IN APRIL, the Agency for Healthcare Research and Quality published the 2014 National Healthcare Quality and Disparities Report,1 or QDR, which is mandated by the Congress and has been published annually since 2003.2,3 The latest report contains good news, but depending on what you are looking for, its findings might point you in a different direction. For instance, it is gratifying to learn that insurance rates have improved substantially, especially after implementation of the Affordable Care Act's Health Insurance Marketplaces. However, the QDR also tells us that major disparities persist in quality and safety of care-inequities that are by no means acceptable in our health care system.4-6 When health care quality improves for everyone at approximately the same rate, disparities that existed previously are carried forward-but this does not excuse the relatively poorer quality of care that some populations receive.

These findings may seem muddled, but that is because the delivery of health care is complicated. Ensuring meaningful measurement of its successes or failures is an ongoing challenge that we fully appreciate as we refine the QDR each year.

The QDR features annual trends on more than 250 measures compiled from more than 40 national sources. This report is both broad and deep. The large number of measures makes it necessarily complicated, but the findings are revealing. The QDR is much more than a snapshot in time-it is a yardstick by which we can truly gauge national progress on important measures of health care quality and disparities.

This report has been developed each year since 2003, but this year it is slightly different. Starting with the 2014 report, the QDR now tracks performance measures that align with the National Quality Strategy (NQS), which was mandated by the Affordable Care Act to catalyze and direct a nationwide focus on quality improvement efforts and approach to measuring quality.

We have also created user-friendly chartbooks7 to make the results of the QDR more immediately useful to nurses and other health care professionals. Data from the 2014 report are detailed in a series of topic-specific chartbooks. Each chartbook includes downloadable slides that nurses can use as teaching or presentation tools. The chartbooks are as follows: Access to Health Care; Patient Safety; Person- and Family-Centered Care; Care Co-ordination; Care Affordability; Healthy Living; Effective Treatment; and Rural Health Care. Additional chartbooks will include ones on women's health and Hispanic health.

The QDR features one additional instrument that nurses and other health care professionals will find useful in comparing their communities against national averages: State Snapshots, a Web-based tool that provides state-specific quality information, including strengths, weaknesses, and opportunities for improvement. State Snapshots can be used to determine your state's performance on more than 200 health care quality measures and pinpoint statewide health care quality weaknesses to target improvement initiatives.8

THE CENTRAL ROLE OF THE NQS

The Affordable Care Act is best known for its expansion of health care coverage to millions of Americans. But it also generated the NQS, which aims to improve health care, achieve healthy people and healthy communities, and improve the affordability of health care for all Americans. The Congress saw that US health care spending was (and remains) the highest per capita in the world; yet, Americans have shorter life expectancy than other wealthy countries, suggesting that the amount of money spent does not mean better health and health care.9

This was never due to lack of effort. Ever since the Institute of Medicine published its landmark reports on quality and medical error,10,11 there have been many efforts to improve the quality and safety of US health care, at federal, regional, state, and local levels; among both public and private sectors; and in large academic medical centers and small rural facilities. Many of these efforts have helped improve the quality of US health care.

However, even the most successful of these individual achievements cannot alone make care better and more affordable or lead to a healthier population. Moving toward this goal requires health care leaders and professionals to grapple with a discouraging array of barriers-nursing scope of practice and regulatory issues,12 competing priorities, confusing guidance, and duplicative reporting requirements, to name a few. The NQS was created to align efforts on a set of public and private sector, consensus-based national priorities and goals.

Therein lies the special power of this year's report: We can use it to track ongoing progress in achieving improved health and health care as defined by the overarching national strategy. Aligning the nation's report card on health care quality and disparities with the nation's overall strategy, the QDR now tracks progress along the 6 priorities that form the foundation of the NQS:

* Making care safer by reducing harm caused in the delivery of care

* Ensuring that each person and family is engaged as partners in their care

* Promoting effective communication and coordination of care

* Promoting the most effective prevention and treatment practices for the leading causes of mortality, starting with cardiovascular disease

* Working with communities to promote wide use of best practices to enable healthy living

* Making quality care more affordable for individuals, families, employers, and governments by developing and spreading new health care delivery models.13

The 2014 QDR shows that quality has improved for most of the NQS priorities. That is important news for nurses, who are often the first ones to see the impact of quality improvement activities either at the point of care or through the management of hospital patient safety efforts.

IMPACT ON ACCESS, DISPARITIES

The 2014 QDR also provides an opportunity to look at how the Affordable Care Act impacts access to health care. The report's findings about coverage are unmitigated good news. Data covering January to June 2014 show that the overall rate of uninsurance (people lacking health coverage) decreased substantially to 15.6% in the second quarter of 2014, from a high of 22.3% in 2010, among Americans aged 18 to 64 years.14 The decline in uninsurance was greatest among blacks and Hispanics, who historically have had higher uninsurance rates. For blacks, the uninsurance rate decreased from 24.6% in the last quarter of 2013 to 15.9% in the first half of 2014. During the same period, the uninsurance rate dropped from 40.3% to 33.2% for Hispanics. These findings indicate that the Health Insurance Marketplaces, established under the Affordable Care Act, are enabling many Americans to gain access to the health care system.

Other disparities also have been greatly reduced. For instance, Hispanic adults with obesity received nutrition counseling and advice to eat fewer high-fat foods at similar rates as other adults with obesity, compared with 2004 when 41% of Hispanic adults and 50% of white adults received counseling. And, American Indian children received hepatitis B vaccines at similar rates as other children, compared with 2002 when 81% of American Indian children and 91% of white children received the vaccine.

But inequity is a stubborn thing. The QDR documents that blacks and Hispanics still had lower access to care for about half of the access measures tracked in the report, which include encountering difficulties or delays in receiving care. A few disparities were eliminated, but most were not; people in poor households generally experienced less access and poorer quality. Disparities in quality and outcomes by income and race and ethnicity are large and persistent, and they were not, through 2012, improving substantially.

NURSES' ROLE IN IMPROVING QUALITY

The 2014 report shows that one measure of patient safety improved quickly. The rate of central line-associated bloodstream infection per 1000 medical and surgical discharges (age 18+ years or obstetric admissions) improved at an annual rate of change of more than 10%. Through the fall of 2012, this infection was the focus of a major Agency for Healthcare Research and Quality project that led hospital intensive care units to reduce central line-associated bloodstream infections by 41%.15 This success reflects the direct impact that nurses can have in making care safer for their patients. Many nurses led individual intensive care unit efforts in that project. Without the work that nurses put in at the unit level, it is hard to imagine the project would have reached the same level of accomplishment.

Our health care system depends heavily on nurses, not only as providers of care but also as leaders of quality improvement. Put simply, making care better, making it more affordable, and improving the health of Americans cannot be done without the engaged participation of nurses. We have made a lot of progress and learned a great deal about how to effect change, but there is more to be done. Keeping everything pointing north requires nurses' leadership and guidance to steer health care quality in the right direction. This means we rely on nurses to help us understand what works and what does not and to contribute effective solutions that can positively impact patient safety and quality.

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