rangements and across all geographic areas and health care delivery settings (Chassin and Galvin, 1998).

The convergence of a series of studies and reports beginning in 1998 has brought renewed urgency to the quality debate. These reports reveal widespread defects in the delivery of medical care that taken together “detract from the health, functioning, dignity, comfort, satisfaction, and resources of Americans” (Institute of Medicine, 2001, p. 2). According to the IOM’s National Roundtable on Health Care Quality: “The burden of harm conveyed by the collective impact of all of our health care quality problems is staggering…. The challenge is to bring the full potential benefit of effective health care to all Americans while avoiding unneeded and harmful interventions and eliminating preventable complications of care…. Our present efforts resemble a team of engineers trying to break the sound barrier by tinkering with a Model T Ford” (Chassin and Galvin, 1998, p. 1004). The extent and impact of quality problems are confirmed in the report of the Advisory Commission on Consumer Protection and Quality in the Health Care Industry (Advisory Commission, 1998, p. 21): “[T]oday in America, there is no guarantee that any individual will receive high-quality care for any particular problem. The health care industry is plagued with overutilization … underutilization … and errors…. ”

Results of studies of the treatment of specific diseases, such as cancers, indicate that serious quality problems emerge at virtually every stage of medical care (Institute of Medicine, 1999a). A lack of conformity with practice standards in the prevention, diagnosis, and treatment of disease is compounded by issues of basic patient safety in the delivery of care. Avoidable deaths due to medical errors exceed the number of deaths attributable to many leading causes of mortality, including AIDS, breast cancer, and motor vehicle crashes and injuries (Institute of Medicine, 1999b).

In its report Crossing the Quality Chasm: A New Health System for the 21st Century, the IOM (2001) calls for fundamental reform of the health care system directed at effecting substantial improvements to achieve six quality aims—safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity. Achieving these aims will require changes at four levels: patient experiences, microsystems that deliver care (e.g., multidisciplinary team), health care organizations that house the microsystems (e.g., hospitals), and the environment (e.g., payment policies, regulatory framework) (Berwick, 2002).

This steady stream of analyses, pronouncements, and consensus perspectives has created a national climate within which it is now expected that responsible health care programs will be accountable for demonstrating that the services they provide not only meet minimal standards of care quality, but also achieve continuous improvement. Major public- and



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