Crossing the Quality Chasm A New Health System for the 21st Century (2001) / Chapter Skim
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Executive Summary
Executive Summary
Pages 1-22
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Crucial reports from disciplined review bodies document the scale and gravity of the problems (Chassin et al.,1998; Institute of Medicine, 1999; Advisory Commission on Consumer Protection and Quality in the Health Care Industry, 1998~. Quality problems are everywhere, affecting many patients.
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. As disturbing as the committee's report on safety is, it reflects only a small part of the unfolding story of quality in American health care.
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. A highly fragmented delivery system that largely lacks even rudimentary clinical information capabilities results in poorly designed care processes characterized by unnecessary duplication of services and long waiting times and delays.
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Yet there remains a dearth of clinical programs with the infrastructure required to provide the full complement of services needed by people with heart disease, diabetes, asthma, and other common chronic conditions (Wagner et al., 1996~. 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 communicate and coordinate care (The Robert Wood Johnson Foundation, 1996~.
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· That clinicians and patients, and the health care organizations that support care delivery, adopt a new set of principles to guide the redesign of care processes. · That the Department of Health and Human Services identify a set of priority conditions upon which to focus initial efforts, provide resources to stimulate innovation, and initiate the change process.
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Additionally, without ongoing tracking to assess progress in meeting the six aims, policy makers, leaders within the health professions and health organizations, purchasers, and consumers will be unable to determine progress or understand where improvement efforts have succeeded and where further work is most needed. The National Quality Report has the potential to play an important role
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It should be noted that although this report focuses only on health care for individuals, the above overarching statement of purpose and six aims for improvement are sufficiently robust that they can be applied equally to decisions and evaluations at the population-health level. Formulating New Rules to Redesign and Improve Care As discussed earlier, improved performance will depend on new system designs.
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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.
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To initiate the process of change, the committee believes the health care system must focus greater attention on the development of care processes for the common conditions that afflict many people. A limited number of such conditions, about 15 to 25, account for the majority of health care services (Centers for Disease Control and Prevention, 1999; Medical Expenditure Panel Survey, 2000; Ray et al., 2000~.
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Recommendation 5: The Agency for Healthcare Research and Quality should identify not fewer than 15 priority conditions, taking into account frequency of occurrence, health burden, and resource use. In collaboration with the National Quality Forum, the agency should convene stakeholders, including purchasers, consumers, health care organizations, professional groups, and others, to develop strategies, goals, and action plans for achieving substantial improvements in quality in the next 5 years for each of the priority conditions.
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producing substantial improvements in quality for the priority conditions. The fund's resources should be invested in projects that will produce a public-domain portfolio of programs, tools, and technologies of widespread applicability.
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Use of such measures makes it possible to understand the degree to which performance is consistent with best practices, and the extent to which patients are being helped. Recommendation 7: The Agency for Healthcare Research and Quality and private foundations should convene a series of workshops involving representatives from health care and other industries and the research community to identify, adapt, and implement state-ofthe-art approaches to addressing the following challenges: · Redesign of care processes based on best practices · Use of information technologies to improve access to clinical information and support clinical decision making · Knowledge and skills management · Development of effective teams · Coordination of care across patient conditions, services, and settings over time · Incorporation of performance and outcome measurements for improvement and accountability
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Provide, where possible, assets and encouragement for positive change. For example, national funding agencies could promote research on new designs for the care of priority conditions, state and national activities could be undertaken to facilitate the exchange of best practices and shared learning among health care delivery systems, and a national system for monitoring progress toward the six aims for improvement could help improvement efforts remain on track.
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Development of decision support tools to assist clinicians and patients in applying the evidence Establishment of goals for improvement in care processes and outcomes Development of quality measures for priority conditions More systematic approaches are needed to analyze and synthesize medical evidence for both clinicians and patients. Far more sophisticated clinical decision support systems will be required to assist clinicians and patients in selecting the best treatment options and delivering safe and effective care.
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The development of a more effective infrastructure to synthesize and organize evidence around priority conditions would also offer new opportunities to enhance quality measurement and reporting. A stronger and more organized evidence base should facilitate the adoption of best practices, as well as the development of valid and reliable quality measures for priority conditions that could be used for both internal quality improvement and external accountability.
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Yet, the Internet is rapidly transforming many aspects of society, and many health-related processes stand to be reshaped as well. In the absence of a national commitment and financial support to build a national health information infrastructure, the committee believes that progress on quality improvement will be painfully slow.
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Aligning Payment Policies with Quality Improvement 17 Current payment methods do not adequately encourage or support the provision of quality health care. Although payment is not the only factor that influences provider and patient behavior, it is an important one.
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Recommendation 10: Private and public purchasers should examine their current payment methods to remove barriers that currently impede quality improvement, and to build in stronger incentives for quality enhancement. Payment methods should: · Provide fair payment for good clinical management of the types of patients seen.
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Examples of possible means of achieving this end include blended methods of payment for providers, multiyear contracts, payment modifications to encourage use of electronic interaction among clinicians and between clinicians and patients, risk adjustment, bundled payments for priority conditions, and alternative approaches for addressing the capital investments needed to improve quality. Preparing the Work force A major challenge in transitioning to the health care system of the 21st century envisioned by the committee is preparing the workforce to acquire new skills and adopt new ways of relating to patients and each other.
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can be modified to support health care professionals and organizations that seek to accomplish the six aims set forth in Chapter 2. SUMMARY The changes needed to realize a substantial improvement in health care involve the health care system as a whole.
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Yearbook of Medical Informatics National Library of Medicine, Bethesda, MD:53-7, 1999. Medical Expenditure Panel Survey.
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Toward a National Health Information Infrastructure: Report of the Work Group on Computerization of Patient Records. Washington, D.C.: U.S.
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