The Problem

Despite advances in medical technology and science, health care in America is still fraught with uneven and often poor quality, especially in the treatment of chronic diseases that affect millions of Americans, like diabetes, asthma and cardiovascular disease. Although we know many of the best practices to improve the quality of treatment, formidable barriers prevent these practices from taking hold and transforming care across the country. In most communities, health care is delivered through fragmented systems within which hospitals, clinics, doctors, nurses and patients struggle to understand what quality care is and how to achieve it.

Beyond the burdens placed on providers and patients by dysfunctional health care systems, health care costs are growing at a rate that places bigger burdens on our country’s economy. Therefore, we need far more rational ways to determine if our health care delivers value that’s worth the investment—value to patients, physicians, nurses, hospitals, health plans, businesses and government. Right now, health care in America represents one of the biggest expenditures by the federal government and others and people still aren’t getting the right care at the right time. For instance, the Dartmouth Atlas, an ongoing research project that produces data on regional differences in the delivery of health care services, reported huge variations in Medicare spending for end-of-life care in hospitals. One region showed an average of $20,000 of Medicare expenditures on seriously ill patients, another region showed approximately $50,000 as an average total. Yet these differences in Medicare spending were not directly related to the number of patients, how sick the patients were, and worse yet, whether patients experienced better outcomes as a result of the higher expenditures. In other words, more and more costly care did not result in better care.

Not only do we have a quality and value problem in U.S. health care, but research shows that certain groups—from specific racial, ethnic, cultural and socioeconomic backgrounds—persistently suffer the lowest-quality care. These gaps in quality persist even when other factors, such as insurance status and income level, are taken into account between minority and non-minority patients.

In recent years, national organizations and the federal government have begun to coalesce around concepts of value and public reporting of quality and price information. These concepts depend upon the belief that making health care information about things like the cost and quality of health care more available to relevant stakeholder groups—like consumers, doctors, hospitals and businesses—can create a better understanding of what high-quality care looks like and how to demand and achieve it. Although the Foundation has been and will remain active in these national efforts, we are now focusing our attention on our most ambitious effort to transform health care quality at the ground level, in communities across the country.

View or download an overview of the current state of quality.

Our approach

One of the lessons we’ve learned from RWJF’s long history of investments to improve chronic care is that it is possible, with RWJF support and knowledge, to make incremental improvements in the quality of health care. Now, with our Quality/ Equality strategy, we want to go beyond the sum of what we’ve learned through our many programs and projects and achieve more sustained impact on the ground. Working in targeted communities is not a new experience for us—we have supported many quality demonstration projects involving hospitals and health plans in many different communities. However, most of our local initiatives on quality were not designed to influence all of the major forces that influence the quality of health care in any one community. Some have focused on hospitals, while others looked at the role of health plans and financial incentives. It will take the efforts of all forces working together to achieve fundamental communitywide improvements in quality. What we are driving towards now is sustained local collaboration towards shared and ambitious goals of high-quality health care.

In addition, we have brought together different strands from previous targeted strategies and made them explicit points of emphasis in the Quality/Equality strategic approach. We know, for example, that nurses play an integral role in patient care and can be a galvanizing force when they lead quality improvement efforts; we also know that we can take traditional quality improvement strategies like performance measurement and integrate ideas of how to address racial and ethnic gaps within those strategies.

Read a glossary of health care quality terms.

Learn more about our strategy and the issues we are seeking to address in this area:

• Download our complete overview