On the other hand, despite scientific and technological advances, investments of billions of dollars in
healthcare reforms and improvement initiatives, enhanced activities in health data reporting, and evidence
suggesting that publishing performance data stimulates quality improvement, the impact of these measures
on the effectiveness, safety, and patient-centeredness of care remains unclear. Health outcomes in terms of
equity, access, and quality remain problematic for many rural communities and populations. Furthermore,
increasing awareness among the public of healthcare errors, and heightened competition for dwindling healthcare resources, led to demands for greater accountability to balance patient safety and quality, costs, health outcomes, patient-centered care, and a reorientation in relationships among healthcare improvement stakeholders (e.g. patients and the public, healthcare enterprise, and purchasers and funders of healthcare) to incorporate the paradigm shift to value-based healthcare.8,9 Opportunities for sustainable effective improvement (e.g. clearer policy goals, implementation targets, appropriate measurable indicators addressing policy goals, and achieving health outcomes) remain a challenge.