In the decade since the Institute of Medicine identified quality deficiencies in the U.S. health care system, numerous quality improvement initiatives have sought to improve the safety and quality of U.S. health care. Many of the initiatives that have improved care have done so by focusing on points at which care is delivered (e.g., acute care hospitals, nursing homes). 

While focusing on care delivery in a particular setting improves care in that one area, it ignores others. Consequently, even successful quality improvement interventions have focused attention on the location of care rather than on the patient receiving that care. But ideally, health care should be of equally high quality across settings, including within an acute care hospital, in an emergency department, at the doctor‘s office or similar ambulatory setting, in the home, and in nursing homes. And, just as importantly, care should be of high quality through transitions, when a person moves from one setting to another.
Aligning Forces for Quality (AF4Q), the Robert Wood Johnson Foundation‘s (RWJF) signature effort to lift the overall quality of health care in targeted communities, has turned its attention to improving the quality of care across settings. Among its many activities, AF4Q is working with its 16 community alliances across the nations to define problems related to care transitions and care across settings, design interventions, and measure and improve the quality of care. Some communities have succeeded; others have stumbled and have had to regroup. But all are engaging in the important task of improving care such that the patient receiving care, rather than the setting in which that care is provided, is what matters most.