November 1999
I N S T I T U TE OF M E D I C I N E
Shaping the Future for Health
TO ERR IS HUMAN:
BUILDING A SAFER HEALTH SYSTEM
H
ealth care in the United States is not as safe as it should be--and can
be. At least 44,000 people, and perhaps as many as 98,000 people, die
in hospitals each year as a result of medical errors that could have
been prevented, according to estimates from two major studies. Even using
the lower estimate, preventable medical errors in hospitals exceed attributable
deaths to such feared threats as motor-vehicle wrecks, breast cancer, and
AIDS.
Medical errors can be defined as the failure of a planned action to be
completed as intended or the use of a wrong plan to achieve an aim. Among
the problems that commonly occur during the course of providing health care
are adverse drug events and improper transfusions, surgical injuries and
wrong-site surgery, suicides, restraint-related injuries or death, falls, burns,
pressure ulcers, and mistaken patient identities. High error rates with serious
consequences are most likely to occur in intensive care units, operating rooms,
and emergency departments.
Beyond their cost in human lives, preventable medical errors exact
other significant tolls. They have been estimated to result in total costs (in
cluding the expense of additional care necessitated by the errors, lost income
and household productivity, and disability) of between $17 billion and $29
billion per year in hospitals nationwide. Errors also are costly in terms of loss
of trust in the health care system by patients and diminished satisfaction by
both patients and health professionals. Patients who experience a long hospi
tal stay or disability as a result of errors pay with physical and psychological
discomfort. Health professionals pay with loss of morale and frustration at
not being able to provide the best care possible. Society bears the cost of er
rors as well, in terms of lost worker productivity, reduced school attendance
by children, and lower levels of population health status.
A variety of factors have contributed to the nation’s epidemic of medi
cal errors. One oft-cited problem arises from the decentralized and frag
mented nature of the health care delivery system--or “nonsystem,” to some
observers. When patients see multiple providers in different settings, none of
whom has access to complete information, it becomes easier for things to go
Errors…are costly
in terms of loss of
trust in the health
care system by pa
tients and dimin
ished satisfaction
by both patients
and health profes
sionals.
Types of Errors
Diagnostic
Error or delay in diagnosis
Failure to employ indicated tests
Use of outmoded tests or therapy
Failure to act on results of monitoring or testing
Treatment
Error in the performance of an operation, procedure, or test
Error in administering the treatment
Error in the dose or method of using a drug
Avoidable delay in treatment or in responding to an abnormal test
Inappropriate (not indicated) care
Preventive
Failure to provide prophylactic treatment
Inadequate monitoring or follow-up of treatment
Other
Failure of communication
Equipment failure
Other system failure
Health Care System at Odds with Itself
The Quality of Health Care in America
Committee of the Institute of Medicine
(IOM) concluded that it is not acceptable
for patients to be harmed by the health
care system that is supposed to offer healing and comfort--a system that promises,
“First, do no harm.” Helping to remedy this problem is the goal of To Err is Hu
man: Building a Safer Health System, the IOM Committee’s first report.
In this report, issued in November 1999, the committee lays out a compre
hensive strategy by which government, health care providers, industry, and con
sumers can reduce preventable medical errors. Concluding that the know-how
already exists to prevent many of these mistakes, the report sets as a minimum
goal a 50 percent reduction in errors over the next five years. In its recommenda
tions for reaching this goal, the committee strikes a balance between regulatory
and market-based initiatives, and between the roles of professionals and organi
zations.
One of the report’s main conclusions is that the majority of medical er
rors do not result from individual recklessness or the actions of a particular
group--this is not a “bad apple” problem. More commonly, errors are caused by
faulty systems, processes, and conditions that lead people to make mistakes or
fail to prevent them. For example, stocking patient-care units in hospitals with
certain full-strength drugs, even though they are toxic unless diluted, has re
sulted in deadly mistakes.
Thus, mistakes can best be prevented by designing the health system at all
levels to make it safer--to make it harder for people to do something wrong and
easier for them to do it right. Of course, this does not mean that individuals can
be careless. People still must be vigilant and held responsible for their actions.
But when an error occurs, blaming an individual does little to make the system
safer and prevent someone else from committing the same error.
SOURCE: Leape, Lucian; Lawthers, Ann G.; Brennan, Troyen A., et al. Pr eventing Medical Injury. Qual Rev Bull. 19(5):144–149, 1993.
More commonly,
errors are caused
by faulty systems,
processes, and
conditions that
lead people to
make mistakes or
fail to prevent
them.
wrong. In addition, the processes by
which health professionals are licensed
and accredited have focused only limited
attention on the prevention of medical er
rors, and even these minimal efforts have
confronted resistance from some health
care organizations and providers. Many
providers also perceive the medical liabil
ity system as a serious impediment to sys
tematic efforts to uncover and learn from
errors. Exacerbating these problems, most
third-party purchasers of health care provide little financial incentive for health
care organizations and providers to im
prove safety and qua lity.
2
Strategy for Improvement
To achieve a better safety record, the report recommends a four-tiered approach:
• Establishing a national focus to create leadership, research, tools,
and protocols to enhance the knowledge base about safety.
Health care is a decade or more behind many other high-risk industries in
its attention to ensuring basic safety. This is due, in part, to the lack of a single
designated government agency devoted to improving and monitoring safety
throughout the health care delivery system. Therefore, Congress should create a
Center for Patient Safety that would set national safety goals and track progress in
meeting them; develop a research agenda; define prototype safety systems; de
velop, disseminate, and evaluate tools for identifying and analyzing errors; de
velop methods for educating consumers about patient safety; and recommend ad
ditional improvements as needed.
Funding for the center should be adequate and secure, starting with $30
million to $35 million per year and growing over time to at least $100 million an
nually--modest investments relative to the consequences of errors and to the resources devoted to other public safety issues. The center should be housed within
the Agency for Healthcare Research and Quality (AHRQ), which already is in
volved in a broad range of quality and safety issues, and has established the infra
structure and experience to fund research, education, and coordinating activities.
• Identifying and learning from errors by developing a nationwide
public mandatory reporting system and by encouraging health care organi
zations and practitioners to develop and participate in voluntary reporting
systems.
Under the mandatory reporting system, state governments will be required
to collect standardized information about adverse medical events that result in
death and serious harm. Hospitals should be required to begin reporting first, and
eventually reporting should be required by all health care organizations. This
system will ensure a response to specific reports of serious injury, hold health care
organizations and providers accountable for maintaining safety, provide incen
tives to organizations to implement internal safety systems that reduce the likeli
hood of errors occurring, and respond to the public’s right to know about patient
safety. Currently, about a third of the states have mandatory reporting require
ments.
Voluntary reporting systems will provide an important complement to the
mandatory system. Such systems can focus on a much broader set of errors,
mainly those that do no or minimal harm, and help detect system weaknesses that
can be fixed before the occurrence of serious harm, thereby providing rich info r
mation to health care organizations in support of their quality improvement ef
forts. To foster participation in voluntary systems, Congress should enact laws to
protect the confidentiality of certain information collected. Without such legisla
tion, health care organizations and providers may be discouraged from partic i
pating in voluntary reporting systems out of worry that the information they provide might ultimately be subpoenaed and used in lawsuits.
3
Health care is a
decade or more behind many other
high-risk industries
in its attention to
ensuring basic
safety.
Voluntary reporting
systems will provide an important
complement to the
mandatory system.
• Raising performance standards and expectations for improve
ments in safety through the actions of oversight organizations, professional
groups, and group purchasers of health care.
The process of de
Setting and enforcing explicit performance standards for patient safety
veloping and
through regulatory and related mechanisms, such as licensing, certification, and
adopting standards accreditation, can define minimum performance levels for health professionals,
also helps to form
the organizations in which they work, and the tools (drugs and devices) they use
expectations for
to care for patients. The process of developing and adopting standards also helps
safety among pro
to form expectations for safety among providers and consumers.
viders and con
Standards and expectations are not only set through regulations, however.
sumers.
The values and norms set by the health professions influence the practice, train
ing, and education for providers. Thus, professional societies should become
leaders in encouraging and demanding improvements in patient safety, by such
actions as setting their own performance standards, convening and communicat
ing with members about safety, incorporating attention to patient safety in training
programs, and collaborating across disciplines.
The actions of large purchasers of health care and health care insurance, as
well as actions by individual consumers, also can affect the behaviors of health
care organizations. Public and private purchasers, such as businesses buying in
surance for their employees, must make safety a prime concern in their contract
ing decisions. Doing so will create financial incentives for health care organiza
tions and providers to make needed changes to ensure patient safety.
Medication errors
now occur fre
quently in hospi
tals, yet many hos
pitals are not mak
ing use of known
systems for im
proving safety…
• Implementing safety systems in health care organizations to ensure safe practices at the delivery level.
Health care organizations must develop a “culture of safety” such that
their workforce and processes are focused on improving the reliability and safety
of care for patients. Safety should be an explicit organizational goal that is dem
onstrated by strong leadership on the part of clinicians, executives, and governing
bodies. This will mean incorporating a variety of well-understood safety princ i
ples, such as designing jobs and working conditions for safety; standardizing and
simplifying equipment, supplies, and processes; and enabling care providers to
avoid reliance on memory. Systems for continuously monitoring patient safety
also must be created and adequately funded.
The medication process provides an example where implementing better
systems will yield better human performance. Medication errors now occur fre
quently in hospitals, yet many hospitals are not making use of known systems for
improving safety, such as automated medication order entry systems, nor are they
actively exploring new safety systems. Patients themselves also could provide a
major safety check in most hospitals, clinics, and practice. They should know
which medications they are taking, their appearance, and their side effects, and
they should notify their doctors of medication discrepancies and the occurrence of
side effects.
4
Progress Under Way
The response to the IOM report was swift and positive, within both government
and the private sector.
Almost immediately, the Clinton administration issued an executive order
instructing government agencies that conduct or oversee health-care programs to
implement proven techniques for reducing medical errors, and creating a task
force to find new strategies for reducing errors. Congress soon launched a series
of hearings on patient safety, and in December 2000 it appropriated $50 million to
the Agency for Healthcare Research and Quality to support a variety of efforts
targeted at reducing medical errors.
The AHRQ already has made major progress in developing and imple
menting an action plan. Efforts under way include:
• Developing and testing new technologies to reduce medical errors.
• Conducting large-scale demonstration projects to test safety interve n
tions and error-reporting strategies.
• Supporting new and established multidisciplinary teams of researchers
and health-care facilities and organizations, located in geographically diverse locations, that will further determine the causes of medical errors and develop new
knowledge that will aid the work of the demonstration projects.
• Supporting projects aimed at achieving a better understanding of how
the environment in which care is provided affects the ability of providers to im
prove safety.
• Funding researchers and organizations to develop, demonstrate, and
evaluate new approaches to improving provider education in order to reduce er
rors.
Casting its net even more broadly, the AHRQ has produced a booklet of
practical tips on what individual consumers can do to improve the quality of
health-care services they receive. The booklet focuses on key choices that indi
viduals and their families face, such as choosing doctors, hospitals, and treat
ments, and it stresses the importance of individuals taking an active role in se
lecting and evaluating their care. (The booklet is available on the organization’s
Web site at www.ahrq.gov.)
In efforts focused at the state level, during the past year the National
Academy for State Health Policy (NASHP) convened leaders from both the ex
ecutive and legislative branches of the states to discuss approaches to improving
patient safety. The NASHP also helped lead an initiative to better understand
how states with mandatory hospital error-reporting requirements administer and
enforce their programs. (A report on this initiative is available on the organiza
tion’s Web site at www.nashp.org). In addition, the Agency for Healthcare Research and Quality has contracted with the National Quality Forum to produce a
list of so-called “never events” that states might use as the basis of a mandatory
reporting system.
Among activities in the private sector, the Leapfrog Group, an association
of private and public sector group purchasers, unveiled a market-based strategy to
improve safety and quality, including encouraging the use of computerized phys i5
cian-order entry, evidence-based hospital referrals, and the use of ICUs staffed by
physicians credentialed in critical care medicine.
Professional groups within the health-care community also have been ac
tive. As but one example, the Council on Graduate Medical Education (COGME)
and the National Advisory Council on Nurse Education and Practice (NACNEP)
held a joint meeting on “Collaborative Education Models to Ensure Patient
Safety.” Participants addressed such issues as the effect of the relationships between physicians and nurses on patient safety, the impact of physician-nurse col
laboration on systems designed to protect patient safety, and educational programs to ensure interdisciplinary collaboration to further patient safety. (A report
on the meeting is available on the COGME’s Web site at www.cogme.org.)
Pulling Together
With adequate
leadership, atten
tion, and resources,
improvements can
be made.
Although no single activity can offer a total solution for dealing with medical er
rors, the combination of activities proposed in To Err is Human offers a roadmap
toward a safer health system. With adequate leadership, attention, and resources,
improvements can be made. It may be part of human nature to err, but it is also
part of human nature to create solutions, find better alternatives, and meet the
challenges ahead.
For More Information…
Copies of To Err is Human: Building a Safer Health System are available for
sale from the National Academy Press; call (800) 624-6242 or (202) 334-3313 (in
the Washington metropolitan area), or visit the NAP home page at www.nap.edu.
The full text of this report is available at
http://www.nap.edu/books/0309068371/html/
Support for this project was provided by The National Research Council and The
Commonwealth Fund. The views presented in this report are those of the Institute
of Medicine Committee on the Quality of Health Care in America and are not
necessarily those of the funding agencies.
The Institute of Medicine is a private, nonprofit organization that provides health
policy advice under a congressional charter granted to the National Academy of
Sciences. For more information about the Institute of Medicine, visit the IOM
home page at www.iom.edu.
Copyright ©2000 by the National Academy of Sciences. All rights reserved.
Permission is granted to reproduce this document in its entirety, with no additions
or alterations
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6
COMMITTEE ON QUALITY OF HEALTH CARE IN AMERICA
WILLIAM C. RICHARDSON (Chair), President and CEO, W.K. Kellogg
Foundation, Battle Creek, MI
DONALD M. BERWICK, President and CEO, Institute for Healthcare
Improvement, Boston
J. CRIS BISGARD, Director, Health Services, Delta Air Lines, Inc., Atlanta
LONNIE R. BRISTOW, Past President, American Medical Association, Walnut
Creek, CA
CHARLES R. BUCK, Program Leader, Health Care Quality and Strategy
Initiatives, General Electric Company, Fairfield, CT
CHRISTINE K. CASSEL, Professor and Chairman, Department of Geriatrics
and Adult Development, Mount Sinai Medical Center, New York City
MARK R. CHASSIN, Professor and Chairman, Department of Health Policy,
The Mount Sinai Medical Center, New York City
MOLLY JOEL COYE, Vice President and Director, West Coast Office, The
Lewin Group, San Francisco
DON E. DETMER, Dennis Gillings Professor of Health Management,
University of Cambridge, UK
JEROME H. GROSSMAN, Chairman and CEO, Lion Gate Management, LLC,
Boston
BRENT JAMES, Executive Director, Intermountain Health Care, Institute for
Health Care Delivery Research, Salt Lake City, UT
DAVID McK. LAWRENCE, Chairman and CEO, Kaiser Foundation Health
Plan, Inc., Oakland, CA
LUCIAN LEAPE, Adjunct Professor, Harvard School of Public Health
ARTHUR LEVIN, Director, Center for Medical Consumers, New York City
RHONDA ROBINSON-BEALE, Executive Medical Director, Managed Care
Management and Clinical Programs, Blue Cross Blue Shield of Michigan,
Southfield
JOSEPH E. SCHERGER, Associate Dean for Clinical Affairs, University of
California at Irvine College of Medicine
ARTHUR SOUTHAM, Partner, 2C Solutions, Northridge, CA
MARY WAKEFIELD, Director, Center for Health Policy and Ethics, George
Mason University
GAIL L. WARDEN, President and CEO, Henry Ford Health System, Detroit
� � �
7
Study Staff
JANET M. CORRIGAN, Director, Division of Health Care Services, Director,
Quality of Health Care in America Project
MOLLA S. DONALDSON, Project Codirector
LINDA T. KOHN, Project Codirector
TRACY McKAY, Research Assistant
KELLY C. PIKE, Senior Project Assistant
Auxiliary Staff
MIKE EDINGTON, Managing Editor
KAY HARRIS, Financial Advisor
SUZANNE MILLER, Senior Project Assistant
Copy Editor
FLORENCE POILLON
� � �
8
March 2001
I N S T I T U TE OF M E D I C I N E
Shaping the Future for Health
CROSSING THE Q UALITY CHASM:
A NEW HEALTH SYSTEM FOR THE 21ST CENTURY
T
he U.S. health care delivery system does not provide consistent, highquality medical care to all people. Americans should be able to count
on receiving care that meets their needs and is based on the best scien
tific knowledge--yet there is strong evidence that this frequently is not the
case. Health care harms patients too frequently and routinely fails to deliver
its potential benefits. Indeed, between the health care that we now have and
the health care that we could have lies not just a gap, but a chasm.
A number of factors have combined to create this chasm. Medical sci
ence and technology have advanced at an unprecedented rate during the past
half-century. In tandem has come growing complexity of health care, which
today is characterized by more to know, more to do, more to manage, more to
watch, and more people involved than ever before. Faced with such rapid
changes, the nation’s health care delivery system has fallen far short in its
ability to translate knowledge into practice and to apply new technology
safely and appropriately. And if the system cannot consistently deliver today’s science and technology, it is even less prepared to respond to the ex
traordinary advances that surely will emerge during the coming decades.
The public’s health care needs have changed as well. Americans are
living longer, due at least in part to advances in medical science and techno l
ogy, and with this aging population comes an increase in the incidence and
prevalence of chronic conditions. Such conditions, including heart disease,
diabetes, and asthma, are now the leading cause of illness, disability, and
death. But today’s health system remains overly devoted to dealing with
acute, episodic care needs. There is a dearth of clinical programs with the
multidisciplinary infrastructure required to provide the full complement of
services needed by people with common chronic conditions.
The health care delivery system also is poorly organized to meet the
challenges at hand. The delivery of care often is overly complex and uncoor
dinated, requiring steps and patient “handoffs” that slow down care and decrease rather than improve safety. These cumbersome processes waste resources; leave unaccountable voids in coverage; lead to loss of information;
Faced with such
rapid changes, the
nation’s health care
delivery system has
fallen far short in its
ability to translate
knowledge into
practice and to ap
ply new technology
safely and appro
priately.
CARE SYSTEM
Supportive
payment and
regulatory en
vironment
Organizations
that facilitate
the work of
patientcentered teams
High perform
ing patientcentered teams
Outcomes:
• Safe
• Effective
• Efficient
• Personalized
• Timely
• Equitable
REDESIGN IMPERATIVES: SIX CHALLENGES
•
Reengineered care processes
•
Effective use of information technologies
•
Knowledge and skills management
•
Development of effective teams
•
Coordination of care across patientconditions, services, sites of care over time
and fail to build on the strengths of
all health professionals involved to
ensure that care is appropriate,
timely, and safe. Organizational
problems are particularly apparent
regarding chronic conditions. The
fact that more than 40 percent of
people with chronic conditions have
more than one such condition
argues strongly for more
sophisticated mechanisms to
coordinate care. Yet health care
organizations, hospitals, and
physician groups typically operate
as separate “silos,” acting without
the benefit of complete information
about the patient’s condition,
medical history, services provided
in other settings, or medications
provided by other clinicians.
Making change possible.
Strategy for Reinventing the System
Advances must
begin with all
health care con
stituencies…
committing to a
national statement
of purpose…
Bringing state-of-the-art care to all Americans in every community will require a
fundamental, sweeping redesign of the entire health system, according to a report
by the Institute of Medicine (IOM), an arm of the National Academy of Sciences.
Crossing the Quality Chasm: A New Health System for the 21st Century, prepared
by the IOM’s Committee on the Quality of Health Care in America and released
in March 2001, concludes that merely making incremental improvements in current systems of care will not suffice.
The committee already has spoken to one urgent care problem--patient
safety--in a 1999 report titled To Err is Human: Building a Safer Health System.
Concluding that tens of thousands of Americans die each year as a result of pre
ventable mistakes in their care, the report lays out a comprehensive strategy by
which government, health care providers, industry, and consumers can reduce
medical errors.
Crossing the Quality Chasm focuses more broadly on how the health sys
tem can be reinvented to foster innovation and improve the delivery of care. Toward this goal, the committee presents a comprehensive strategy and action plan
for the coming decade.
Six Aims for Improvement
Advances must begin with all health care constituencies--health professionals,
federal and state policy makers, public and private purchasers of care, regulators,
organization managers and governing boards, and consumers--committing to a
2
national statement of purpose for the health care system as a whole. In making
this commitment, the parties would accept as their explicit purpose “to continually
reduce the burden of illness, injury, and disability, and to improve the health and
functioning of the people of the United States.” The parties also would adopt a
shared vision of six specific aims for improvement. These aims are built around
the core need for health care to be:
• Safe: avoiding injuries to patients from the care that is intended to help
them.
• Effective: providing services based on scientific knowledge to all who
could benefit, and refraining from providing services to those not likely to benefit.
• Patient-centered: providing care that is respectful of and responsive to in
dividual patient preferences, needs, and values, and ensuring that patient values
guide all clinical decisions.
• 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.
• Equitable: providing care that does not vary in quality because of personal
characteristics such as gender, ethnicity, geographic location, and socioeconomic
status.
A health care system that achieves major gains in these six areas would be
far better at meeting patient needs. Patients would experience care that is safer,
more reliable, more responsive to their needs, more integrated, and more available,
and they could count on receiving the full array of preventive, acute, and chronic
services that are likely to prove beneficial. Clinicians and other health workers also
would benefit through their increased satisfaction at being better able to do their
jobs and thereby bring improved health, greater longevity, less pain and suffering,
and increased personal productivity to those who receive their care.
A health care sys
tem that achieves
major gains in
these six areas
would be far better
at meeting patient
needs.
Ten Rules for Redesign
To help in achieving these improvement aims, the committee deemed that it
would be neither useful nor possible to specify a blueprint for 21st-century health
care delivery systems. Imagination abounds at all levels, and all promising routes
for innovation should be encouraged. At the same time, the committee formu
lated a set of ten simple rules, or general principles, to inform efforts to redesign
the health system. These rules are:
1. Care is based on continuous healing relationships. Patients should re
ceive care whenever they need it and in many forms, not just face-to-face visits.
This implies that the health care system must be responsive at all times, and ac
cess to care should be provided over the Internet, by telephone, and by other
means in addition to in-person visits.
2. Care is customized according to patient needs and values. The system
should be designed to meet the most common types of needs, but should have the
capability to respond to individual patient choices and preferences.
3. The patient is the source of control. Patients should be given the nec3
…the health care
system must be
responsive at all
times, and access
to care should be
provided over the
Internet, by tele
phone, and by
other means in
addition to inperson visits.
Reducing risk and
ensuring safety
require greater a t
tention to systems
that help prevent
and mitigate er
rors.
essary information and opportunity to exercise the degree of control they choose
over health care decisions that affect them. The system should be able to accom
modate differences in patient preferences and encourage shared decision making.
4. Knowledge is shared and information flows freely. Patients should
have unfettered access to their own medical information and to clinical knowl
edge. Clinicians and patients should communicate effectively and share informa
tion.
5. Decision making is evidence-based. Patients should receive care based
on the best available scientific knowledge. Care should not vary illogically from
clinician to clinician or from place to place.
6. Safety is a system property. Patients should be safe from injury caused
by the care system. Reducing risk and ensuring safety require greater attention to
systems that help prevent and mitigate errors.
7. Transparency is necessary. The system should make available to pa
tients and their families information that enables them to make informed decisions
when selecting a health plan, hospital, or clinical practice, or when choosing
among alternative treatments. This should include information describing the
system’s performance on safety, evidence-based practice, and patient satisfaction.
8. Needs are anticipated. The system should anticipate patient needs,
rather than simply react to events.
9. Waste is continuously decreased. The system should not waste resources or patient time.
10. Cooperation among clinicians is a priority. Clinicians and institutions
should actively collaborate and communicate to ensure an appropriate exchange
of information and coordination of care.
Taking the First Steps
To initiate the pro
cess of change,
Congress should
establish a Health
Care Quality Inno
vation Fund
To initiate the process of change, Congress should establish a Health Care Quality
Innovation Fund--roughly $1 billion for use over three to five years to help pro
duce a public-domain portfolio of programs, tools, and technologies of widespread applicability, and to help communicate the need for rapid and significant
change throughout the health system. Some of the projects funded should be tar
geted at achieving the six aims of improvement.
The committee also calls for immediate attention on developing care proc
esses for the common health conditions, most of them chronic, that afflict great
numbers of people. The federal Agency for Healthcare Research and Quality
(AHRQ) should identify 15 or more common priority conditions. (The agency
has requested guidance from the IOM on selection of these conditions, and the
Institute expects to issue its report in September 2002.) The AHRQ then should
work with various stakeholders in the health community to develop strategies and
action plans to improve care for each of these priority conditions over a five-year
period.
4
Changing the Environment
Redesigning the health care delivery system also will require changing the struc
tures and processes of the environment in which health professionals and organi
zations function. Such changes need to occur in four main areas:
• Applying evidence to health care delivery. Scientific knowledge about
best care is not applied systematically or expeditiously to clinical practice. It now
takes an average of 17 years for new knowledge generated by randomized controlled trails to be incorporated into practice, and even then application is highly
uneven. The committee therefore recommends that the Department of Health and
Human Services establish a comprehensive program aimed at making scientific
evidence more useful and more accessible to clinicians and patients.
It is critical that leadership from the private sector, both professional and
other health care leaders and consumer representatives, be involved in all aspects
of this effort to ensure its applicability and acceptability to clinicians and patients.
The infrastructure developed through this public-private partnership should focus
initially on priority conditions. Efforts should include analysis and synthesis of
the medical evidence, delineation of specific practice guidelines, identification of
best practices in the design of care processes, dissemination of the evidence and
guidelines to the professional communities and the general public, development
of support tools to help clinicians and patients in applying evidence and making
decisions, establishment of goals for improvement in care processes and outcomes, and development of measures for assessing quality of care.
• Using information technology. Information technology, including the
Internet, holds enormous potential for transforming the health care delivery sys
tem, which today remains relatively untouched by the revolution that has swept
nearly every other aspect of society. Central to many information technology ap
plications is the automation of patient-specific clinical information. Such infor
mation typically is dispersed in a collection of paper records, which often are
poorly organized, illegible, and not easy to retrieve, making it nearly impossible
to manage various illnesses, especially chronic conditions, that require frequent
monitoring and ongoing patient support. Many patients also could have their
needs met more quickly and at a lower cost if they could communicate with health
professionals through e-mail. In addition, the use of automated systems for or
dering medications can reduce errors in prescribing and dosing drugs, and com
puterized reminders can help both patients and clinicians identify needed services.
The challenges of applying information technology should not be underestimated, however. Health care is undoubtedly one of the most, if not the most,
complex sectors of the economy. Sizable capital investments and multiyear
commitments to building systems will be needed. Widespread adoption of many
information technology applications also will require behavioral adaptations on
the part of large numbers of clinicians, organizations, and patients. Thus, the
committee calls for a nationwide commitment of all stakeholders to building an
information infrastructure to support health care delivery, consumer health, qua l
ity measurement and improvement, public accountability, clinical and health
services research, and clinical education. This commitment should lead to the
elimination of most handwritten clinical data by the end of the decade.
5
It is critical that
leadership from
the private sector,
both professional
and other health
care leaders and
consumer repre
sentatives, be in
volved in all as
pects of this ef
fort…
Information tech
nology…holds
enormous poten
tial for transform
ing the health care
delivery system…
Clinicians should
be adequately
compensated for
taking good care
of all types of pa
tients…
…the importance
of adequately preparing the
workforce to make
a smooth transi
tion into a thor
oughly revamped
health care sys
tem cannot be un
derestimated.
Now is the right
time to begin work
on reinventing the
nation’s health
care delivery sys
tem.
• Aligning payment policies with quality improvement. Although pay
ment is not the only factor that influences provider and patient behavior, it is an
important one. The committee calls for all purchasers, both public and private, to
carefully reexamine their payment policies to remove barriers that impede quality
improvement and build in stronger incentives for quality enhancement. Clinicians
should be adequately compensated for taking good care of all types of patients,
neither gaining nor losing financially for caring for sicker patients or those with
more complicated conditions. Payment methods also should provide an opportu
nity for providers to share in the benefits of quality improvement, provide an op
portunity for consumers and purchasers to recognize quality differences in health
care and direct their decisions accordingly, align financial incentives with the im
plementation of care processes based on best practices and the achievement of
better patient outcomes, and enable providers to coordinate care for patients
across settings and over time.
To assist purchasers in their redesign of payment policies, the federal go v
ernment, with input from the private sector, should develop a program to identify,
pilot test, and evaluate various options for better aligning payment methods with
quality improvement goals. Examples of possible means of achieving this end
include blended methods of payment designed to counter the disadvantages of one
payment method with the advantages of another, multiyear contracts, payment
modifications to encourage use of electronic interaction among clinicians and
between clinicians and patients, and bundled payments for priority conditions.
• Preparing the workforce. Health care is not just another service in
dustry. Its fundamental nature is characterized by people taking care of other
people in times of need and stress. Stable, trusting relationships between a patient
and the people providing care can be critical to healing or managing an illness.
Therefore, the importance of adequately preparing the workforce to make a
smooth transition into a thoroughly revamped health care system cannot be un
derestimated.
Three approaches can be taken to support the workforce in this transition.
One approach is to redesign the way health professionals are trained to emphasize
the six aims for improvement, which will mean placing more stress on teaching
evidence-based practice and providing more opportunities for interdisciplinary
training. Second is to modify the ways in which health professionals are regu
lated and accredited to facilitate needed changes in care delivery. Third is to use
the liability system to support changes in care delivery while preserving its role in
ensuring accountability among health professionals and organizations. All of
these approaches likely will prove valuable, but key questions remain about each.
The federal government and professional associations need to study these ap
proaches to better ascertain how they can best contribute to ensuring the strong
workforce that will be at the center of the health care system of the 21st century.
No Better Time
Now is the right time to begin work on reinventing the nation’s health care deliv
ery system. Technological advances are making it possible to accomplish things
today that were impossible only a few years ago. Health professionals and or6
ganizations, policy makers, and patients are becoming all too painfully aware of
the shortcomings of the nation’s current system and of the importance of finding
radically new and better approaches to meeting the health care needs of all
Americans. Although Crossing the Quality Chasm does not offer a simple pre
scription--there is none--it does provide a vision of what is possible and the path
that can be taken. It will not be an easy road, but it will be most worthwhile.
� � �
For More Information…
Copies of Crossing the Quality Chasm: A New Health System for the 21st Century are
available for sale from the National Academy Press; call (800) 624-6242 or (202) 3343313 (in the Washington metropolitan area), or visit the NAP home page at
www.nap.edu. The full text of this report is available at
http://www.nap.edu/books/0309072808/html/
Support for this project was provided by: the Institute of Medicine; the National Research
Council; The Robert Wood Johnson Foundation; the California Health Care Foundation;
the Commonwealth Fund; and the Department of Health and Human Services’ Health
Care Finance Administration, Public Health Service, and Agency for Healthcare Research and Quality. The views presented in this report are those of the Institute of Medi
cine Committee on the Quality of Health Care in America and are not necessarily those
of the funding agencies.
The Institute of Medicine is a private, nonprofit organization that provides health policy
advice under a congressional charter granted to the National Academy of Sciences. For
more information about the Institute of Medicine, visit the IOM home page at
www.iom.edu.
Copyright ©2000 by the National Academy of Sciences. All rights reserved.
Permission is granted to reproduce this document in its entirety, with no additions or al
terations
� � �
COMMITTEE ON QUALITY OF HEALTH CARE IN AMERICA
WILLIAM C. RICHARDSON (Chair), President and CEO, W.K. Kellogg Foundation,
Battle Creek, MI
DONALD M. BERWICK, President and CEO, Institute for Healthcare Improvement,
Boston, MA
J. CRIS BISGARD, Director, Health Services, Delta Air Lines, Inc., Atlanta, GA
LONNIE R. BRISTOW, Former President, American Medical Association, Walnut
Creek, CA
CHARLES R. BUCK, Program Leader, Health Care Quality and Strategy Initiatives,
General Electric Company, Fairfield, CT
CHRISTINE K. CASSEL, Professor and Chairman, Department of Geriatrics and Adult
Development, The Mount Sinai School of Medicine, New York, NY
7
MARK R. CHASSIN, Professor and Chairman, Department of Health Policy, The
Mount Sinai School of Medicine, New York, NY
MOLLY JOEL COYE, Senior Fellow, Institute for the Future, and President, Health
Technology Center, San Francisco, CA
DON E. DETMER, Dennis Gillings Professor of Health Management, University of
Cambridge, UK
JEROME H. GROSSMAN, Chairman and CEO, Lion Gate Management Corporation,
Boston, MA
BRENT JAMES, Executive Director, Intermountain Health Care Institute for Health
Care Delivery Research, Salt Lake City, UT
DAVID McK. LAWRENCE, Chairman and CEO, Kaiser Foundation Health Plan, Inc.,
Oakland, CA
LUCIAN L. LEAPE, Adjunct Professor, Harvard School of Public Health, Boston, MA
ARTHUR LEVIN, Director, Center for Medical Consumers, New York, NY
RHONDA ROBINSON-BEALE, Executive Medical Director, Managed Care Manage
ment and Clinical Programs, Blue Cross Blue Shield of Michigan, Southfield
JOSEPH E. SCHERGER, Associate Dean for Primary Care, University of California,
Irvine College of Medicine
ARTHUR SOUTHAM, President and CEO, Health Systems Design, Oakland, CA
MARY WAKEFIELD, Director, Center for Health Policy, Research, and Ethics,
George Mason University, Fairfax, VA
GAIL L. WARDEN, President and CEO, Henry Ford Health System, Detroit, MI
Study Staff
JANET M. CORRIGAN,
Director, Quality of Health Care in America Project
Director, Board on Health Care Services,
MOLLA S. DONALDSON, Project Codirector
LINDA T. KOHN, Project Codirector
SHARI K. MAGUIRE, Research Assistant
KELLY C. PIKE, Senior Project Assistant
Auxiliary Staff
MIKE EDINGTON, Managing Editor
JENNIFER CANGCO, Financial Advisor
Consultant
RONA BRIER, Brier Associates, Inc.
� � �
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