3.3. Main Findings. Guiding Question 1: Which frameworks have been developed or are used for quality of care?

Findings - Updating the Framework for the Agency for Healthcare Research and Quality’s National Healthcare Quality and Disparities Report - NCBI Bookshelf An official website of the United States government Here's how you know The .gov means it's official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you're on a federal government site. The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely. Log in Show account info Close Account Logged in as: username Dashboard Publications Account settings Log out Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation Bookshelf Search database Books All Databases Assembly Biocollections BioProject BioSample Books ClinVar Conserved Domains dbVar Gene Genome GEO DataSets GEO Profiles GTR Identical Protein Groups MedGen MeSH NLM Catalog Nucleotide OMIM PMC Protein Protein Clusters Protein Family Models PubChem BioAssay PubChem Compound PubChem Substance PubMed SNP SRA Structure Taxonomy ToolKit ToolKitAll ToolKitBookgh Search term Search Browse Titles Advanced Help Disclaimer NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health. Ye F, Zhang D, Martino S, et al. Updating the Framework for the Agency for Healthcare Research and Quality’s National Healthcare Quality and Disparities Report [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2025 Jul. (Technical Brief, No. 50.) Updating the Framework for the Agency for Healthcare Research and Quality’s National Healthcare Quality and Disparities Report [Internet]. Show details Technical Brief, No. 50. Ye F, Zhang D, Martino S, et al. Rockville (MD): Agency for Healthcare Research and Quality (US) ; 2025 Jul. Contents Search term < Prev Next > 3 Findings This Technical Brief drew on multiple sources of information, including input from Key Informants, documents in the grey literature, and documents in the published literature. This section provides an overview of the key findings by source of information. The remainder of the result chapter is organized by the Guiding Questions. The chapter documents existing quality of care frameworks as well as a suggested revision of the National Healthcare Quality and Disparities Report ( NHQDR ) framework. 3.1. Key Informant Input Key Informants were generally in agreement that this Technical Brief addresses the right questions. One common suggestion from Key Informants was to delineate the framework for population health and the framework for healthcare quality, noting the lack of a population health perspective and disconnect between healthcare quality and population health. Another frequent suggestion was to differentiate the intended use and the actual use of the framework, as they may not be the same. We further asked Key Informants whether they could recommend an established quality of care framework. There were no suggestions for a framework that was ready to potentially underpin the NHQDR going forward, but Key Informants suggested several frameworks that may help in updating the NHQDR framework or they suggested sources that may have published a relevant framework. Key Informants also emphasized the need to consult sources other than scientific journal publications as well as the international literature. Suggestions for relevant work included those that integrate social determinants of health and other drivers of health with a healthcare focus. Some discussion focused on the challenge of defining social determinants of health, the lack of comprehensive systems, and arguments that social class may be more predictive than variables such as race. Furthermore, there is a need for distinction between broad environmental social drivers of health and individual unmet social needs including their implications for measurement. A stated example was one cannot deliver safe care for a person with diabetes unless one knows whether they have food insecurity. Some Key Informants recommended an equity-centered quality measurement framework for addressing quality of care, while emphasizing that the equity-centered quality framework may serve a different purpose from the framework underpinning the NHQDR. A shift in focus from traditional clinical metrics to a more equity-focused approach in healthcare measurement is likely needed, similar to a shift from a disparity focus to an equity focus. Some discussions focused on disparities and system performance, examining disparities by comparing healthcare system performance within and across regions, and identifying the potential for improvement (e.g., by examining the gap between current performance and optimal performance). Furthermore, discussions centered on initiatives aimed at reducing disparities, especially in underserved minority populations, and the challenges in scaling these efforts nationally, as well as the increasing focus on systems of oppression and structural racism as central factors in health disparities. Discussions focused also on the difference between a framework for assessing healthcare system performance and evaluating broader public health outcomes. Similarly, care delivery measures are different from public health measures where care delivery quality is strongly condition specific. Other discussions addressed the challenge of communicating healthcare equity and quality measures in a way that influences policymakers and aligns with health system goals. Most Key Informants agreed that the 2010 framework would benefit from updates. However, Key Informants expressed concerns that the existing framework is insufficiently used and suggested that the framework may need to be re-conceptualized completely. One suggestion was to develop a comprehensive model incorporating health system access, social determinants of health, implementation science, and payment reform. Several Key Informants pointed out that the existing framework lacks the population health perspective and indicated that a shift from health to well-being may be useful, as well as displaying the connection between healthcare quality and population health more clearly. Suggestions for concepts that should be included or emphasized stronger in the framework included social determinants of health or social drivers of health. Social drivers of health play a critical role in shaping healthcare outcomes. Better integration of drivers of in the framework will help to better address disparities. Some of the discussions centered around challenges for current measurement practices and the potential of using incentives to drive improvement in care that focus on diversity, equity, and inclusion ( DEI ). There are no established measures that quantify how good an organization is at implementing DEI or that could be used in a reward system. One specific suggestion was to either remove the types or care or to expand it to include end of life care (care without curative intent). Others stressed the importance of a community-centered perspective: the healthcare system can bring along with the community elements, including conditions that people live in, resources that people need to enable them to achieve health and well-being. This entails exploring what roles the healthcare system should play in addressing public health issues and social drivers of health. For example, blood pressure control and glycemic control require resources and skills that the healthcare system can bring along with community elements. Key Informants emphasized the need for healthcare systems to work closely with communities and to foster integration of healthcare and community to address broader drivers of health. A further domain to integrate in the framework may be health literacy, given that health literacy affects how people are able to access, interact with, and benefit from the healthcare system. Promoting patients’ health literacy is associated with patient activation measures, or other measures of patient engagement and empowerment in healthcare decision-making. This can include the family given that decision-making is often family centric. A further suggested concept that may be lacking was whole-person care. Care coordination should emphasize whole person. The important coordination is not necessarily across specialties or across providers, but it could also be connected to other sectors such as housing and end of life care to ensure a more holistic model of care. The framework could expand to social drivers and social service organizations. In addition, Key Informants discussed the role of education and social drivers of health and stressed that healthy behaviors are driven by education levels and translate into income disparities. Frameworks need to generalize sufficiently to incorporate a range of different systematically underserved groups. This includes different dimensions of equity, including challenges faced by people with disabilities beyond race and ethnicity. Furthermore, it was emphasized that primary care holds a critical role in delivering high-value, equitable care. In terms of changes to the existing framework, one Key Informant noted that the inclusion of health systems infrastructure capabilities may need to be reframed or further defined. Discussions included suggestions to expand to a broader set of structural factors, some of which are health systems related, others are larger environmental systems level, or to restrict to aspects that are amenable to change to support equitable and accessible care. Several Key Informants stressed that integrating social determinants of health in a quality-of-care framework is still a rapidly changing area, and it is important to have a framework that can be adjusted to further changes in terminology and operationalizations. Key Informants called for a clearer description of the terms equity , value , and person-centered in the framework as the definitions may have changed over time. Key Informants highlighted that equity and value are currently separate outcomes and achieving one may not necessarily improve the other. However, they could be conceptualized as interconnected and depicted in a way that if the objective function is equity, you get value. 28 Key Informants advocated for treating equity as an integral part of quality care, embedded in all aspects of healthcare delivery rather than a separate domain. Several Key Informants highlighted structural problems of the U.S. healthcare system, mentioning a broken system as well as the lack of a system and segmented care. Key Informants also noted that the U.S. distributes resources differently from other countries, i.e., spending two thirds of spending into care delivery rather than public health. Finally, multiple content experts also addressed the disconnect between healthcare and population health. Key Informants agreed that dimensions to compare and critical appraisal of frameworks are important but had few suggestions regarding tools that could be used to appraise frameworks. Observations on framework development included emphasis on consensus finding when establishing frameworks and selecting domains and measures. Engaging interest holders and incorporating different perspectives in the development of frameworks. Advocating for more inclusive approaches was also highlighted, in particular to ensure that patient and community advocacy voices inform our understanding of healthcare quality. In addition, there are recent advances in measurement, especially in capturing patient experiences and frameworks need to adapt to the evolution of measurement domains. Key Informants that had developed or revised frameworks for their agencies highlighted the importance of working with a multi-disciplinary group. A further aspect that is critical to frameworks is the engagement with end users and the importance of involving a diverse range of end users to ensure that tools are practical and useful. Appraising the tradeoff between measurement burden and evidence of impact on outcomes was also frequently mentioned in discussions. Discussions focused on measurement overload and Key Informants advocated for developing a concise and effective set of measures to capture healthcare quality and equity without overwhelming interest holders. Further considerations were the importance of actionable metrics, i.e., rather than an exhaustive list of measures, selecting a small number of actionable measures that can drive improvement. It is easy to add measures, but there needs to be a focus on areas where there is evidence that measuring something will improve outcomes. Equity is not going to have the same level of evidence because the impact may not have been evaluated in a large randomized controlled trial. But emphasis needs to be on meaningful metrics that reflect true improvement rather than simply measuring for compliance or comparison. Some discussions focused on the exploration of how technology and standardized data can support the transition to quality measures that enhance equity and address social drivers of health. A further suggestion when comparing and appraising frameworks was to pay attention to the contexts in which frameworks were developed, which will account for some differences across available frameworks. Some of the discussion focused on the difference between framework alignment and intersection in quality reporting where alignment describes a policy effort to derive shared domains or measures. Discussions with the Agency for Healthcare Research and Quality ( AHRQ ) around the framework use and function aimed to understand better which changes to the current framework would be most helpful. The NHQDR is mandated by Congress and AHRQ submits a yearly report to congress. However, the audience of the reports and particularly the NHQDR website tools, is much broader. Combining the originally parallel reports on quality of care and care disparities was triggered by the fact that both reports had substantial overlap and the conceptual decisions that both areas are intrinsically linked, and we cannot have quality of care if there are disparities. Discussions with AHRQ also indicated that the framework cannot be too specific (e.g., pre-specify the chapters of the NHQDR), because the team needs flexibility to be able to address changing priorities over time. Regarding the question of whether the NHQDR should address only healthcare (i.e., target only measures that are under the control of the healthcare system, or expand to health (i.e., to provide a full picture of the nation’s status), is a complex question. To some extent, the healthcare system may already be held accountable for drivers of health (e.g., social determinants of health), that are outside the purview of healthcare. 3.2. Literature Review Results The flow diagram ( Figure 6 ) shows the disposition of identified sources of information. Figure 6 Flow diagram. Across sources, we reviewed over 8,786 citations, 2,864 publications were obtained as full text. We identified 4 frameworks developed specifically for the NHQDR or its predecessor reports and 150 frameworks reported in the international literature. The frameworks were described in 172 publications. 1 , 5–9 , 29 , 36 , 91–254 In addition, 497 background articles provided additional information relevant to the project or were retrieved for reference-mining to potentially identify additional frameworks. The list of included, background, and excluded publications are shown in Appendix B . 3.3. Main Findings. Guiding Question 1: Which frameworks have been developed or are used for quality of care? The identified frameworks are summarized in the evidence table in Appendix C . The earliest included framework was the 1966 Donabedian quality of care framework introducing structure, process, and outcome measures, 131 but most frameworks were published more recently, many in the last two years, indicating a renewed interest in addressing quality of care. Examples are a recent framework developed by the National Committee for Quality Assurance with overall well-being at the center, 189 the Centers for Medicare & Medicaid Services ( CMS ) framework for outlining priorities for health equity, 123 and a framework developed to support a large scale assessment of Australia’s health performance. 107 Figure 7 depicts the number of publications by year. Figure 7 Number of framework publications by time period. Identified frameworks were developed in Australia, Belgium, Canada, China, Greece, Iran, Japan, New Zealand, Nigeria, Portugal, Qatar, Saudia Arabia, Singapore, Sweden, Switzerland, Taiwan, the Netherlands, United Kingdom, and US, or were multi-site (e.g., developed by a European committee). All included frameworks addressed quality of care; however, the role of care quality in the model varied. Some publications showed quality of care dimensions as the only topic or the center of the framework, 104 , 125 , 137 while other frameworks depicted healthcare quality in the context of other healthcare performance characteristics. More recent conceptualizations often highlighted healthcare quality as only one of many factors driving health. These frameworks included in particular non-medical determinants of health or community and health system characteristics. 118 An example is the current Australian health performance framework that embedded health systems characteristics in a complex model of determinants of health (socioeconomic factors, health behaviors, personal biomedical factors, environmental factors), health system context (demographics; community and social capital; governance and structure; financing; workforce; infrastructure; information, research and evidence), with equity as an overarching domain, and health status parsed into different components (health conditions, human function, well-being, deaths). 107 The frameworks included very different domains. Using the latest framework specifically developed for the NHQDR 7 as an anchor, we collated a framework component table to summarize the relative frequency of domains in the identified framework (see Appendix D ). Figure 8 shows the frequency of domains across frameworks from the international literature meeting eligibility criteria. The figure excludes frameworks specifically developed for the NHQDR or its predecessors National Healthcare Quality Report and National Healthcare Disparities Report. Figure 8 Domains included in identified frameworks. Abbreviations: SDOH = social determinants of health Two thirds (60%) of the identified frameworks included the domain access . Over half of the frameworks included equity (52%), while few used the term disparities (10%). Other frequently depicted domains were effectiveness (50%) and safety (46%). Similarly, about half (55%) of the frameworks included system capabilities or system limitations in the framework. Only a small percentage of frameworks mentioned value (9%). The frequency analysis informed the update of the NHQDR framework documented in Guiding Question 2. We were particularly interested in the concept of equity in published frameworks, and Figure 9 tracks the inclusion of equity, disparities, and social determinants of health in published frameworks (excluding frameworks specifically developed for the NHQDR or its predecessor reports). Figure 9 Number of published frameworks that include the domains disparities, equity, or social drivers of health by year. Notes: SDOH social drivers of health The figure shows how the interest in disparities, equity, and social drivers of health have generally increased over time based on the analysis of published frameworks. An uptake of equity in inclusion in frameworks in U.S. publications is likely associated with an executive order on advancing racial equity and support for underserved communities through the federal government in January 2021. 255 In addition to the content of the frameworks, we also collected information about the development process and endorsement of the framework. The evidence table ( Appendix C ) summarizes the process where the publication provided details on the development of the framework. Authors often reported a literature review, followed by discussions with content experts, and a workshop for committee members charged with developing the framework. A large proportion of the frameworks were endorsed by health agencies such as the Assistant Secretary for Planning and Evaluation ( ASPE ) rather than published by individual authors. Half of the authors explicitly stated the framework was developed with interest holder engagement or input from different perspectives. However, only a third of all authors mentioned an evidence-based process with empirical data contributing to the development or validation stage of the framework or its components. Almost all identified frameworks defined the population the framework aimed to depict, although for some frameworks, the population was a very broad category (e.g., the general public 29 or users of the healthcare system 165 ). Frameworks also varied widely regarding reporting validity testing, such as applying the framework to a set of quality of care measures. Finally, all frameworks that included a model or figure are depicted in full Appendix E where copyright agreements permitted. 3.3.1. Findings. Guiding Question 1a: For what settings, populations, and intended use were the frameworks developed? The two most frequent settings for identified frameworks were healthcare, and population and public health. Other settings included care management, hospital, regional healthcare (e.g., Ohio, Boston), 64 , 256 primary care and family practice, home-based medical care, community-based healthcare, and research and policy. Populations for the identified frameworks include general U.S. population (most common), non-U.S. or global populations (e.g., Europe), regional populations (e.g., residents of Ohio). Populations also included persons with chronic and complex health needs, healthcare centers and professionals, users of nursing care or primary care, Medicaid enrollees and healthcare system users, and individuals experiencing disparities, and minority populations. Frameworks serve different purposes, such as supporting the reporting of quality, providing accountability for systems, or monitoring quality improvement. The evidence table in Appendix C documents the intended use of the identified frameworks in detail. Half of the identified frameworks did not report the context or contexts for which the framework had been developed or to which it has been applied. Some were intended to describe and assess quality of healthcare, assess health system performance (including healthcare system in general, and more specific systems such as hospital, primary healthcare systems, and Medicaid managed care). Others were designed to improve the public’s health and reduce health disparities or address health equity and social determinants of health (where the intended use was reported). 3.3.2. Findings. Guiding Question 1b: How are the framework domains defined? We included quality of care and care disparities frameworks. While often not explicitly defined, a review of the frameworks indicated that both quality of care and disparities were conceptualized differently across frameworks. For the NHQDR , quality was described as follows: Quality: Performance of the healthcare delivery system with regard to personal healthcare, rather than public health functions. 5 This definition has guided the National Healthcare Quality Report and represents a specific and deliberately narrow conceptualization of healthcare quality. The first National Healthcare Disparities Report defined disparities as follows: Disparity: The condition or fact of being unequal, as in age, rank, or degree. Synonyms for disparity include inequality, unlikeness, disproportion, and difference. While disparity in healthcare has been closely associated with equity, there are several potential reasons for the differences observed at the individual level. The purpose of this National Healthcare Disparities Report was to describe differences in quality of and access to healthcare to help identify disparities in health outcomes that may be responsive to improvements in healthcare. Disparities are most easily identified when there is a clear reference point for what is appropriate and reasonable to expect. The presented quality measures have been developed around healthcare interventions for which there is sound scientific evidence of effectiveness and for which there is a professional consensus and expectation that these services would be provided to all patients. Even after consideration of variation in a patient’s medical conditions and severity of illness, there should be little deviation from specific quality measures associated with population. 2 Many frameworks intended to be used for describing and assessing quality of healthcare include all or some domains of the STEEEP (Safe, Timely, Efficient, Effective, Equitable, Patient-Centered) model, 8 defined as follows: Safe: Avoiding harm to patients from the care that is intended to help them. Timely: Reducing waits and sometimes harmful delays for both those who receive and those who give care. Efficient: Avoiding waste, including waste of equipment, supplies, ideas, and energy. Effective: Providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit (avoiding underuse and misuse, respectively). Equitable: Providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status. Patient-centered: Providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions. The domains are defined differently in the identified frameworks. This includes the definition of equity , where our understanding has shifted from providing the same care to consistent and systematic fair, just, and impartial treatment of all individuals. 255 , 257 Frameworks differed in whether they focused on equality in treatment, equity in treatment, or equity in health. Health equity addresses individuals having fair and just opportunity to attain the highest level of health. 258 The latter is not necessarily or sufficiently achieved through equal care. The framework domain patient-centered has also often been modified and further developed. For example, it was expanded in the 2010 framework recommendation for the NHQDR to read patient/family centered. Key Informants also stressed that patient-centered means ensuring health literacy goals are met, i.e., to ensure that patients are aware of the options before expressing preferences, needs, and values; and may need to expand to patient/family/community-centered. Another emergent paradigm shift is the change from patient to person, i.e., rephrasing the domain as person-centered care. This change in perspective focuses on the person rather than the patient. It is routed in the concept of whole health which shifts the focus from disease-oriented medical care to health and well-being. 259 Furthermore, well-being is defined by the individuals, their families, and their communities. A further concept is value that was introduced in 2010 into the NHQDR framework and was defined as follows: 7 Value: A measure of stakeholder utility (subjective preference by a group or individual) for a particular combination of quality and cost of care or performance output. Most identified frameworks for assessing quality of care and healthcare system performance included the domains equity and efficiency . While there may be uncertainty regarding many aspects of clinical care, the quality measures presented here have been developed around healthcare interventions for which there is sound scientific evidence of effectiveness and for which there is a professional consensus and expectation that these services would be provided to all patients. After consideration of variation in patients’ medical conditions and severity of illness, there should be little-to-no deviation in quality associated with demographic group membership. The frameworks intended to assess health system performance include predominantly the quality-of-care domains of structure, process, and outcomes. For example, in the Donabedian framework, structure is defined as the capability of the context in which care is delivered, including hospitals, buildings, staff, financing, equipment. 131 Processes are the care services provided, while outcomes refer to the health outcomes of patients. Care quality in this model is assessed in the process measures, while outcomes measure quality of care indirectly. 260 The frameworks aiming to address equity include similar components as the frameworks for determinants of health, including healthcare system, health status, health-related quality of life and well-being, and non-healthcare drivers of health, such as personal and behavioral factors, social and community networks, general socio-economic, cultural, and environmental conditions. 3.3.3. Findings. Guiding Question 1c: In what context have these frameworks been used? Half of the identified frameworks did not report the context for which it had been developed or applied. Among those that did report, the context varied widely. In general, the frameworks intended to describe and assess quality of healthcare have been used for clinical practice regarding education, direct patient care and leadership, Medicare local indicators, hospital/local health networks, education, training, research, and policy. The frameworks intended to assess health system performance have been used in diverse healthcare settings and among various levels within a delivery system, and in the context of analyzing the admitting process, the point of entry, and input into the hospital system. The frameworks aimed to address equity, disparity, or social drivers of health have been used in the contexts of racial justice and health equity, public health, public policy, youth leadership development, leveraging public and private sector partnerships and resources, and more. Contexts included international jurisdiction (e.g., World Health Organization–Core Health Indicators, European Union Health Promotion Monitoring); 29 national jurisdiction (e.g., U.S. Healthy People 2020); 128 and local jurisdiction (e.g., County Health Rankings published by the Robert Wood Johnson Foundation). 220 3.3.4. Findings. Guiding Question 1d: How do these frameworks intersect with levers and tools available to federal and state governments? The National Quality Strategy as a national effort to guide quality improvement efforts across the U.S. differentiated nine levers to achieve the aims and priorities: payment; public reporting; learning and technical assistance; certification, accreditation, and regulation; consumer incentives and benefit designs; measurement and feedback; health information technology; workforce development; and innovation and diffusion. 261 We systematically abstracted any information on how published frameworks and their intended use are associated with levers and tools available to federal and state government such as policy and legislative changes. Table 3 shows all U.S. framework publications. Table 3 Framework associations with levers and tools available to federal and state governments in U.S. developed frameworks. A few frameworks were developed with the alignment of quality initiatives and policy making in mind, so that the frameworks can be used by policymakers to form a clearer image of what it is they want to measure and the key goals of health policy. 102 , 106 , 119 , 121 For example, in the National Quality Strategy framework, CMS ’s initial actions include developing dashboards to inform policy decisions and increasing alignment across quality initiatives with policies 122 to improve quality in high priority clinical areas. In our Key Informant discussions, one Key Informant suggested building the link of the framework with the policy levers of federal and state governments before applying the framework to track the trends due to policy changes. Other Key Informants recommended that tracking the effect of policy should be the subject of research publications, rather than being an integral part of the NHQDR . 3.3.5. Findings. Guiding Question 1e: How are the frameworks and domains similar to or different from the 2010 National Academies of Sciences, Engineering, and Medicine (NASEM) framework? In general, the frameworks intended to describe and assess quality of healthcare are similar to the framework suggested for the NHQDR in 2010in that they include all or some STEEEP domains, 8 and many also include access to care and equity . Identified frameworks varied regarding inclusion of other domains as shown earlier in Figure 4 . The 2010 framework also includes the crosscutting domains equity and value . Both are included in several other frameworks, but with different definitions. For example, in the Comprehensive Model of Patient Centered Care and Outcomes, value represents patient values and cultures. 231 A framework referencing Berwick’s triple aim uses the term value in the context of cost effectiveness (best value for public health system resources). 103 Some of the Key Informants understood value as a reference to value-based care, i.e., a healthcare delivery model that rewards quality of care and patient health outcomes rather than throughput (volume of care services rendered). 263 Furthermore, the identified frameworks that aim to address equity and the frameworks for drivers of health were generally broader in scope (e.g., governance and leadership, and financial sustainability, social, political, and cultural drivers of health), while the 2010 NASEM framework more narrowly addresses healthcare delivery. The 2010 NASEM framework differentiates types of care, i.e., preventive care, acute treatment, and chronic condition management. Only one other identified framework explicitly included types of care; it differentiated a continuum of care, ranging from health promotion/prevention to diagnosis/treatment. 176 Almost all frameworks include domains not included in the 2010 framework suggested for the NHQDR . Examples of domains often unique to the identified framework included availability, affordability, choice, communications, coverage, dignity , and engagement . We have abstracted all additional domains, and the results are presented in the context of each framework in Appendix C . Of the identified frameworks, several referred to the term environment , both as the practice environment 211 as well as environmental factors as a determinant of patient health. 118 The concept of social determinants/drivers of health was integrated in multiple frameworks. 96 , 119 , 128 , 147 , 160 , 202 , 249 The concept of appropriateness was also mentioned in identified frameworks, for example culturally and linguistically appropriate care and care resources. 36 , 207 Patient experience was also frequently part of frameworks. 29 , 121 , 196 Each frequently included domain was considered in detail to determine whether the concept is included in a domain of the NHQDR framework, whether it should be added to the NHQDR framework as a new domain, or whether it should be added to a description of an existing framework domain to make this connection more obvious to users of the NHQDR. Multiple frameworks incorporated Donabedian’s structure, process, outcome domains explicitly. 94 , 96 , 116 , 131 , 165 , 172 , 181 , 202 , 203 , 211 , 219 , 225 , 228 The concept of responsiveness was also frequently part of frameworks, 102 , 121 , 152 , 162 , 185 , 229 , 230 , 233 , 249 in particular responsiveness to patient expectations and health goals. Several also included integrated care as a feature of the healthcare system. 121 , 170 , 208 , 216 Many frameworks referenced organizational culture , for example referencing a quality culture. 157 , 172 , 206 , 216 , 229 , 231 Furthermore, sustainability was repeatedly part of frameworks, often referring to financial sustainability of programs. 107 , 110 , 147 , 169 , 185 , 192 , 216 , 219 , 251 , 252 A further recurrent organizational domain was productivity as a performance domain. 169 , 178 , 229 , 233 Domains varied widely and were often purpose specific. Half of all included frameworks mentioned health explicitly, most often in the contexts of patient health status (the 2010 NASEM framework does not include the term health ). Well-being 107 , 127 , 157 and wellness 159 , 252 were also frequent framework components. In addition to the included domains of care quality, it is also important to determine how the domains are interrelated, i.e., how the individual domains interact within the framework. The current NHQDR framework provides only limited information regarding how the framework domains are connected. The 2010 NASEM report stressed that care coordination and health systems infrastructure are not necessarily healthcare aims or attributes themselves, but foundational elements, i.e., means to enable improving effectiveness, safety, timeliness, patient-centeredness, access , or efficiency . 7 We also systematically reviewed all identified frameworks for any information explaining how the domains fit together in the frameworks. This is documented in Appendix C . Across included frameworks, we found few descriptions of relations between domains. Exceptions include the Donabedian model explicitly stating that structure affects process, which affects outcomes; 131 , 165 the relationship was also described in other frameworks 116 , 203 citing Donabedian. Furthermore, several frameworks described cross-cutting domains and how these interact with the other framework domains. 100 , 102 , 107 , 118 , 121 , 139 , 174 , 206 , 207 , 246 , 248 , 251 Which domains were considered cross-cutting varied across frameworks (e.g., patient-centeredness, safety, equity ), with equity most frequently conceptualized as cross-cutting. One publication stated that all its framework domains interact with each other. 213 One publication presenting a complex, multi-level framework hypothesized that health equity as a goal of the organization leads to collecting health equity information, which leads to community participation and engagement with communities affected by health inequities, which leads to planning and enacting effective strategies to address inequities, which is comprised of addressing determinants of local health inequities and orienting local primary healthcare services towards health equity. 135 One framework conceptualized person-centered outcomes as a central measure, and that identifying what matters to the person leads to more efficient, effective, and equitable healthcare. 190 In other published frameworks, information on the interrelationship of domains in existing frameworks was typically limited to how drivers of health affect individual patients’ health 238 or population health more broadly, 193 including health-related behaviors. 132 This included frameworks pointing out how upstream pathways from social determinants of health to racial inequity leads to midstream determinants, which leads to downstream determinants, which then leads to disease. 160 In addition, several frameworks provided information on which subdomains are part of the domains (e.g., the patient-centered delivery system consists of the patient, care team, healthcare system, and external context). 231 Some models stated explicitly what the framework sections entail (e.g., one framework outlined that hospital performance is comprised of a patient perspective, financial perspective, quality of care perspective, internal business perspective, and learning and growth perspective). 93 Some of the frameworks provided a broad overview, for example how health system design, policy and context affect healthcare system performance 121 or how policies affect health factors, which then affects health outcomes. 220 Another publication addressed how health status affects access to healthcare. 180 3.4. Main Findings. Guiding Question 2: How could the NHQDR framework and its domains be updated? We have assessed each identified framework published in the literature for suitability of being adopted by the NHQDR , but did not identify any tool that seems to fit the NHQDR considering the purpose of the NHQDR. The annual reports and the online resources are unique in that they provide a picture of the current US healthcare landscape. The NHQDR does not provide measurement and performance feedback for individual organizations, certifications, or incentives and is therefore different from the purpose of many existing frameworks identified in the literature. The NHQDR does not request specific data and instead uses measures available from other sources to compile the report, which has implications for how the measures are selected and what function the framework serves. The NHQDR framework also needs to consider the broad audience of the NHQDR. In addition to the annual report to Congress, the NHQDR online resources are widely used by a very different audience, including researchers and students. As outlined, the NHQDR framework has undergone considerable changes throughout the years, both in format and function. We used the last published framework update in 2010 as the basis of our proposed suggestions for the proposed revisions. Figure 10 shows the proposed revision of the framework, informed by the outlined sources. Figure 10 Proposed updated NHQDR framework. The proposed framework continues to focus on quality of healthcare, rather than expanding to the health status of the population. The framework includes the domains person-centeredness, equity, access, effectiveness, safety, timeliness, efficiency , coordination , and levers addressing drivers of health . The proposed framework differentiates four types of care , including preventive care, acute treatment, chronic condition management, and end of life care, where quality of care and care disparities measures can be applied for a comprehensive evaluation. In addition, the framework distinguishes different care settings , such as primary care practice, specialty care practice, emergency department, hospital, nursing home, hospice, home care, or the community. The following provides the definitions of the guiding ( person-centered ), foundational (access, coordination, levers addressing drivers of health), performance-indicating ( effectiveness, safety, timeliness, efficiency ), and crosscutting ( equity ) domains below, adapted from definitions in the 2010 NASEM report, building on the STEEEP model. 8 Person-centeredness : Providing care that is respectful of and responsive to the values, preferences, needs, experiences, and care goals of individuals in the context of their community, that guides all clinical decisions. This umbrella domain entails a number of different aspects. Care goals may require different levels of support to achieve goals for different people. This domain is not limited to care needs from a medical standpoint but is centered around a person’s perspective and experiences. It should consider the whole person and align with a shift from a disease and symptom-focused to a health and well-being-focused approach. Person-centeredness entails that each person is engaged as a partner in their care. 9 What matters to individuals, their caregivers, their families, in the context of their community is the overarching domain that should be the first priority, governing all aspects of care. Equity : Fair, just, and impartial treatment of all individuals, with individuals having fair and just opportunity to attain the highest level of health, is the lens through which access to care and quality of the received care is evaluated and healthcare disparities are identified. The domain encompasses equity in health and equity in healthcare. Access : Ability to get needed care. It is traditionally defined as timely use of personal health services to achieve the best possible health outcomes. 156 Access is a broad topic with multiple dimensions spanning insurance coverage, affordability, health literacy, geographic availability, culture, stigma and mistrust. It may entail making quality care more affordable, not just for individuals but also families, employers, and governments, 9 to enable and ensure access to quality care. A health crisis such as the COVID-19 pandemic can foster additional access issues and disparities (e.g., access to digital resources, telehealth). Effectiveness : Providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit (avoiding underuse and misuse, respectively), as well as selecting the most appropriate intervention. Benefits must be weighed against harms, and the most appropriate intervention may be no intervention or no medical intervention. It should increasingly be guided by comparative effectiveness data. The domain encompasses effective prevention, screening, diagnosing, and management as well as treatment, in particular for leading causes of mortality 9 such as cardiovascular disease 264 to align with the National Quality Strategy. Safety : Avoiding, preventing, and reducing harm or risk of harm to individuals from the care that is intended to help them. 9 Safety includes the AHRQ Patient Safety Indicators that address potentially avoidable safety events such as in-hospital complications and adverse events following surgeries, procedures, and childbirth. 265 While healthcare can strive to avoid preventable harms, there are inherent trade-offs when considering patient choice, preferences, and characteristics, as well as care services and care systems. In recent years, safety has been assessed in the context of the COVID-19 pandemic, given that the public health emergency disrupted many normal activities in hospitals and other facilities. 90 Timeliness : Obtaining needed care and minimizing unnecessary and potentially harmful delays in getting care. This domain is unchanged and has been included in the NHQDR framework since its inception. 5 While traditionally anchored in acute care, this domain deserves more attention with regard to prevention and lifestyle changes (e.g., addressing childhood obesity to avoid the development of diabetes in young adults). Efficiency : Avoiding waste, including waste of resources, equipment, supplies, ideas, energy, time, and duplication of services. The current NHQDR framework defines this domain as maximizing the quality of a comparable unit of healthcare delivered or unit of health benefit achieved for a given unit of healthcare resources used. 266 This domain was introduced in the 2010 NASEM framework revision 7 and remains unchanged. Efficiency was not included in earlier versions of the NHQDR as the committee at the time felt that, in particular the basic aspect of efficiency ‘cost per unit of service’ was falling outside the purview of a national report focusing on the quality of healthcare services. 5 However, efficiency is of particular importance to the U.S. healthcare system due to its fragmentation, which can lead to duplication of services (e.g., diagnostic tests in different settings) and wasting patients’ time and resources due to lack of coordination. Coordination : Ensure individuals receive well-coordinated care within and across healthcare organizations, settings, and levels of care, and across services and across time. Care coordination is a proactive approach to bringing together care professionals and providers to meet the needs of service users to ensure that they receive integrated, person-focused care across various settings. Similar to efficiency, coordination of care is of particular importance to the U.S. healthcare system due to its fragmented nature and lack of integration. The implementation of electronic health records aimed to improve care coordination through making communicating and sharing information more efficient 267 and more effective. Coordination can foster continuity of care, the degree to which a series of discrete healthcare events is experienced by people as coherent and interconnected over time and consistent with their health needs and preferences. 268 As our understanding of drivers of health grows, the coordination may need to include coordination with services outside of healthcare to ensure basic needs are met, including housing, nutrition, and other social needs. Levers addressing drivers of health : Demonstrating strategies that aim to reduce healthcare disparities and strategies to promote health equity. This domain is not limited to documenting disparities in healthcare that may become apparent in the equity domain. This domain may includes efforts to promote health equity through reducing disparities in healthcare and health, through counteracting discrimination, and through compensatory healthcare processes with the goal of achieving equity in health outcomes (e.g., increased screening for at risk populations). This domain may include prevention and initiatives to improve health behavior and foster health literacy. It includes actions to address social determinants of health, but is not limited to behavioral or social drivers. Addressing drivers of health may entail working with communities to promote healthy living (e.g., targeting physical activity, nutrition, or stress). 9 The proposed updates to the framework include several suggested changes. First, the framework shows person-centeredness as the overarching domain that should guide all aspects of care. The principle interacts with all other domains in the framework. For example, to ensure person-centered care, healthcare needs to address drivers of health, including social determinants of health. Vice versa, personal experiences are shaped by all other domains (e.g., access , efficiency , and timeliness of healthcare services). Effectiveness can mean different things for different people when guided by person-centered care to find the most appropriate care approach. The proposed framework suggests changes in the terminology from patient/family-centeredness to person-centeredness and changes the position of this domain to an overarching position of the framework. The move represents the importance of this domain to the evaluation of healthcare; person-centeredness should guide all healthcare decisions. The renaming also represents the paradigm shift in healthcare from illness (patient) to health and well-being (person) focus. It is consistent with the principles of shared decision making and healthcare professionals shifting from asking What is the matter? to What matters to you? 259 , 269 Rather than singling out family members in the domain name as in the 2010 NHQDR framework (e.g., patient/family-centeredness), the framework leaves it at “person,” acknowledging that individuals have different priorities, and the community or specific individuals can be as important as family members. We have also merged this domain with the ambiguous concept of value . Value represents different concepts in different frameworks and its meaning has changed over time and it is likely context dependent. In addition, value is a key part of person-centeredness as it describes preferences and goals of healthcare decisions. The domain equity is depicted as a lens through which we need to view the quality of healthcare. It remains a cross-cutting domain that may influence all other elements of the framework. The domain equity has moved to a more central position in the framework to indicate that it is the lens through which quality of care is evaluated and disparities are identified (it has not a more prominent position as in the 2010 NHQDR framework because the crosscutting position is not shared with the concept of value). Furthermore, the updated framework replaced the broad foundational component Health Systems Infrastructure Capabilities with the more directed domain Levers addressing drivers of health to increase focus on this important aspect of healthcare. Many Key Informant discussions were centered around drivers of health, in particular social determinants of health. These drivers include a multitude of patient characteristics, health literacy and behavior, community characteristics, environments, contexts, provider behaviors, organizational characteristics, and resources available to patients, the community, and the healthcare system. Further discussions regarding the responsibilities of the healthcare system resulted in the proposed framework addressing drivers of health more specifically rather than system capabilities generally, i.e., levers addressing drivers of health . This can include healthcare structures and processes, i.e., aspects that are under the control of the healthcare system. The domain may also capture evidence of the presence or absence of disparities in health outcomes. This domain is also not limited to reducing disparities in healthcare but may include strategies that promote health equity though counteracting discrimination, reducing disparities in healthcare and health, and compensatory healthcare processes with the goal of achieving equity in health outcomes (e.g., increased screening for at risk populations). This entails tailoring prevention and treatment strategies, advice and interventions to the context of people’s lives, providing culturally safe care, including trauma and violence-informed care. 135 Furthermore, the proposed framework takes the domain access out of the original grid of quality-of-care components to show that access is foundational to all other care domains. The revision repositioned the domain access to depict access as the first step in a sequence that starts with engaging in the healthcare system, specific healthcare services, types of care, and care settings. Without entering the healthcare system, several of the healthcare performance domains such as effectiveness and patient safety are irrelevant. The domains a ccess, coordination , as well as levers addressing drivers of health are foundational domains that enable the more specific healthcare performance domains effectiveness, safety, timeliness , and efficiency . Changes in one domain may indicate concurrent or initiate follow up changes in other domains. For example, the domain levers addressing drivers of health may capture actions undertaken to remove barriers to care, which could be observed in the domain access . All domains in the framework can be addressed as structure, process, or outcome measures. 131 We added “end of life care” back into Types of Care to clarify that end-of-life care without preventive or curative intent is an explicit part of types of care. End of life care was also included in the 2001 framework for the National Healthcare Quality Report and the 2002 framework for the National Healthcare Disparities Report. 6 By taking the types of care out of a grid as shown in the 2010 NASEM framework conceptualization, we also tried to communicate that the listed types of care are examples, and not a finite list. There are other populations, for example people with long-term disabilities or vulnerable elders, 270 that may require crosscutting services. Finally, the revised framework lists examples of Care Settings . Given the focus on public reporting of quality of care in hospitals, many users of the NHQDR may not realize the broad range of different facets of healthcare addressed in the NHQDR. This section is also meant to show only examples rather than an exhaustive list (e.g., it does not call out outpatient surgery, or community clinics). We added community as one additional setting where care can take place, including prevention initiatives through community engagement. 9 Measuring community initiatives may become increasingly important for the many lifestyle-dependent conditions such as obesity. 3.4.1. Findings. Guiding Question 2a: How would the existing AHRQ NHQDR measures be reorganized in an updated framework? The proposed framework can be translated into measurement areas. The main suggested change to the framework is that the types of care areas are not organized in a strict grid anymore. The grid gave the impression that care quality, such as effectiveness, had to be measured for the three specific types of care, and only those listed types of care should be measured. However, based on discussions with the AHRQ NHQDR team and a review of recent NHQDR reports, we changed the grid structure of the original 2010 framework to allow for more flexibility and changes in reporting priorities over time. A significant change with measurement implications is represented by moving the domain person-centeredness to the top of the framework with an umbrella function that guides all healthcare processes. Healthcare consumers should be central for measuring healthcare quality and disparities with more emphasis on patient experiences and well-being of the person behind the patient. Consequently, this domain guides the choice of measures to identify indicators that are relevant and important. However, person-centeredness also challenges the interpretation of results where interventions align with individual preferences, rather than universal treatment standards that are the same for all patients. Equity remains a cross-cutting domain and it is conceptualized even more central in the revised framework it as the lens through with quality of care should be reviewed. The measurement implications are that all domains can be viewed from a standpoint of equity and possible areas of disparities. Many Key Informant discussions were centered around drivers of health and the responsibilities of the healthcare system, resulting in a framework that explicitly includes levers addressing drivers of health . This inclusion indicates that the NHQDR measures could include healthcare structures, processes, and outcomes that represent strategies to promote equity. The domain equity is also central to the selection of populations and comparisons. Furthermore, access is included in the revised framework in a different way and the implications for measurement are that access needs to be assessed and monitored closely. Many quality-of-care domains are only relevant to those that successfully entered the healthcare system. Monitoring access also remains important once patients have successfully entered the healthcare system and lack of, or delayed, access should be measured across types of care and care settings. Multiple Key Informants indicated that the original grid structure and the three types of care included in the 2010 framework (preventive care, acute treatment, chronic condition management) should either be removed or expanded. In terms of expansion, the only concrete suggestion was end of life care, i.e., where care has no curative function and is not focused on treating or preventing underlying causes of symptoms. We included a broader box of types of care where the listed types serve as examples in the framework. These could be used as chapters in the NHQDR . Discussions with Key Informants and the AHRQ NHQDR team also suggested that settings of care that the NHQDR covers should be depicted in the framework to emphasize the broad range of measures that are eligible for inclusion in the NHQDR. The settings and sites of care are meant as examples, not an exhaustive list, especially as the NHQDR needs flexibility to add measures for additional settings or may need to use a different care site structure in the future. The current (2023) NHQDR is organized by a combination of clinical topics, care settings, structural data, process measures, patient outcomes, and results for priority populations. 90 The proposed framework domains could function as chapters or subsections of the annual NHQDR. The domains could also organize the measures available on the NHQDR website. However, addressing all domains covered in the framework for all measures would result in a very long report, even when many of the results could be presented in an appendix. To facilitate readability, the report likely needs to remain selective and highlight areas of interest instead of providing data for all combinations of the included dimensions. 3.4.2. Findings. Guiding Question 2b: Are there available measures for new framework domains? We did not identify specific measures that were reported as missing by Key Informants, or that were consistently included in published frameworks but that are missing from the original framework. However, for the suggested domain equity , more information on measurement is available. A recent literature review identified multiple examples for three types of measures: approaches focused on determining which existing quality measures are suitable for health equity comparisons; approaches that engage in particular comparisons; and approaches that developed a system for combining different dimensions of health equity into a single summary index. 31 As shown in the evidence table in Appendix C , ASPE provides concrete examples of measures that can be used as measures of health equity, including rates of health literacy, self-reported access to care, rates of screening for social drivers of health, and self-reported health status. 207 28 The National Committee for Quality Assurace measures maternal and child health, behavioral health, chronic disease, home- and community-based services, and other upstream and downstream elements of health to account for the many factors that drive health. 189 A framework approach focused on community health indicators also provides concrete suggestions for measures of social cohesion (social integration; social networks; social supports; single parent homes; community competence; social capital), social structure (social structure: income equity; racial segregation; political process and power relationships; engagement of non-traditional partners; discrimination), and other aspects of care as documented in detail in Appendix C . 29 Nonetheless, multiple Key Informants indicated that while our ability to identify and document disparities has increased, measuring health equity remains a challenge. 31 For the domain levers addressing drivers of health that we proposed to replace the original health systems infrastructure capabilities domain, there have also been recent relevant developments. A key resource is the ASPE report that lists measures such as the Clinician/Group’s Cultural Competence based on the CAHPS (Consumer Assessment of Healthcare Providers and Systems) Cultural Competence Item Set. 31 Some specific measures include transportation help, patients receiving language services, screening for preferred spoken language for healthcare, and cultural competency. 31 This is a rapidly growing field and more measures are under development. We also note that although person-centeredness or patient-centeredness was a feature in multiple existing frameworks, we identified few definitions, operationalizations, or measures of person/patient/family-centeredness in general. One publication translated patient-centeredness into specific structure, process, and outcome measures. 225 Examples are structures to measure and monitor person-centered culture, processes to engage patients in managing their care, and collecting patient experiences and health outcomes; more details are shown in Appendix C . One framework specified the provision of educational resources as an example operationalization of patient-centeredness. 170 Other framework publications provided further descriptions of patient-centeredness, such as respect for patients, 100 , 139 , 226 , 248 but did not suggest specific measures. A quality-of-care framework that consisted of detailed operationalizations of quality of care in hospitals used patient feedback management as a measure of patient-centeredness and listed other concrete suggestions for effectiveness, safety, or timeliness. 230 3.4.2.1. Guiding Question 2b.i: Describe measures in terms of their definition, population, years available, geographic representation, data sources, and supporting evidence We did not identify specific measures that were reported as missing by Key Informants, or that were consistently included in published frameworks but that are missing from the original framework. We abstracted all available measures (see Appendix C ); however, most framework publications did not provide measures. The few publications that suggested operationalizations of framework domains did not report the population, years available, geographic representation, data sources, supporting evidence, or similar levels of detail. Copyright Notice Bookshelf ID: NBK618273 Contents < Prev Next > Share Views PubReader Print View Cite this Page Ye F, Zhang D, Martino S, et al. Updating the Framework for the Agency for Healthcare Research and Quality’s National Healthcare Quality and Disparities Report [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2025 Jul. (Technical Brief, No. 50.) 3, Findings. PDF version of this title (9.4M) Disable Glossary Links In this Page Key Informant Input Literature Review Results Main Findings. Guiding Question 1: Which frameworks have been developed or are used for quality of care? Main Findings. Guiding Question 2: How could the NHQDR framework and its domains be updated? Other titles in this collection AHRQ Comparative Effectiveness Technical Briefs Recent Activity Clear Turn Off Turn On Findings - Updating the Framework for the Agency for Healthcare Research and Qua... Findings - Updating the Framework for the Agency for Healthcare Research and Quality’s National Healthcare Quality and Disparities Report Your browsing activity is empty. Activity recording is turned off. Turn recording back on See more... 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