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Crossing the Quality Chasm A New Health System for the 21st Century Committee on Quality of Health Care in America INSTITUTE OF MEDICINE NATIONAL ACADEMY PRESS Washington, D.C.
NATIONAL ACADEMY PRESS â¢ 2101 Constitution Avenue, N.W. â¢ Washington, DC 20418 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. 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 Com- monwealth Fund; and the Department of Health and Human Servicesâ Health Care Financing Admin- istration and Agency for Healthcare Research and Quality. 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. Library of Congress Cataloging-in-Publication Data Crossing the quality chasm : a new health system for the 21st century / Committee on Quality Health Care in America, Institute of Medicine. p. ; cm. Includes bibliographical references and index. ISBN 0-309-07280-8 1. Medical careâUnited States. 2. Health care reformâUnited States. 3. Medical careâUnited StatesâQuality control. I. Institute of Medicine (U.S.). Committee on Quality of Health Care in America. [DNLM: 1. Health Care ReformâmethodsâUnited States. 2. Quality of Health CareâUnited States. WA 540 AA1 C937 2001] RA395.A3 C855 2001 362.1â²0973âdc21 2001030775 Additional copies of this report are available for sale from the National Academy Press, 2101 Constitution Avenue, N.W., Box 285, Washington, D.C. 20055. Call (800) 624-6242 or (202) 334- 3313 (in the Washington metropolitan area), or visit the NAPâs home page at www.nap.edu. The full text of this report is available at www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2001 by the National Academy of Sciences. All rights reserved. Printed in the United States of America. The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin.
âKnowing is not enough; we must apply. Willing is not enough; we must do.â âGoethe INSTITUTE OF MEDICINE Shaping the Future for Health
National Academy of Sciences National Academy of Engineering Institute of Medicine National Research Council The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Bruce M. Alberts is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achieve- ments of engineers. Dr. William A. Wulf is president of the National Academy of Engi- neering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Kenneth I. Shine is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sci- ences in 1916 to associate the broad community of science and technology with the Academyâs purposes of furthering knowledge and advising the federal government. Func- tioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Bruce M. Alberts and Dr. William A. Wulf are chairman and vice chairman, respectively, of the National Research Council.
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 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, Senior Fellow, Center for Business and Government, John F. Kennedy School of Government, Harvard University, 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 Management 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 v
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 ANTHONY BURTON, Administrative Assistant MIKE EDINGTON, Managing Editor JENNIFER CANGCO, Financial Advisor Consultant/Editor RONA BRIERE, Briere Associates, Inc. vi
Reviewers The report was reviewed by individuals chosen for their diverse perspectives and technical expertise in accordance with procedures approved by the National Research Councilâs Report Review Committee. The purpose of this independent review is to provide candid and critical comments to assist the authors and the Institute of Medicine in making the published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The content of the review comments and the draft manuscript remain confidential to protect the integrity of the deliberative process. The committee wishes to thank the following individuals for their par- ticipation in the report review process: TERRY CLEMMER, Intermountain Health Care, Salt Lake City, UT SUSAN EDGMAN-LEVITAN, The Picker Institute, Boston, MA ANN GREINER, Center for Studying Health System Change, Washington, D.C. DAVID LANSKY, The Foundation for Accountability, Portland, OR DAVID MECHANIC, Rutgers, The State University of New Jersey, New Brunswick, NJ L. GORDON MOORE, Brighton Family Medicine, Rochester, NY DAVID G. NATHAN, Dana-Farber Cancer Institute (Emeritus), Boston, MA VINOD K. SAHNEY, Henry Ford Health System, Detroit, MI WILLIAM STEAD, Vanderbilt University, Nashville, TN EDWARD WAGNER, Group Health Center for Health Studies, Seattle, WA vii
viii REVIEWERS Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommenda- tions nor did they see the final draft of the report before its release. The review of this report was overseen by WILLIAM H. DANFORTH, Washington Univer- sity, St. Louis, Missouri, and EDWARD B. PERRIN, University of Washington and VA Puget Sound Health Care System, Seattle, Washington. Appointed by the National Research Council and the Institute of Medicine, they were respon- sible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review com- ments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.
Preface This is the second and final report of the Committee on the Quality of Health Care in America, which was appointed in 1998 to identify strategies for achieving a substantial improvement in the quality of health care delivered to Americans. The committeeâs first report, To Err Is Human: Building a Safer Health System, was released in 1999 and focused on a specific quality concernâpatient safety. This second report focuses more broadly on how the health care delivery system can be designed to innovate and improve care. This report does not recommend specific organizational approaches to achieve the aims set forth. Rather than being an organizational construct, rede- sign refers to a new perspective on the purpose and aims of the health care system, how patients and their clinicians should relate, and how care processes can be designed to optimize responsiveness to patient needs. The principles and guidance for redesign that are offered in this report represent fundamental changes in the way the system meets the needs of the people it serves. Redesign is not aimed only at the health care organizations and professionals that comprise the delivery system. Change is also required in the structures and processes of the environment in which those organizations and professionals function. Such change includes setting national priorities for improvement, cre- ating better methods for disseminating and applying knowledge to practice, fos- tering the use of information technology in clinical care, creating payment poli- cies that encourage innovation and reward improvement in performance, and enhancing educational programs to strengthen the health care workforce. The Quality of Health Care in America project is supported largely by the income from an endowment established within the Institute of Medicine by the ix
x PREFACE Howard Hughes Medical Institute and income from an endowment established for the National Research Council by the W. K. Kellogg Foundation. Generous support was provided by the Commonwealth Fund for a workshop on applying information technology to improve the quality of clinical care, by the Health Care Financing Administration for a workshop aimed at exploring the relationship between payment policy and quality improvement, by the Robert Wood Johnson Foundation for a survey of exemplary systems of care, by the California Health Care Foundation for a workshop to explore methods for communicating with the public about quality in health care, and by the Agency for Healthcare Research and Quality for a workshop on the relationship between patient outcomes and provider volume. Although the committee takes full responsibility for the content of this re- port, many people have made important contributions. The Subcommittee on Designing the Health System of the 21st Century, under the direction of Donald Berwick, combined a depth of knowledge and creativity to propose a vision on how health care could be delivered in the 21st century. The Subcommittee on Creating an External Environment for Quality, under the direction of J. Cris Bisgard and Molly Joel Coye, provided expert guidance and a wealth of experi- ence on how the external environment could support improved delivery of care. Lastly, the IOM staff, under the direction of Janet Corrigan, have provided excel- lent research, analysis and writing. Now is the right time for the changes proposed in this report. Technological advances make it possible to accomplish things today that were impossible only a few years ago. Patients, health care professionals, and policy makers are becoming all too painfully aware of the shortcomings of our current care delivery systems and the importance of finding better approaches to meeting the health care needs of all Americans. The committee does not offer a simple prescription, but 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. William C. Richardson, Ph.D. Chair March 2001
Foreword This is the second and final report of the Committee on the Quality of Health Care in America. Response to the committeeâs first report, To Err is Human: Building a Safer Health System, has been swift, positive, and ongoing from many health care organizations, practitioners, researchers, and policy makers. The present report addresses quality-related issues more broadly, providing a strategic direction for redesigning the health care delivery system of the 21st century. Fundamental reform of health care is needed to ensure that all Ameri- cans receive care that is safe, effective, patient centered, timely, efficient, and equitable. As this report is being released, we are reflecting on the recent loss of a great 20th-century leader in the field of health care quality. Avedis Donabedian, member of the Institute of Medicine, leaves behind a rich body of work on the conceptualization and measurement of quality. His extraordinary intellectual con- tributions will continue to guide efforts to improve quality well into the coming century. The Quality of Health Care in America project continues the Institute of Medicineâs long-standing focus on quality-of-care issues. The Instituteâs Na- tional Roundtable on Health Care Quality has described the variability of the quality of health care in the United States and highlighted the urgent need for improvement. The report Ensuring Quality Cancer Care issued by the Instituteâs National Cancer Policy Board, offers the conclusion that there is a wide gulf between ideal cancer care and the reality experienced by many Americans. And a forthcoming report from the Instituteâs Committee on the National Quality xi
xii FOREWORD Report on Health Care Delivery will offer a framework for periodic reporting to the nation on the state of quality of care. This report reinforces the conviction of these and other concerned groups that we cannot wait any longer to address the serious quality-of-care challenges facing our nation. A comprehensive and strong response is needed now. Kenneth I. Shine, M.D. President, Institute of Medicine March 2001
Acknowledgments The Committee on the Quality of Health Care in America first and foremost acknowledges the tremendous contribution by the members of two subcommit- tees, both of which spent many hours working on exceedingly complex issues. Although individual subcommittee members put forth differing perspectives on a variety of issues, there was no disagreement on the ultimate goal of providing the leadership, strategic direction, and analytic tools needed to achieve a substantial improvement in health care quality during the next decade. We take this oppor- tunity to thank each subcommittee member for his or her contribution. Subcommittee on Creating an Environment for Quality in Health Care: J. Cris Bisgard (Cochair), Delta Air Lines, Inc.; Molly Joel Coye, (Cochair), Institute for the Future; Phyllis C. Borzi, The George Washington University; Charles R. Buck, General Electric Company; Jon Christianson, University of Minnesota; Mary Jane England, Washington Business Group on Health; George J. Isham, HealthPartners; Brent James, Intermountain Health Care; Roz D. Lasker, New York Academy of Medicine; Lucian L. Leape, Harvard School of Public Health; Patricia A. Riley, National Academy of State Health Policy; Gerald M. Shea, American Federation of Labor and Congress of Industrial Organizations; Gail L. Warden, Henry Ford Health System; and A. Eugene Washington, Univer- sity of California, San Francisco School of Medicine. Subcommittee on Building the 21st Century Health Care System: Don M. Berwick (Chair), Institute for Healthcare Improvement; Christine K. Cassel, Mount Sinai School of Medicine; Rodney Dueck, HealthSystem Minnesota; xiii
xiv ACKNOWLEDGMENTS Jerome H. Grossman, John F. Kennedy School of Government, Harvard Univer- sity; John E. Kelsch, Consultant in Total Quality; Risa Lavizzo-Mourey, Univer- sity of Pennsylvania; Arthur Levin, Center for Medical Consumers; Eugene C. Nelson, Hitchcock Medical Center; Thomas Nolan, Associates in Process Im- provement; Gail J. Povar, Cameron Medical Group; James L. Reinertsen, CareGroup; Joseph E. Scherger, University of California, Irvine; Stephen M. Shortell, University of California, Berkeley; Mary Wakefield, George Mason University; and Kevin Weiss, Rush Primary Care Institute. Paul Plsek served as an expert consultant to the subcommittee. In addition, a number of people willingly and generously contributed their time and expertise as the committee and both subcommittees conducted their deliberations. The planning committee for the Workshop on Using Information Tech- nology to Improve the Quality of Care did an excellent job of organizing the workshop. This committee consisted of E. Andrew Balas, University of Missouri School of Medicine; Don E. Detmer, University of Cambridge; Jerome H. Grossman, John F. Kennedy School of Government, Harvard University; and Brent James, Intermountain Health Care. The participants in this workshop provided a great deal of useful information that is reflected in this report. These participants were E. Andrew Balas, University of Missouri School of Medicine; David W. Bates, Brigham Internal Medicine Associates; Mark Braunstein, Pa- tient Care Technologies; Charles R. Buck, General Electric Company; Maj. Gen. Paul K. Carlton, Jr., Air Force Medical Operations Agency; David C. Classen, University of Utah; Paul D. Clayton, Intermountain Health Care; Kathryn L. Coltin, Harvard Pilgrim Health Care; Louis H. Diamond, The MEDSTAT Group; J. Michael Fitzmaurice, Agency for Health Care Policy and Research; Janlori Goldman, Georgetown University; Jerome H. Grossman, John F. Kennedy School of Government, Harvard University; David Gustafson, University of Wisconsin- Madison; Betsy L. Humphreys, U.S. National Library of Medicine; Brent James, Intermountain Health Care; John T. Kelly, AETNA/U.S. Healthcare; David B. Kendall, Progressive Policy Institute; Robert Kolodner, Department of Veterans Affairs; George D. Lundberg, Northwestern University; Robert Mayes, Health Care Financing Administration; Ned McCulloch, IBM, formerly Office of Sena- tor Joseph Lieberman; Elizabeth A. McGlynn, The RAND Corporation; Blackford Middleton, MedicaLogic; Gregg S. Meyer, Agency for Health Care Policy and Research; Arnold Milstein, Pacific Business Group on Health; Donald Moran, The Moran Company; Michael Nerlich, University of Regensburg; William C. Richardson, W. K. Kellogg Foundation; Richard D. Rubin, Foundation for Health Care Quality; Charles Saunders, Healtheon/WebMD; Joseph E. Scherger, Uni- versity of California, Irvine; Kenneth Smithson, VHA, Inc.; William W. Stead, Vanderbilt University; Stuart Sugarman, Mount Sinai/NYU Health; Paul C. Tang,
ACKNOWLEDGMENTS xv Palo Alto Medical Clinic; and Jan H. van Bemmel, Erasmus University Rotterdam. The technical advisory panel on the Communication of Quality of Care Information organized a successful Workshop on Communicating with the Pub- lic About Quality of Care. This panel consisted of Mary Wakefield (Chair), George Mason University; Robert J. Blendon, Harvard School of Public Health and Kennedy School of Government; Charles R. Buck, General Electric Com- pany; Molly Joel Coye, Institute for the Future; Arthur Levin, Center for Medical Consumers; Lee N. Newcomer, Vivius, Inc., formerly with United HealthCare Corporation; and Richard Sorian, Georgetown University. Participants in the Workshop on Communicating with the Public about Quality of Care pro- vided many useful insights reflected in this report. They included Lisa Aliferis, Dateline NBC; Carol Blakeslee, News Hour with Jim Lehrer; Robert J. Blendon, Harvard School of Public Health and Kennedy School of Government; Charles R. Buck, General Electric Company; Christine Cassel, Mount Sinai School of Medicine; Molly Joel Coye, Institute for the Future; W. Douglas Davidson, Foun- dation for Accountability; Susan Dentzer, News Hour with Jim Lehrer; Mason Essif, HealthWeek Public Television; David Glass, Kaiser-Permanente; Ann Greiner, Center for Studying Health System Change; Madge Kaplan, WGBH Radio; Richard Knox, Boston Globe; Arthur Levin, Center for Medical Consum- ers; Trudy Lieberman, Consumer Reports; Lani Luciano, Money Magazine; Laura Meckler, Associated Press; Duncan Moore, Modern Healthcare; Lee N. New- comer, Vivius, Inc., formerly with United HealthCare Corporation; William Richardson, W.K. Kellogg Foundation; Marty Rosen, New York Daily News; Sabin Russell, San Francisco Chronicle; Stuart Schear, The Robert Wood Johnson Foundation; Richard Sorian, Georgetown University; Abigail Trafford, Washington Post; Mary Wakefield, George Mason University; Lawrence Wallack, Portland State University; Michael Weinstein, New York Times; and Ronald Winslow, Wall Street Journal. The technical advisory panel on the State of Quality in America, through their findings, based on a commissioned paper from Mark Schuster at RAND, provided important input to the committeeâs deliberations. The panel included Mark R. Chassin, The Mount Sinai School of Medicine; Arnold Epstein, Harvard School of Public Health; Brent James, Intermountain Health Care; James P. Logerfo, University of Washington, Seattle; Harold Luft, University of Califor- nia, San Francisco; R. Heather Palmer, Harvard School of Public Health; and Kenneth B. Wells, University of California, Los Angeles. Participants in the one-day Workshop on the Effects of Financing Poli- cies on Quality of Care also provided important input to the committeeâs delib- erations. They included Robert Berenson, Health Care Financing Administra-
xvi ACKNOWLEDGMENTS tion; Don Berwick, Institute for Healthcare Improvement; J. Cris Bisgard, Delta Air Lines, Inc.; Phyllis Borzi, The George Washington University; David Brad- ley, Sentinel Health Partners Inc.; Lonnie Bristow, Former President, American Medical Association; Charles R. Buck, General Electric Company; Kathleen Buto, Health Care Financing Administration; Lawrence Casalino, The University of Chicago; Molly Joel Coye, Institute for the Future; Rick Curtis, Institute for Health Policy Solutions; Charles Cutler, American Association of Health Plans; Geraldine Dallek, Georgetown University; Irene Fraser, Agency for Healthcare Research and Quality; Jerome H. Grossman, John F. Kennedy School of Govern- ment, Harvard University; Sam Ho, PacifiCare Health Systems; Thomas Hoyer, Health Care Financing Administration; Brent James, Intermountain Health Care; Glenn D. Littenberg, Practicing Gastroenterologist; James Mortimer, Midwest Business Group on Health; Don Nielsen, American Hospital Association; Ann Robinow, Buyers Health Care Action Group; Gerald Shea, AFLâCIO; David Shulkin, DoctorQuality.com; Bruce Taylor, GTE Service Corporation; and Gail R. Wilensky, Project Hope & MedPAC. Participants in a workshop held to explore the relationship between volume and outcomes made valuable contributions to this study as well. They included Richard Bae, University of California San Francisco; Colin Begg, Memorial Sloan-Kettering Cancer Center; Donald M. Berwick, Institute for Healthcare Improvement; Bruce Bradley, General Motors; Mark R. Chassin, The Mount Sinai School of Medicine; Steve Clauser, Health Care Financing Admin- istration; Jan De la Mare, Agency for Healthcare Research and Quality; Suzanne DelBanco, The Leapfrog Group; R. Adams Dudley, University of California, San Francisco; John Eisenberg, Agency for Healthcare Research and Quality; Irene Fraser, Agency for Healthcare Research and Quality; Robert Galvin, General Electric Company; Ethan Halm, The Mount Sinai School of Medicine; Edward Hannan, State University of New York, Albany; Norman Hertzer, Cleveland Clinic; Bruce Hillner, Virginia Commonwealth University; Sam Ho, PacifiCare Health Systems; George J. Isham, HealthPartners; Clara Lee, The Mount Sinai School of Medicine; Arthur Levin, Center for Medical Consumers; Arnold Milstein, William M. Mercer, Inc.; Peggy McNamara, Agency for Healthcare Research and Quality; Don Nielsen, American Hospital Association; Diana Petitti, Kaiser Permanente of Southern California; Joseph Simone, Huntsman Cancer Foundation and Institute; Jane Sisk, Mount Sinai School of Medicine; and Ellen Stovall, National Coalition for Cancer Survivorship. A steering group that provided invaluable advice and review of the design of the microsystems study included Paul B. Batalden, Dartmouth Medi- cal School; Donald M. Berwick, Institute for Healthcare Improvement; Eugene C. Nelson, Dartmouth Medical Center; Thomas Nolan, Associates in Process Improvement; and Stephen M. Shortell, University of California, Berkeley. The
ACKNOWLEDGMENTS xvii assistance of Susan B. Hassimiller, Project Officer at The Robert Wood Johnson Foundation was critical to the undertaking of this study. The following indi- viduals provided assistance in formulating interview questions and identify- ing study sites: E. Andrew Balas, University of Missouri-Columbia School of Medicine; Connie Davis, Center for Health Studies of the Group Health Coopera- tive of Puget Sound; Joanne Lynn, Center to Improve Care of the Dying; and Charles M. Kilo, Institute for Health Care Improvement. The committee also wishes to thank the individuals at the study sites who gave their time to provide information on their practice settings. Several other individuals made important contributions to the com- mitteeâs work. They include John Demakis and Lynn McQueen, Health Ser- vices Research and Development Service, Department of Veterans Affairs; Joy Grossman, Center for Studying Health System Change; Stephanie Maxwell, the Urban Institute; and Ann Gauthier, Academy for Health Services Research and Health Policy. Support for this project was provided by the Institute of Medicine, the National Research Council, The Robert Wood Johnson Foundation (Study of Micro-Systems), the California Health Care Foundation (Workshop on Commu- nicating with the Public about Quality of Care), the Commonwealth Fund (Work- shop on Using Information and Technology to Improve the Quality of Care), and the Department of Health and Human Servicesâ Health Care Financing Adminis- tration (Workshop on the Effects of Financing Policy on Quality of Care), and Agency for Healthcare Research and Quality (Volume/Outcomes Workshop).
Contents EXECUTIVE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1 A NEW HEALTH SYSTEM FOR THE 21ST CENTURY . . . . . . . 23 The Quality Gap, 23 Underlying Reasons for Inadequate Quality of Care, 25 Agenda for the Future and Road Map for the Report, 33 2 IMPROVING THE 21ST-CENTURY HEALTH CARE SYSTEM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Six Aims for Improvement, 41 A Vision of Future Care, 54 3 FORMULATING NEW RULES TO REDESIGN AND IMPROVE CARE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 Health Care Organizations as Complex Adaptive Systems, 63 Ten Simple Rules for the 21st-Century Health Care System, 66 4 TAKING THE FIRST STEPS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 The Value of Organizing Around Priority Conditions, 92 Applications of Priority Conditions, 96 Criteria for Identifying Priority Conditions, 103 Providing the Resources Needed to Initiate Change, 103 xix
xx CONTENTS 5 BUILDING ORGANIZATIONAL SUPPORTS FOR CHANGE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111 Stages of Organizational Development, 112 Key Challenges for the Redesign of Health Care Organizations, 117 Leadership for Managing Change, 137 6 APPLYING EVIDENCE TO HEALTH CARE DELIVERY . . . . . . 145 Background, 147 Synthesizing Clinical Evidence, 148 Using Computer-Based Clinical Decision Support Systems, 152 Making Information Available on the Internet, 155 Defining Quality Measures, 157 7 USING INFORMATION TECHNOLOGY . . . . . . . . . . . . . . . . . . . . 164 Potential Benefits of Information Technology, 166 Automated Clinical Information, 170 Need for a National Health Information Infrastructure, 176 8 ALIGNING PAYMENT POLICIES WITH QUALITY IMPROVEMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181 Incentives of Current Payment Methods, 184 Barriers to Quality Improvement in Current Payment Methods, 191 Adapting Existing Payment Methods to Support Quality Improvement, 199 Need for a New Approach, 201 9 PREPARING THE WORKFORCE . . . . . . . . . . . . . . . . . . . . . . . . . . 207 Clinical Education and Training, 208 Regulation of the Professions, 214 Legal Liability Issues, 218 Research Agenda for the Future Health Care Workforce, 219 APPENDIXES A Report of the Technical Panel on the State of Quality to the Quality of Health Care in America Committee, 225 B Redesigning Health Care with Insights from the Science of Complex Adaptive Systems, 309 INDEX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 323
Crossing the Quality Chasm