancer, Cancer Cytopathology, CA: A Cancer Journal for Clinicians, and Cancer Practice. The ACS also maintains a twenty-four-hour consumer telephone line staffed by trained cancer information specialists and a Web site with information for professionals, patients and families, and the media.

Besides education, prevention, and patient services, the ACS advocates for cancer survivors, their families, and every potential cancer patient. The ACS seeks to obtain support and passage of laws, policies, and regulations that benefit people affected by cancer. The ACS is especially concerned with developing strategies to better serve the poor and people with little formal education, who historically have been disproportionately affected by cancer.

March of Dimes

The March of Dimes was founded in 1938 by President Franklin D. Roosevelt (1882–1945) to help protect American children from polio. Besides supporting the research that produced the polio vaccine, it has advocated birth defects research and the fortification of food supplies with folic acid to prevent neural tube defects. It has also supported increasing access to quality prenatal care and the growth of neonatal intensive care units to help improve the chances of survival for babies born prematurely or those with serious medical conditions.

The March of Dimes continues to partner with volunteers, scientific researchers, educators, and community outreach workers to help prevent birth defects. It funds genetic research, investigates the causes and treatment of premature birth, educates pregnant women, and provides health care services for women and children, such as immunization, checkups, and treatment for childhood illnesses.

In 2008 the March of Dimes championed initiatives to address and reduce racial disparities in infant health outcomes, funded research to study the role genes and heredity play in premature births, and advocated for adequate funding to ensure that children receive essential, appropriate, and quality health care.