expenditures (Hoffman et al., 1996; The Robert Wood Johnson Foundation, 1996). As the need for community-based acute and long-term care services has grown, the portion of health care resources devoted to hospital care has declined, while that expended on pharmaceuticals has risen dramatically (Copeland, 1999). 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). Yet physician groups, hospitals, and other health care organizations operate as silos, often providing care without the benefit of complete information about the patient’s condition, medical history, services provided in other settings, or medications prescribed by other clinicians. For those without insurance, care is often unobtainable except in emergencies. It is not surprising, then, that studies of patient experience document that the health system for some is a “nightmare to navigate” (Picker Institute and American Hospital Association, 1996).


The committee is confident that Americans can have a health care system of the quality they need, want, and deserve. But we are also confident that this higher level of quality cannot be achieved by further stressing current systems of care. The current care systems cannot do the job. Trying harder will not work. Changing systems of care will.

The committee’s report on patient safety offers a similar conclusion in its narrower realm. Safety flaws are unacceptably common, but the effective remedy is not to browbeat the health care workforce by asking them to try harder to give safe care. Members of the health care workforce are already trying hard to do their jobs well. In fact, the courage, hard work, and commitment of doctors, nurses, and others in health care are today the only real means we have of stemming the flood of errors that are latent in our health care systems.

Health care has safety and quality problems because it relies on outmoded systems of work. Poor designs set the workforce up to fail, regardless of how hard they try. If we want safer, higher-quality care, we will need to have redesigned systems of care, including the use of information technology to support clinical and administrative processes.

Throughout this report, the committee offers a strategy and action plan for building a stronger health system over the coming decade, one that is capable of delivering on the promise of state-of-the-art health care to all Americans. In some areas, achieving this ideal will require crossing a large chasm between today’s system and the possibilities of tomorrow.

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