1. Shared knowledge and the free flow of information. Patients should have unfettered access to their own medical information and to clinical knowledge. Clinicians and patients should communicate effectively and share information.

  2. Evidence-based decision making. 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.

  3. Safety as a system property. Patients should be safe from injury caused by the care system. Reducing risk and ensuring safety require greater attention to systems that help prevent and mitigate errors.

  4. The need for transparency. The health care system should make information available to patients and their families that allows them to make informed decisions when selecting a health plan, hospital, or clinical practice, or choosing among alternative treatments. This should include information describing the system’s performance on safety, evidence-based practice, and patient satisfaction.

  5. Anticipation of needs. The health system should anticipate patient needs, rather than simply reacting to events.

  6. Continuous decrease in waste. The health system should not waste resources or patient time.

  7. Cooperation among clinicians. Clinicians and institutions should actively collaborate and communicate to ensure an appropriate exchange of information and coordination of care.

These ten rules translate readily into a set of new patient expectations for health care (see Box 3–1). The committee believes these new expectations are consistent with and reinforce the steps that must be taken to achieve a significant improvement in quality. We also believe they are consistent with the kind of care most clinicians strive to provide each day, but without the support of well-designed care systems and absent an environment that nurtures innovation and excellence.

To create a new health care system that more closely matches the purpose and aims described in Chapter 2, it will be necessary, first, to examine old assumptions to understand why they have led to our current ineffective health care systems, and second, to consciously craft new operating assumptions embodied in the rules set forth above. As a guide in formulating its agenda for change, the committee used as a framework recent work in understanding complex adaptive systems (Kauffman, 1995; Stacey, 1996; Waldrop, 1992; Weick, 1995; Zimmerman et al., 1998) and its application to what have become known as “learning organizations” (Senge, 1990) (see Appendix B for an introduction to this field).

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