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In compliance with ACA, the National Quality Strategy was released via a report to Congress in 2011. Consistent with the initiatives of the National Quality Forum and the National Priorities Partners Goals and Priorities, the National Quality Strategy pursued three broad aims—similar to those referenced by the Institute for Health Care Improvement as the Triple Aims—to guide and assess local, state, and national efforts to improve the quality of health care. Subsequently, a fourth aim was added to improve the experience of providing care.

The aims included the following:

 Better care. Improve the overall quality by making health care more patient centered, reliable, accessible, and safe.

 Healthy people/healthy communities. Improve the health of the US population by supporting proven interventions to address behavioral, social, and environmental determinants of health in addition to delivering higher‐quality care.

 Affordable care. Reduce the cost of quality health care for individuals, families, employers, and government.

 Attaining joy and meaning in the work of health care staff for providers, clinicians, and staff.

The National Quality Strategy was based on the recognition that in the end, all health care is local, and its intent has been to help ensure that these local efforts remain consistent with shared national aims and priorities. The Secretary of HHS developed this initial strategy and plan through a participatory, transparent, and collaborative process that reached out to more than 300 groups, organizations, and individuals who provided comments. The Agency for Healthcare Research and Quality (AHRQ) was tasked with supporting and coordinating the implementation plan and further development and updating of the strategy, which it has continued to do.

At the federal level, the National Quality Strategy has guided the development of HHS programs, regulations, and strategic plans for new initiatives, in addition to serving as a mechanism for evaluating the full range of federal health efforts. The first‐year strategy did not include HHS‐specific plans, goals, benchmarks, and standardized quality metrics, but AHRQ developed these through collaboration with the participating agencies and private‐sector consultations. The 2015 Strategy speaks to the following six evolving priorities that inform the advancement of efforts to keep patients safe (http://www.ahrq.gov/workingforquality/nqs/overview.htm):

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

 Ensuring that each person and family members are 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.

AHRQ integrated the National Quality Strategy with the National Healthcare Quality and Disparities Report in 2015. The ACA originally called for the establishment of an Interagency Working Group on Health Care Quality (IWG), composed of senior officials representing 24 federal agencies with major responsibility for health care quality and quality improvement. The working group’s function has been to provide a platform for collaboration, cooperation, and consultation among relevant agencies regarding quality initiatives as a means to ensure alignment and coordination across federal efforts and with the private sector for more than 250 structure, process, and outcomes measures. As of 2018, the IWG continued to meet to provide guidance and oversight to the collective quality efforts, and currently includes nine of the federal agencies (https://www.ahrq.gov/research/findings/nhqrdr/nhqdr18/index.html).

Access to care logically relates to the outcomes of care individuals and populations receive. The 2019 National Healthcare Quality and Disparities Report identified that from 2000 to 2018, while more than 50% of access measures showed improvement, 25% of access measures did not show improvement, and 20% of access measures showed worsening conditions. Directly related to quality, this same report identified that 14 of 29 person‐centered care measures showed improvement, 50% of patient safety measures displayed improvement, and almost 60% of healthy living measures showed improvement; 40% of effective treatment measures showed improvement, as did 40% of care coordination measures and care affordability measures (https://www.ahrq.gov/research/findings/nhqrdr/nhqdr19/index.html).

In analyzing these results, the report points out that state‐level data reflect wide variation in quality, dependent upon both state and region. It also noted that even if overall a state performed well on certain measures of quality, there may be wide variation within the state or from community to community, caused by great disparities in health care access or reflected in specific areas of quality. These variations can be documented by using the query process for the Annual Report (https://nhqrnet.ahrq.gov/inhqrdr/data/query). From a nursing perspective, many of these measures can be seen as a reflection of nursing practice, both positive and negative.