deliver health care services and how to assess and improve their quality. Our present efforts resemble a team of engineers trying to break the sound barrier by tinkering with a Model T Ford. We need a new vehicle or perhaps, many new vehicles. The only unacceptable alternative is not to change. (Chassin et al., 1998)

The Advisory Commission on Consumer Protection and Quality also released a report on quality. That report calls for a national commitment to improve quality, concluding: “Exhaustive research documents the fact that today, in America, there is no guarantee that any individual will receive high-quality care for any particular health problem. The health care industry is plagued with overutilization of services, underutilization of services and errors in health care practice” (Advisory Commission on Consumer Protection and Quality in the Health Care Industry, 1998).

Finally, the reports of both of these national panels were supported by the results of an extensive literature review conducted by researchers at RAND Corporation and encompassing publications in leading peer-reviewed journals between 1993 and mid-1997 (Schuster et al., 1998). The report on those results substantiates the serious and pervasive nature of quality-of-care problems.

In the fall of 1998, the Committee on the Quality of Health Care in America established a Technical Advisory Panel on the State of Quality to review the most recent literature on quality. In collaboration with RAND, the earlier synthesis of the quality literature was updated to include work published between July 1997 and August 1998. The detailed results of this review, now covering 8 years and more than 70 publications, are included in Appendix A. The committee concurs with the findings of the panel that “…there is abundant evidence that serious and extensive quality problems exist throughout American medicine resulting in harm to many Americans.”

The literature reviews conducted by RAND encompass studies categorized under the rubric of quality of care. Other reviews that probe more deeply in a specific clinical area (e.g., oncology) or focus on a particular type of quality problem (e.g., errors) provide further evidence of the systemic nature of quality-of-care problems.

One such study, an IOM report examining cancer care, reveals that quality problems occur across all types of cancer care and in all aspects of the process of care (Institute of Medicine, 1999). For example, problems with breast cancer care include underuse of mammography for early cancer detection, lack of adherence to standards for diagnosis (such as biopsies and pathology studies), inadequate patient counseling regarding treatment options, and underuse of radiation therapy and adjuvant chemotherapy following surgery.

In its first report, To Err Is Human: Building a Safer Health System, this committee reviewed the literature on a specific type of quality problem—medical errors. We found about 30 publications published during the last 10 to 12 years

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