drive about 40 percent of the accreditation score. Institute of Medicine Puts New Emphasis on Quality Improvement Although the world of health care was slowly assuming Donabedian’s structureprocess-outcomes approach to quality improvement, doubts about the effectiveness of various improvement initiatives moved Congress in the late 1980s to commission a study on quality assurance for Medicare.16 The Institute of Medicine (IOM) conducted the study, which found that many health services were inadequate. In response to the IOM findings, the Health Care Finance Administration launched several quality improvement initiatives during the early 1990s. However, it was the publication of two IOM reports in 1999 and 2001 that finally fixed national attention on the critical need for quality improvement in health care. The first report, To Err is Human: Building a Safer Health System, magnified the safety gaps in United States health care, noting that as many as 98,000 people die yearly in hospitals due to preventable medical errors.17 The second report, Crossing the Quality Chasm: A New Health System for the 21st Century, (2001), further indicted the country’s entire health care delivery system for failing to provide “consistent, high-quality medical care to all people.”18 Echoing the philosophies of Deming, Juran and Crosby, the reports blamed the health care system, instead of individuals, for widespread errors. “Mistakes can best be prevented by designing the health system at all levels to make it safer — to make it harder for people to do something wrong and easier for them to do it right.”19 The IOM defined quality by what and how well something is done and attached it to doing the right thing (delivering the health care services that are needed), at the right time (when a patient needs them), and in the right way (using appropriate tests or procedures).19 In Crossing the Quality Chasm, the IOM charged the health care system with frequently lacking “…the environment, the processes, and the capabilities needed to ensure that services are safe, effective, patient-centered, timely, efficient, and equitable,” qualities it calls “six aims for improvement.” In addition to achieving these aims, the IOM recommended: improving patient safety and reducing medical error by establishing a national focus on leadership, research, tools and protocols about safety; expecting mandatory and voluntary reporting of errors; raising safety standards by involving oversight organizations, purchasers and professional societies; and creating safety systems inside health care organizations.18 Hospital Quality Measurement Leads to Major Improvement The development and implementation of standardized quality measurement for hospitals in the first decade of the 21st century led to substantial improvements in performance across a wide variety of evidencebased measures. The Joint Commission convened experts who reviewed and summarized evidence, and produced the first nationally standardized quality measures for hospitals for patients with acute myocardial infarction, heart failure, pneumonia and pregnancy. The Joint Commission required all accredited hospitals to collect and report performance data on at least two of these groups of measures in 2002 and began publicly reporting the data two years later. The Centers for Medicare and Medicare Services (CMS) initiated a program to penalize hospitals financially if they did not report to CMS the same data they were reporting to The Joint Commission and began a public reporting program the next year. Both The Joint Commission and CMS programs expanded their reporting requirements over the second half of that decade. Hospitals resisted the collection and reporting of these data at the beginning. The American Hospital Association, the Federation of American Hospitals and the 6 marchofdimes.com Toward Improving the Outcome of Pregnancy III History of the Quality Improvement Movement Association of American Medical Colleges vigorously supported the effort to collect and publish data on nationally standardized measures of hospital quality of care.20 As public reporting increased, hospitals increasingly directed resources to improve the clinical processes of care in order to enhance performance on the public measures. The results have been impressive. Throughout the 1990’s, it was not uncommon for hospitals to exhibit rates of performance on these quality measures of 40 to 60 percent, with substantial variability among hospitals.21-23 By 2009, hospitals had achieved very high levels of performance on many of these measures, and variation among hospitals was markedly reduced.24 For example, the national average of performance by hospitals on discharging eligible acute myocardial infarction patients on a beta blocker was 98.3 percent, up from 87.3 percent in 2002. Also in 2009, on that same measure, fully 96.8 percent of hospitals exhibited rates of performance over 90 percent, compared to 75.2 percent in 2006. In addition, the need for improvement in hospital quality measurement became clear by 2010. While many measures worked well to promote improvement activities that led clearly to improved outcomes for patients, others did not. In 2010, The Joint Commission adopted new criteria that define a higher standard for quality measures that are