To enable the profound changes in health care recommended in this report, the environment of care must also change. The committee believes the current environment often inhibits the changes needed to achieve quality improvement. Two types of environmental change are needed:
Focus and align the environment toward the six aims for improvement. To effect this set of changes, purchasers and health plans, for example, should eliminate or modify payment practices that fragment the care system, and should establish incentives designed to encourage and reward innovations aimed at improving quality. Purchasers and regulators should also create precise streams of accountability and measurement reflecting achievements in the six aims. Moreover, efforts should be made to help health care consumers understand the aims, why they are important, and how to interpret the levels of performance of various health care systems.
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.
Such environmental changes need to occur in four major areas: the infrastructure that supports the dissemination and application of new clinical knowledge and technologies, the information technology infrastructure, payment policies, and preparation of the health care workforce.
Changes will also be needed in the quality oversight and accountability processes of public and private purchasers. This issue is not addressed here. The IOM will be issuing a separate report on federal quality measurement and improvement programs in Fall 2002. In addition, the National Quality Forum has an extensive effort under way to develop a national framework for quality measurement and accountability and will be issuing a report in Summer 2001.
In the current health care system, scientific knowledge about best care is not applied systematically or expeditiously to clinical practice. An average of about 17 years is required for new knowledge generated by randomized controlled trials to be incorporated into practice, and even then application is highly uneven (Balas and Boren, 2000). The extreme variability in practice in clinical areas in