The call for such improvement is not an indictment of physicians, nurses, or, indeed, any of the people who give or lead care. The committee asserts, without reservation, that our health care can and should be far better than it is today, but it would be futile to seek that improvement by further burdening an overstressed health care workforce or by exhorting committed professionals to try harder. Instead, the improvements outlined here will require significant changes in the ways health care is organized, in the accessibility and usefulness of clinical evidence, in the environment of payment, and in other incentives that set the context for delivery of care. A redesigned care system can offer the health care workforce what it wants—a better opportunity to provide high-quality care.

The ultimate test of the quality of a health care system is whether it helps the people it intends to help. This rather simple statement, as expanded upon in the following detailed discussion of the six aims for improvement set forth earlier, represents a major shift in thinking about the purpose of health care—a shift in attention from what is done to patients to what is accomplished for them. The IOM has defined quality as “the degree to which health care services for individuals and populations increase the likelihood of desired outcomes and are consistent with current professional knowledge” (Institute of Medicine, 1990). The committee believes the health care system should define safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity using measures determined by the outcomes patients desire, although clinicians should not be asked to compromise their ethical values. Desirable personal health outcomes include improvement (and prevention of deterioration) of health status and health-related quality of life, and management of physical and psychological symptoms. Desirable outcomes also include attention to interpersonal aspects of care, such as patients’ concerns and expectations, their sense of dignity, their participation in decision making, and in some cases reduced burden on family and caregivers and spiritual well-being.

Such outcomes can be described at both the individual level (e.g., improvement in individual health status) and the population level (e.g., reduced aggregate burden of illness and injury in a population). The committee recognizes that the health of the public could be greatly improved by attention to and investment in a variety of areas, such as reducing violence and substance abuse and improving nutrition and transportation safety. This report, however, is focused specifically on the improvement of health care services to individuals. For this reason, we describe the six aims for improvement from the perspective of the individual’s— usually a patient’s—experience.


Patients should not be harmed by the care that is intended to help them, nor should harm come to those who work in health care. The earlier report by this committee, To Err Is Human: Building a Safer Health System (Institute of

The National Academies | 500 Fifth St. N.W. | Washington, D.C. 20001
Copyright © National Academy of Sciences. All rights reserved.
Terms of Use and Privacy Statement