Health 

Care Quality How to know it when you see it

Guide to

Advancing Excellence in Health Care • www.ahrq.gov

Agency for Healthcare Research and Quality
Agency for Healthcare Research and Quality

This booklet was developed by the Agency for Healthcare Research

and Quality (AHRQ), part of the U.S. Department of Health and

Human Services. AHRQ works to improve health care quality,

prevent medical errors, and assess what happens to people as a result

of the care they receive. 

AHRQ publishes two annual reports on the quality of health care in

the United States. The National Healthcare Quality Report and the

National Healthcare Disparities Report.

To obtain free copies of these reports or additional copies of this

booklet, call the AHRQ Publications Clearinghouse at 1-800-358-

9295 or send an e-mail to ahrqpubs@ahrq.gov.

Care about your health. 

Help make the decisions.
Purpose of this Booklet

The purpose of this booklet is to

help you get quality health care.

Getting quality health care can

help you stay healthy and recover

faster when you become sick.

Throughout the booklet, tips are

provided to help you be active in

making decisions about your health

care. The goal is to make sure you

receive the best possible care.

You Deserve Quality Health Care

Getting quality health care can help you stay healthy and recover

faster when you become sick. However, we know that often, people

do not get high-quality care. A 2004 study of 12 large U.S.

communities found that just over half (54.9 percent) of people were

receiving the care they needed.

What exactly is health care quality? We know that quality means

different things to different people. Some people think that getting

quality health care means seeing the doctor right away, being treated

courteously by the doctor’s staff, or having the doctor spend a lot of

time with them. 

While these things are important to all of us, clinical quality of care

is even more important. Think of it like this: getting quality health

care is like taking your car to a mechanic. The people in the shop

can be friendly and listen to your complaints, but the most important

thing is whether they fix the problem with your car.

Health care providers, the government, and many other groups are

working hard to improve health care quality. You also have a role to

play to make sure you and your family members receive the best

quality care possible.

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Be Active: Take Charge of Your Health Care

The single, most important thing you can do to ensure you get highquality health care is to find and use health information and take an

active role in making decisions about your care. Here are some steps

you can take to improve your care:

• Work together with your doctor and other members of the

health care team to make decisions about your care.

• Be sure to ask questions. Examples of questions to ask your

doctor begin on this page.

• Ask your doctor what the scientific evidence has to say about

your condition.

• Do your homework; go online or to the library to find out more

information about your condition.

• Find and use quality information in making health care choices.

Be sure the information comes from a reliable source.

Talking with Your Doctor 

Here are some examples of questions to ask your doctor. It is not a

complete list. You will probably have many other questions. You

should keep asking questions until you understand what is wrong

with you and what you need to do to get better.

Understand your diagnosis:

• What is wrong with me?

• What do I need to do to get better?

• Where can I get more information about my condition?

If you need a lab test, an x-ray, or another kind of test, ask your

doctor:

• How will the test be done?

• How accurate will the results be? 

• What are the benefits and risks of the test?

• When and how will I receive the results?

• What should I do if I don’t receive the results? 

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If you receive a prescription for a new medicine:

• What is the name of the medicine?

• What is it supposed to do?

• When should I take the medicine, and how much should I take?

• Does the medicine have any side effects?

If you need surgery:

• What kind of operation do I need?

• Why do I need an operation?

• What are the benefits and risks of the operation?

• How long will it take to recover?

• What will happen if I don’t have the operation?

• Are there any other treatments I could have instead of an

operation?

• Where can I get a second opinion? 

Understanding Health Care Quality

Research has shown that science-based measures can be used to

assess quality for various conditions and for specific types of care.

For example, quality health care is:

• Doing the right thing (getting the health care services you

need).

• At the right time (when you need them).

• In the right way (using the appropriate test or procedure).

• To achieve the best possible results.

Providing quality health care also means striking the right balance of

services by:

• Avoiding underuse (for example, not screening a person for

high blood pressure).

• Avoiding overuse (for example, performing tests that a patient

doesn’t need).

• Eliminating misuse (for example, providing medications that

may have dangerous interactions).

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We would like to think that every doctor, nurse, pharmacist, hospital,

and other provider gives high-quality care, but we know this is not

always the case. Quality varies depending on where you live. Quality

can vary from one State to another, and it can vary from one doctor’s

office across the street to another. Health care quality varies widely

and for many reasons. 

For example, timely receipt of clot-busting drugs can save lives for

patients suffering heart attacks. The national standard for providing

clot-busting drugs is within 30 minutes of a patient’s arrival at the

hospital. But we know that this varies widely across States, from a

low of 20 minutes in one State to a high of 140 minutes in another.

Efforts to Improve Health Care Quality

Improving health care quality is a team effort, and it is ongoing on

many levels. To succeed, every part of the health care system must

become involved, including government and nongovernment

organizations, doctors, nurses, pharmacists, hospitals, other

providers, and you, the patient. 

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Sarah’s story

Sarah can tell you a story about the importance of getting good quality

health care. Last year, she decided to have elective surgery to repair a

hernia. She visited the surgeon in his office before the operation and

was very pleased with his bedside manner and friendly staff. Sarah put

herself in the doctor’s hands and didn’t ask many questions.

Although Sarah’s operation went smoothly, she soon developed a high

fever from an infection. The doctor said she would have to stay in the

hospital a few extra days. That’s when things began to go wrong. When

she really needed them, the nurses were slow to respond to her calls,

her doctor didn’t always stop in to see her during his hospital rounds,

and she sometimes didn’t get her pain medicine on time. 

Fortunately, Sarah’s infection finally cleared up, and she was sent home

to recuperate from her surgery. Sarah is fine now, but this story could

have had a very different ending. If you need surgery, be sure to ask

your doctor about the risks and benefits of the operation. You will find

examples of questions to ask your doctor on page 2 of this booklet.
One way to assess and track quality of care is by using measures that

are based on the latest scientific evidence. A health care measure

clearly defines which health care services should be provided to

patients who have or are at risk for certain conditions. Measures also

set standards for screening, immunizations, and other preventive

care. 

There are two types of measures: clinical measures and consumer

ratings. See the back of this booklet for more information about

health care quality measures. 

Because measures are intended to set general standards for a broad

population, they may or may not apply to you. Always check with

your doctor about your level of risk for a particular condition and

which types of screening and tests you should have.

Clinical Measures

Clinical measures can be used to assess quality of care and patient

satisfaction. Examples are provided here of measures that can be

used to assess care quality for three of the most common conditions:

diabetes, heart disease, and cancer.

Diabetes

More than 6 percent of all

Americans have diabetes. Diabetes

is the leading cause of blindness,

leg amputation not resulting from

trauma, and kidney disease.

Diabetes increases the risk of

complications in pregnant women,

and it is a risk factor for heart

disease and stroke. People who

have diabetes are two to four times

as likely to die from heart disease

or stroke as those without diabetes.

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The following five measures can

be used to assess quality of care

for diabetes. If you have diabetes,

you should receive the following

tests and exams:

• Regular hemoglobin A1c

(blood glucose) testing.

• Regular cholesterol testing.

• Annual retinal eye exam.

• Annual foot exam.

• Flu shot each year.

Heart Disease

Heart disease—or cardiovascular

disease—is a collection of

diseases of the heart and blood

vessels that includes heart attack,

stroke, and heart failure. About 64

million Americans are living with

heart disease.

Heart disease is the number one

cause of death in the United

States. Maintaining control of

blood pressure and cholesterol

can help you prevent heart attack

and stroke. 

The following are examples of

measures that can be used to

assess care for heart disease. 

For adults age 18 and older:

• Blood pressure measurement.

• Cholesterol testing.

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John’s story

John awoke from a restless night’s

sleep with a feeling of tightness

in his chest and pain down his left

arm. John was having a heart

attack. His wife called 911, and

he was taken to the emergency

room via ambulance.

The ER doctors took very good

care of John. He was given an

aspirin almost as soon as he

arrived at the hospital.

Fortunately, John’s heart attack

was mild. After undergoing some

special tests, his heart surgeon

implanted a stent to prop open his

partially clogged artery.

As John was being discharged

from the hospital, his doctor

prescribed beta-blocker therapy to

reduce the risk that he would

have another heart attack. John

was advised to have his blood

pressure and cholesterol checked

regularly. John got the right care

for his heart attack. 

More than 60 million men and

women are living with heart

disease. Everyone should know

what constitutes good quality care

for heart disease.
In general:

• If you smoke, being advised to stop smoking.

• If you suffer a heart attack, receiving aspirin within 24 hours of

hospital admission and being prescribed beta-blocker therapy at

hospital discharge.

Cancer

Cancer is the Nation’s second leading cause of death, after heart

disease. Each year, more than 1 million new cases of cancer are

diagnosed. Four cancers account for over half of the new cases

reported each year. The four

cancers are: lung, colorectal,

breast, and prostate.

Screening to permit early

detection holds the most

promise for successful cancer

treatment. 

Talk to your doctor about

screening tests for all of these

cancers, especially if other

members of your family have

had these cancers or if you

smoke.

The following are examples of

quality measures for several

types of cancer screening.

Breast and cervical cancer:

• Mammography exam for

women age 40 and older.

• Pap smear testing for

women age 18 and older.

Colorectal cancer: Men and

women age 50 and older should

receive the following tests:

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Jean’s story

Jean was 45 when she went to her

doctor for a checkup 5 years ago.

Her doctor performed a clinical

breast exam and found nothing

remarkable. Jean was given a

referral to a nearby x-ray facility

to have a mammogram.

A week or so later, Jean received

a phone call from her doctor’s

office asking her to come in to go

over the results. The

mammogram showed a small

lump in Jean’s right breast. Her

doctor referred her to a breast

surgeon for a biopsy. The biopsy

revealed early-stage breast cancer.

Jean had a lumpectomy and

followup radiation.

Today, Jean is cancer-free and

looking forward to the birth of

her first grandchild. Getting the

right care–a mammogram–at the

right time–over 40 years of

age–saved Jean’s life. For Jean,

getting quality health care gave

her a new lease on life.
• Fecal occult blood testing (a test to detect blood in the stool). 

• Flexible sigmoidoscopy/colonoscopy exam. Check with your

doctor about how often you should have this screening.

Finding Quality

Information

Today, you can find a great deal of

information about health care

quality, both online and in print.

New tools and resources for

assessing and improving health

care quality are being developed

and will be available soon.

Meanwhile, here is a brief look at

what is available now. More

resources are listed at the back of

this booklet.

Report Cards

Reports cards and other quality reports include consumer ratings,

clinical performance measures, or both. They can help you select

the right treatment and the right health care provider based on what

is most important to you. You may be able to get quality reports

from:

• Your employer: Ask your personnel office for information on

health plans.

• Health plans: Ask the plan’s customer service office about

quality reports.

• Other health care providers: Hospitals, nursing homes, and

community health clinics may have quality reports.

Several government agencies publish quality reports and other types

of quality information. 

• For example, the U.S. Department of Health and Human

Services has a quality tool that helps you compare the care

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provided by hospitals in your area. This tool is available online at

www.hospitalcompare.hhs.gov.

• Another Web site (www.medicare.gov/NHCompare/home.asp)

provided by the Centers for Medicare & Medicaid Services has

detailed information on the past performance of every Medicare

and Medicaid certified nursing home in the country.

Accreditation

Accreditation is another indicator that can be used to judge quality.

Accreditation is a “seal of approval” given by a private, independent

group. Health care organizations—such as hospitals—must meet

national standards, including clinical performance measures, in order

to be accredited. Several organizations that award accreditation are

listed at the back of this booklet.

Accreditation reports present quality information on hospitals,

nursing homes, and other health care facilities. For example, the Joint

Commission on Accreditation of Healthcare Organizations (JCAHO)

prepares a performance report on each hospital that it surveys.

Another group, the National Committee for Quality Assurance

(NCQA), rates health plans like HMOs. NCQA’s Health Plan Report

Card presents accreditation results for hundreds of health plans

across the country.

Web addresses and basic information on JCAHO, NCQA, and other

organizations can be found at the back of this booklet. 

If you need help in finding quality reports, accreditation reports, or

other types of quality information, check with your local library or

your local or State health department. You can find your State health

department listed in the blue pages of your phone book. 

Consumer Ratings

Consumer ratings tell you what other people like you think about

their health care. Some consumer ratings focus on health plans. For

example, a survey called CAHPS® asks people about the quality of

care in their own health plans. Their answers can help you decide

whether you want to join one of those plans. 

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Hospital CAHPS (HCAHPS®) will be released for the first time in

2006. It will ask patients about their experiences with hospital care.

Choosing Quality Health

Care

Here are some tips for making

quality a key factor in the health care

decisions you make about health

plans, doctors, treatments, hospitals,

and long-term care. At the end of

this booklet you will find a list of

resources where you can get answers

to these questions.

Look for a health plan that:

• Has been given high ratings by its members on the things that are

important to you.

• Has the doctors and hospitals you want or need.

• Provides the benefits (covered services) you need.

• Provides services where and when you need them.

• Has a documented history of doing a good job of preventing and

treating illness.

Look for a doctor who:

• Has received high ratings for quality of care.

• Has the training and experience to meet your needs.

• Will work with you to make decisions about your health care.

If you become ill, make sure you understand:

• Your diagnosis.

• How soon you need to be treated.

• Your treatment choices, including the benefits and risks of each

treatment.

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• How much experience your doctor has in treating your

condition.

Look for a hospital that:

• Is accredited by the Joint Commission on Accreditation of

Healthcare Organizations (JCAHO).

• Is rated highly by the State and by consumer groups or other

organizations.

• Has a lot of experience and success in treating your condition.

• Monitors quality of care and works to improve quality.

In choosing a nursing home or other long-term care facility, look

for one that:

• Has been found by State agencies and other groups to provide

quality care.

• Provides a level of care, including staff and services, that will

meet your needs.

Moving Forward with

Quality Improvement

The National Healthcare Quality

Report and the National Healthcare

Disparities Report present

important information about the

state of health care in America.

These reports indicate that:

• Quality is improving in many

areas, but change takes time.

• The gap between the best 

possible care and actual care

remains large.

• Quality of care varies widely across the country.

• Continuing improvement in health care is possible.

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People like you have an important role to play in health care quality

improvement. You can use the measures described in this booklet as

a yardstick to assess the quality of care provided to you and your

family members.

In addition, many public and private groups are working to improve

health care quality measures and other quality tools. The goal is to

make these measures and tools reliable, uniform, and helpful to

consumers and patients in making health care choices. See the

resource list that follows to find out how you can get more

information about health care quality and what you can do to ensure

you get the best quality care possible.

Resources for More

Information

If you have access to a computer

and the Internet, you can find

information on every health topic.

If you don’t have a computer,

check with your local library. Most

libraries have computers you can

use and staff who can help you

learn to search the Internet. Phone

numbers are provided where

available.

Resources for More Information

www.ahrq.gov – sponsored by the Agency for Healthcare Research

and Quality. Click on “Consumers & Patients” to find information

and resources on quality of care, medical errors and patient safety,

various clinical conditions, prevention and wellness, prescription

medicines, smoking cessation, choosing a health plan, and many

other topics. Call the AHRQ Publications Clearinghouse at 1-800-

358-9295.

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www.guideline.gov – sponsored by the Agency for Healthcare

Research and Quality. Click on “Patient Resources” for links to

many Web sites that feature science-based health information.

www.qualitytools.ahrq.gov – sponsored by the Agency for

Healthcare Research and Quality. QualityTools is a clearinghouse of

practical, ready-to-use tools for measuring and improving the quality

of health care. Information is provided for patients and consumers,

health care providers, policymakers, and payers and purchasers.

www.nih.gov – sponsored by the National Institutes of Health

(NIH), the government’s primary source for conducting and funding

clinical research. This is the main NIH Web site through which you

can access information on many health topics and link to the various

Institutes that make up NIH. These include the National Cancer

Institute, the National Heart, Lung, and Blood Institute, and many

others. Click on “Institutes” or search the Web site for your topic.

http://clinicaltrials.gov – sponsored by the National Institutes of

Health provides regularly updated information about federally and

privately supported research in human subjects. You can browse the

site or enter a specific location, condition, or other search topic.

www.medicare.gov – sponsored by the Centers for Medicare &

Medicaid Services can help you compare hospitals and nursing

homes in your area. Phone 1-800-MEDICARE.

www.healthfinder.gov -- sponsored by the U.S. Department of

Health and Human Services. It offers links to hundreds of sites on

the Internet that contain reliable health care information. Click on

“Health Care” and then “Health Care Quality” for links to many

government and nongovernment sources of information on health

care quality.

www.jcaho.org – sponsored by the Joint Commission on

Accreditation of Healthcare Organizations. Click on “Quality

Check” to locate JCAHO accredited hospitals, assisted living

13
facilities, laboratories, and other types of health care facilities and

services in your area. Phone 1-630-792-5000.

www.ncqa.org – sponsored by the National Committee for Quality

Assurance. Click on “Report Cards” to access a variety of health

care quality information, including reports on health care quality,

report cards for physicians and health plans, and more. Phone 1-888-

275-7585.

www.ahqa.org – sponsored by the American Health Quality

Association (AHQA). AHQA represents the national network of

Quality Improvement Organizations (QIOs) that help physicians,

hospitals, health plans, nursing homes, and home health agencies

improve the quality of care they deliver. QIOs focus on the adoption

of best practices to provide safe, effective and patient-centered care.

Go to www.ahqa.org/pub/189_1085_5234.cfm to locate a QIO near

you or find out more about health care quality.

www.nahc.org – sponsored by the National Association for Home

Care and Hospice. Click on “consumers” to locate home care,

hospice services, and other resources in your State. Phone 1-202-

547-7424.

www.aaahc.org – sponsored by the Accreditation Association for

Ambulatory Health Care. Click on “Search for Accredited

Organizations” to locate outpatient health care services, such as

freestanding surgery centers, radiology facilities, podiatrists, pain

management clinics, and may other types of outpatient facilities

accredited by the Association. Phone 1-847-853-6060.

www.ama-assn.org – sponsored by the American Medical

Association. Click on “For Patients” to access “DoctorFinder” with

information about virtually every licensed physician in the United

States, as well as links to other helpful Web sites. Phone 1-800-621-

8335.

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www.docboard.org – sponsored by the National Organization for

State Medical and Osteopathic Board Executive Directors. Click on

“DocFinder” to access the physician database, which contains

information from State government licensing boards on the licensing

background and disciplinary information of physicians and other

health care providers.

www.fsmb.org – sponsored by the Federation of State Medical

Boards. The Federation collects information on disciplinary actions

taken against physicians by regulatory and licensing agencies, such

as State medical boards, the National Board of Medical Examiners,

various Federal agencies, and other licensing authorities. Click on

“Public Access” to search the Web site to learn if your physician has

any disciplinary history. Phone 1-817-868-4000.

www.ahip.org – sponsored by America’s Health Insurance Plans.

Click on “Consumer Information” to access guides on health

insurance coverage and links to many other sources of information

about choosing a health insurance plan. Phone 1-202-778-3200.

www.naic.org – sponsored by the National Association of Insurance

Commissioners. Click on “Consumer Information Source” and then

“Health Insurance” to access information about different types of

health insurance, your rights as a consumer, consumer fact sheets,

and other information. Phone 1-816-842-3600.

State and Local Organizations

State and local agencies – Check the blue pages of your phone

book to find the State and local health departments in your area.

Local chapters of national organizations – Check the white pages

of your phone book to find State and local chapters of national

organizations, such as the American Cancer Society and the

American Diabetes Association. Organizations like these often can

refer you to self-help and support groups and other resources in your

community.

15
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Using Measures to Evaluate Care

Health care measures help us to determine whether

services are being provided appropriately and at the right

time. 

For example, we know that:

• It is important to check whether a person’s blood

pressure is high because high blood pressure can

lead to heart disease.

• A patient who is admitted to the hospital with a

heart attack should be given aspirin and a betablocker.

Clinical performance measures and consumer ratings are

the two main types of quality measures. These measures

are used to check up on and improve the quality of

health care provided by doctors, hospitals, and other

providers, including nursing homes, community clinics,

and health plans.

Most of the measures described in this booklet are drawn

from the National Healthcare Quality Report, which is

prepared annually by the Agency for Healthcare

Research and Quality. See the inside front cover of this

booklet to find out more about the quality report and a

companion report, the National Healthcare Disparities

Report.

Other Quality Improvement Efforts 

In addition to the quality measures and other tools

discussed in this booklet and used in the National

Healthcare Quality Report, many other government and

private organizations have developed measures and tools

for assessing health care quality. These include report

cards, consumer ratings, and accreditation reports. See

pages 12-15 of this booklet for a list of resources on

quality assessment and improvement. 
Publication No. 05-0088

September 2005

U.S. Department of Health

and Human Services

Agency for Healthcare

Research and Quality

Rockville, MD

www.ahrq.gov