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Overview Donald M. Berwick It is an honor to be here, and I have deep gratitude for the chance to share my thoughts with this group. In the spirit of thanks, I want to begin my remarks, which will sum- marize the work of the Institute of Medicine's (IOM) Committee on Qual- ity Care in America, with a special note of gratitude and admiration for the person who really led us through this work, and that is lanes Corrigan. Several years ago, in my role as a member of the President's Advisory Commission on Consumer Protection and Quality in the Health Care In- dustry a group that included approximately 30 people, who ranged all the way from as far left to as far right as you can get I watched the mas- terful leadership of lanes as she guided the secretary of labor, the secre- tary of health and human services, and the whole committee, to a consen- sus that would not otherwise have been achievable. Watching lanes move over here to help us on this committee has been a thrill and an honor, and I just want you to know what an impact lanes has had on my career. I appreciate it deeply. I am fortunate to have been involved in this work. The Crossing the Quality Chasm report, which I will discuss, is a complicated document, which means I will have the opportunity to insert my own opinions into it and you won't know. I want to begin by setting the stage for those of you who don't know about the history of this report and its pedigree and the work of the IOM and elsewhere. I believe the foundation of the work was set in place by the IOM roundtable Ken Shine mentioned. That roundtable really put a stake in the ground in about 1998, drawing on five decades of research 7

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8 CROSSING THE QUALITY CHASM about the state of care in the United States, and it made a declaration at length about the need to address improvement of care as an important national priority, a kind of declaration that had not been made before. I want to share with you the words of the IOM roundtable, from the lead article in the Journal of the American Medical Association that appeared late in 1998. Here is what the roundtable said: Serious and widespread quality problems exist throughout American medicine. These problems occur in small and large communities alike, in all parts of the country, and with approximately equal frequency in man- aged care and fee-for-service systems of care. Very large numbers of Americans are harmed as a result. I have enormous respect for the Institute of Medicine, but it is not known for overstatement. A statement with this degree of drama, appear- ing in the public record from a group with the prestige of the roundtable, really set in place the work that I am now going to present to you. The roundtable did offer vocabularies that I will return to later, but as it began to examine the issues that the American public were facing, and were relatively unaware of, it offered us specific ways of thinking about what is wrong with the care we give. It said the problems with health care received by the American public can be understood in three major catego- ries: overuse of unnecessary care, that is, procedures that cannot scientifi- cally help the beneficiaries; underuse of care that is effective but does not reach the population it should help; and what the IOM roundtable called misuse, failures to execute plans successfully, the area of error in care. It was probably the first major body to speak out, leading to the work of our committee. Theirs was not the only voice asking for change in the late 1990s. The IOM roundtable was the most important, but the President's Advisory Commission that lanes led came to very similar conclusions with very similar rhetoric. Similarly, work here at The National Academies by the National Cancer Policy Board produced a relatively underexposed report, one that has not received anywhere near the attention it should, showing that the average American cancer patient does not receive care even close to the state of the art of modern cancer care. Tens of thousands of cancer patients may well, in my opinion, die as a result of not having access to treatments that are known to cure curable cancers nowadays. And when one looks at the area of end of life care and pain control, there are even more serious defects. I don't know what was in Ken's mind and in the minds of the leaders of the Institute of Medicine, but I think courageously and importantly they decided, based on reports like this and other evidence, to begin a major program under lanes's leadership, the IOM program on the quality

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OVERVIEW 9 of care in America. I was privileged to be a member of the first committee, chaired by Bill Richardson, the Committee on Quality of Care in America, and that is the work that I am about to present to you. For someone who had been working in the arena of health care qual- ity for 20 or 30 years, to say that I had been frustrated trying to get the attention of the public would be an understatement. I feel very deeply that there are serious issues in the quality of our care system. But that all changed suddenly. The findings of the IOM report on patient safety were dramatic. They changed the vocabulary of discussion about quality of care in America in a way that I don't think anybody associated with that report would have anticipated. They changed in a single day, on November 30th, 1999. That is when the report was issued. It was an immediate blockbuster. So far as I understand, the reaction to the report, To Err Is Human, was unprecedented in the history of the Institute of Medicine. Within hours, the findings in that report were front page news in the American press and headline news in every radio and TV network news station. Within days, President Bill Clinton had ordered immediate and far-reaching re- sponses from every governmental agency in the United States that pro- vides or pays for health care. Within weeks, major projects in response had begun in the American Medical Association, the American Hospital Association, and in professional and trade societies throughout the na- tion. That wave of reaction to the report on patient safety was not a flash in the pan, it turns out. It is still going on. lust last week, NBC asked me to be interviewed on network news. The findings of the IOM report on patient safety were dramatic. We reviewed decades of prior research, and our committee, the same com- mittee that issued the Chasm report, concluded that health care in America was, after all, remarkably unsafe. We estimated that tens of thousands of Americans are being injured each year in American hospitals. Between 44,000 and 98,000 Americans actually die each year from injuries caused by the care that is supposed to help them, not by their diseases. That would place medical injuries high on the list of public health problems. If those numbers are correct, medical care kills more Americans each year than do AIDS, breast cancer, or motor vehicle accidents. The safety problems were severe, and that was our first conclusion. We then went on to two other major findings. The second finding was that blame, fault finding, would not help solve this problem. Our commit- tee found that safety hazards were only rarely, very rarely, traceable to bad people giving the care. Incompetent doctors or careless nurses, we concluded, are not the primary reasons that patients get hurt. Instead, the reasons for injury lie very deeply embedded in the processes of the work of health care, the designs of the health care system. When a patient gets

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0 CROSSING THE QUALITY CHASM hurt, we can choose to blame the doctor, but we will almost always be wrong when we do that. Let me give you an example of this idea of embeddedness. Suppose a patient gets hurt when a piece of information gets lost. If it turns out that the work design requires that someone, doctor or anyone else human, prevent that injury by remembering information, then we are relying on memory for safety. That is an element of the design. But we know from decades of research in human factors, human cognition, and human memory, that memory is a terribly unreliable function. We always forget things, and we always will forget things. If the health care process relies on memory to function well, it will fail sometimes, no matter how the people in that system try hard not to for- get. The title of the IOM report was, To Err Is Human, and blaming people does not change that fact. The third finding of our committee in this report was much more op- timistic. It said basically, "We can do something about it." The IOM com- mittee found that there is a treasure trove of good science and practice dealing with how to make systems safer, the sciences of safe design. But, sadly, health care systems have not yet used those safety sciences to pre- vent injury, and we urge that this change begin right away. I have been nothing less than thrilled by the response to this report. It is gaining momentum in the United States. Hospitals all over this country are being asked now, quite directly, to replace outmoded medication sys- tems, which often rely on memory, or rely on something even less reli- able, handwriting. These systems can be replaced with computerized phy- sician order entry systems, which are known by systematic, well-designed clinical trials to reduce hospital medication errors by 80 percent. Progres- sive hospitals are learning from aviation and from other high-hazard industries about how investments, for example, in team training, simula- tion, or communication skills can help operating room teams or emer- gency departments reduce errors. So the work of our committee in the second report began with a rela- tively happy story not that health care is safe; it is not safe. But rather that, at long last, it looks as though maybe we are going to do something about it. But then we needed to take a step back. Our committee did so, and I ask you as well to look at the bigger picture, because, as compelling as the story of improving patient safety has been in the past year and a half, it is actually sort of confusing. It is confusing to realize that the IOM report, To Err Is Human, had one very important feature. It said almost nothing new. In fact, the vast majority of the scientific information that the report sum- marized was not new at all. It wasn't even recent. It was quite old. Key studies of patient injury and medical errors appear in our literature as far

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OVERVIEW 11 back as the 1940s and the 1950s, and they are not published in obscure places. They are published in mainstream medical journals. Patient safety might be a new concern for the American public at long last, but the problems of patient safety have been there for a long time. But that is not the whole story about what has been ignored. On the heels of the patient safety report, the same IOM committee, the Committee on Quality Care in America, has written this second report, which I think is actually a more important, though less widely read, document. The re- port was released on March 1 of this year, and although the public reac- tion has been far less loud than the reaction to the safety report, I think the implications of this Chasm report go deeper. I want to take you through it now. In a lot of ways, the Chasm report follows exactly the same format as the safety report, but it is on a bigger topic, a far larger topic, a more important topic than patient safety. It is not concerned with safety alone, you see, it is about the quality of care as a whole. The findings are parallel. First, the new report finds that quality prob- lems are serious and highly prevalent. They take an enormous toll on U.S. citizens. They take a toll on our lives, on our function, on our dignity, on our convenience, and on our wallets. We, in this committee, have catego- rized these quality problems, these dimensions of quality, into six issues or areas, which go beyond the area of the work of the IOM roundtable. The first issue we are flagging remains the same. It is safety. We sug- gest that Americans should be as safe in health care as they are in their own homes, and not a bit less. Yet as the first report said, that is not the case now: we are off target by several orders of magnitude. If you board an airplane today, you would have to fly continuously for 20,000 years in order to have the odds go above 50 percent that you would die. If you enter a hospital today, you would have to lie in a hospital bed for only five years before you would have a 50 percent chance of dying from an . . injury. Our committee stated in this report, as in the first one, that safety ought to be a reliable property of care, but it is not. A particularly compel- ling burden of this has come from a French investigator, Rene Amalberti, whose work has been graphed by Lucien Leape, my friend and colleague and the leader of the patient safety movement. Amalberti says it is pos- sible to categorize industries on a plane, which you see here. The horizon- tal axis, which you will notice is a logarithmic scale, is a measurement of the number of exposures per fatality. If you get on the European railroad, there is one death per 10 million exposures. Amalberti calls that an ultra- safe industry. So is nuclear power less than one death per 10 million exposures. Airplane travel is about one death per 2 million exposures. As you go along the scale to the left you find what you could call dangerous

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2 CROSSING THE QUALITY CHASM industries or enterprises. Bungeejumping wins the prize. There is about one death for every 200 bungee jumps. Aggressive mountain climbing is there and so is health care. The vertical axis adds up the total number of deaths incurred by, in this case, the American population as a result of these activities. Not many people bungeejump for long, but most of us use health care. And because of the rate of exposure, health care occupies the privileged upper left cor- ner of this diagram, killing, as we know, tens of thousand of people per year. Aim two is effectiveness. That single term collapses the two problems of performance in health care in the United States that the roundtable identified, the problem of overuse and the problem of underuse. Over- use refers to the use of care medicine, tests, hospital days that cannot, on scientific grounds, be predicted to help the patient. It refers to useless care, care that won't work. One example in the United States is the wide- spread overuse of powerful antibiotics for simple infections. About 30 percent of American children with first ear infections, easily treated with amoxicillin or Bactrim at five dollars for a course of treatment, instead get powerful toxic antibiotics that cost over a hundred dollars and that en- courage the emergence of resistant strains of organisms, and that inciden- tally place the child at much higher risk of toxicity side effects. Underuse of care is the failure to use care that is known scientifically to be beneficial. About half the elderly people in this country still fail to get pneumococcal vaccine, for example, and 50 percent of people still in hospitals with heart attack fail to get simple drugs that help prevent re- currence of heart attack. In this new report, the Chasm report, our committee says that it is time to reduce the rates of overuse and underuse in this country. Instead, we call for a commitment to put science into practice, which will lead to more effective use of treatment. The third proposed aim is patient centeredness: putting the patient in the driver's seat; offering choices; respecting diversity; and involving loved ones. In general, patient-centeredness is aimed at reminding our- selves that, in the end, the health care system should serve the patient, not the other way around. We find that the current system too often forgets the patient. It fails to respond to individual needs, preferences, and values. It hides informa- tion and fails to answer questions. We know this, in part, because patients who rate our health care system, as a whole, rank it just below the Internal Revenue Service. Our report is a strong call for giving patients control over the care that affects them. The fourth aim is timeliness. We are asking for systematic reductions in delays in waiting times in the United States health care system, not just

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OVERVIEW 13 for patients, but for those who give care as well, who find the system quite unreliable in letting them use their time well. We think that waiting is, per se, poor quality. The fifth aim we call efficiency, which basically refers to the reduction and elimination of what I call pure waste: unwise use of materials; time; space; energy; and human spirit. I remember arriving at Heathrow air- port a few years ago, as the customs official took out a four-part NCR form and a rubber stamp, stamped the first page, stamped the second page, stamped the third page, stamped the fourth page, ripped off the fourth page, and rolled it into a ball and threw it in a wastebasket over- flowing at his feet. That is what I call pure waste. In the U.S. health care system, there is a lot of that. I know, for ex- ample, the vicious expansion of burden on the American nurse today to create and maintain elaborate records, mindless records that no one will ever use. I recently surveyed a hundred nurse cancer specialists, very highly skilled people, in New York City, and asked them to estimate the proportion of their day spent creating records. The median estimate was 50 to 60 percent. I asked them what percentage of those records was ever used by anyone for anything. The median answer was 10 percent. We think that such waste, however it was originally justified, is poor quality. The sixth aim for improvement designated in our committee, more relevant to the United States than any other Western nation, is equity of care. In our wealthy nation we have 40 million uninsured people. More- over, the best predictors of health status in the United States, overwhelm- ing anything else, are race and wealth. Smoking is a distant third. A black American male born in the nation's capital today has a life expectancy eight years shorter than a white one. We find such inequity a travesty. We think it is the biggest American health care problem of them all, and we welcome the initiative of the IOM to deal with that issue. As the patient safety report called for major improvements in safety, the Chasm report calls for improvements across the board in all six areas of performance. This is a clear and direct call to the entire nation from a disciplined and economically disinterested institution. In our committee, we have come to say that the safety report was the tip of the iceberg; the Chasm report is the rest of the iceberg. Remember that the safety report said clearly that the way to a safer health care system does not follow the road of blame. The vast majority of people who work in health care are trying very hard not to make errors. Indeed, they provide the safety net against the flawed systems they work in. We cannot get safer care by blaming them, by exhorting them, by su- ing them, or by punishing them. The new report, the Chasm report, says exactly the same thing about the other five dimensions of quality. It is not the people themselves; rather, it is the processes in which the people work

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4 CROSSING THE QUALITY CHASM that lie at the root of our troubles. Only by changing those processes can we possibly find a way out of our current health care problems and into the care that we want. Quality of all dimensions is a property embedded in the system of work. The first law of improvement that I wrote a number of years ago, not that I have legislative authority, is that every system is perfectly designed to achieve exactly the results it gets. I own a Ford Windstar. If I take it out on the Bonneville salt flats and floor the accelerator, it will rise to a top speed of about 92 miles an hour not that I have tried it. Some days 90, some days 94, but about 92. If I don't like that top speed I can have a plan, such as yelling at the Windstar or providing it incentives or putting an incident report in its file none will make the car go faster. Ninety-two is its capability. If I want to go faster, what do I need to do? Buy a Ferrari, I suppose. That's 150 to 180 miles an hour. The characteristic top speed is an embedded characteristic of the system. A Ferrari is a different system from a Ford Windstar. You can see that in the health care world in incident after incident. If you are interested in safety, look at this slide from the New England Journal of Medicine about an outbreak of deaths in a newborn nursery. A few in- fants died, CDC ended up investigating, and this was the ultimate find- ing. On the left is a bottle of racemic epinephrine intended to be put down the nasotracheal tube of premature infants to help them breathe better. On the right is a bottle of vitamin E intended to be put down the nasogastric tube of young infants who are vitamin E deficient. Can you guess how the babies were dying? The racemic epinephrine was being put into the nasogastric tube and the babies were dying of gastric hemor- rhage. This is a system perfectly designed to kill a few babies. The nurse who puts the racemic epinephrine into the nasogastric tube will be censored, put on probation, and possibly fired. That will have no effect whatsoever on the probability that the next infant will have a gas- tric hemorrhage. Not until this system is fixed does safety become a prop- erty. It would be a lot easier if quality improvement depended on people. The remedy would be obvious. Fire all the wrong people and keep the right ones. That plan, the incentive plan, is bankrupt. But it is seductive. It is so seductive, so clear, that it remains the basic plan for a great deal of the work on health care quality that is forging ahead in this country, and it won't work. I know that, the IOM committee knows that, and I think, in your hearts, you know that. The answer for improvement is a much tougher answer. It is change, change in the way we work. Reject the status quo system of care. Invent new care: change; change; change. There is no other way. The new IOM report, the Chasm report, deeply explores the changes

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OVERVIEW 15 we need, and it becomes a little confusing. It is a hard report to read. I am going to take a minute to guide you through the framework, so if you want to read the report, you can more easily. It is a way to understand the basic categories of change that this report calls for, which I think are the right changes, and the necessary approach to achieve better health care, not just in the United States but in other nations, too. I think of the changes needed as occurring at four levels. At the first level, we will call level one, are changes in the experiences of the people health care serves, the patients, their careers, and the communities. It is in their experience, only in their experience, that quality lives. If we are sat- isfied with those experiences, then change is not an issue, not in the lives of the people we serve nor in the ways we choose to serve them. Change in health care as a system is important. It makes sense only in terms of the intention to change the experiences of the patients and families, and in no other way. The first change, the change that fuels every other change, is change in purpose: the intention to improve. We see this in the six aims for im- provement that are articulated in the report, and it is those aims that make the report something other than a defense of the status quo. We suggest an overarching aim to the system, as the President's Advisory Commis- sion did, to remind us always that the purpose of the health care system is to continually reduce the burden of illness and disability and to improve the health status and function of the people of the Untied States. We make recommendations with respect to this key area of change. We recommend first that there be widespread endorsement of the state- ment of purpose for the health care system. It is the center, the ethical center, of the activities of any stakeholder or actor in the system. We think it needs to be parsed into specific aims for improvement. We encourage the national endorsement of the six aims for improvement and the linkage of that endorsement to specific measurements in annual reports to the president and Congress on the state of quality of care in America. The new report from Bill Roper's committee is in fact attempting to recom- mend how to do that kind of measurement nationally. The second level of change call it level two is change in the care process. It is change in the care from the Windstar to the Ferrari. It is change in the places where the patients who need us actually need us, interact with us, and the others who would help them. This is the heart of care. It is carried out by very small units of production, teams of care- givers that our colleague Paul Batalden calls Microsystems. The emer- gency department is a microsystem. So is the clinical office. A patient is brought through cardiac surgery by a microsystem. A patient in critical care is helped by a microsystem. Our report says that the current Microsystems of care cannot achieve

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6 CROSSING THE QUALITY CHASM the aims we propose even if they wanted to. We say that the Microsystems of today function under rules and specifications that render them inca- pable of giving the care that they ought to be able to give. Exhortation cannot possibly work. To achieve changes in patient experience at level one, we say we have to change the work process at the front end, the sharp end, level two, in the Microsystems. I remind you that not one bit of this is about blame. No one on the IOM committee, I think, actually believes that the problems at the front line of care are fundamentally ones of carelessness, incompetence, or mo- tivation or corruption. Those occasionally occur, but they don't explain what we are talking about. We are not naive about human nature, but we believe without apology that most doctors, most nurses, others at the front lines, deeply want to do the right thing. The question is whether their work is constructed in such a way that they can succeed. For example, if the work design requires reliance on short-term memory, as I have already told you, we have set the doctor and nurse up for failure. Not because they are not trying, but because they are human. Our report calls for changes in the work system, changes in work design at the front line, to make the Microsystems better able to achieve the im- provement aims. We frame our recommendations rather complexly in terms of 10 new simple rules for care, guidelines that would help the de- tail work to occur with fidelity at the microsystem level to allow them to achieve those aims. In many cases, these rules violate current assump- tions about the proper conduct of a microsystem. I am going to discuss a couple. But underneath it all, I think there are three basic pillars to the changes we are recommending. First, base care on the best available knowledge and science not just randomized trials, but knowledge-based care. Second, put the patient at the absolute center of care. Third, cooperate, act as a system. Those three ideas evidence-based care, patient-centered care, and systems-minded care parse into the 10 simple rules, which I will show you very quickly. On the left-hand side of each of these is something like the current belief structure, and on the right is the new rule we are proposing. First new rule: base care on healing relationships, not visits alone. The current system equates care with visits or encounters. We require patients to see clinicians directly, when there are many other, often more effective, ways to answer a lot of their needs. In redesigning care, we suggest that pa- tients should be able to get care over the Internet, through better training in self-care, through group encounters, from other patients, and in many other innovative ways. We strongly suspect that half or more of the visits the current system enforces are pure waste from the viewpoint of the pa- tient, the clinician, and society. The second rule is to customize care based on individual patient needs

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OVERVIEW 17 and values. The current system homogenizes care. It tells the patient to yield or conform to our system, not bending our system to their indi- vidual circumstances, not enough. Videotapes show that the average doc- tor begins speaking approximately 17 seconds into a patient encounter. Listening is cheapened. As a result, patients lose dignity, they lose con- trol, and they lose opportunities to heal, I think. The IOM recommends that the Microsystems of the future adopt the following guideline. Every patient is the only patient. Microsystems must employ much improved approaches to listening to patients and sharing decision making and customizing care. The third proposed new rule is this: the patient is the source of con- trol. The current system seizes or assumes control that the IOM commit- tee feels properly belongs, in the first instance, to the patient. Our patient should start with control, and we should get it only when they choose to give it to us. Wherein, we ask, do health care systems accrue the right to control visiting hours, or to prevent patients from seeing their own medi- cal records or hearing their own laboratory test results? We specifically call, by the way, for free and unfettered access by patients to their own medical records as a routine standard. The fourth proposed new rule relates to changing the attitude toward knowledge. Knowledge should be shared and information should flow freely. We believe that the status quo system, the one we have now, places much too little value on the transfer of information. In fact, many care systems often treat the transfer of information answering patients' ques- tions or helping people understand and manage their own illnesses as impediments they have to get through so they can go ahead and give care. They don't recognize these as forms of care itself. In the postmodern era, information is care. We think that withholding information is unworthy of this era. The health care system needs to make a much greater invest- ment in the habits, beliefs, and technologies that make providing infor- mation a form of care itself. The fifth rule we suggest is to base decisions on evidence. We oppose the overuse of scientifically discredited, unsupported care, and we op- pose the underuse of scientifically effective care. We want to guarantee patients evidence-based care with high reliability. If this implies, and it does, a reduction in the so-called autonomy of physicians, so be it. We believe that the modern physician would rather have some help in making sure that his or her care reflects the best avail- able knowledge rather than preserving some medieval rights. I think it is a mistake to give care exactly the way one wants if that care deviates from evidence systematically gained and critically interpreted. The sixth rule goes back to To Err Is Human. We just declare again here that safety is a system property. In this simple rule, we reaffirm the

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8 CROSSING THE QUALITY CHASM findings of the first report: safe patient care won't be found by exhorta- tion or blame, but only by adopting ever-safer designs for the systems of care themselves. We need to stop the bungeejumping. The seventh rule is that transparency is necessary. We think that a transparent care system, in the long run, will do far better than a secretive one. Our recommendation for the Microsystems of the future is that they know and report on their own work, openly and to all and with honesty. The absolute right of patients to confidentiality does not give health care systems the right to secrecy about their performances and their achieve- ments. We don't believe in blame, but we do believe in openness. The eighth rule is to move to anticipation from reaction. Anticipate needs. We find the current system far too reactive for its own good or the patient's good. Using registries, which most practices don't use; informa- tion systems, which most practices don't have; and sound planning, we believe we can construct a far more proactive system of care: a system with memory that can maintain continuity in transitions over time, even when the patient's own memory has failed. The ninth rule is to continually decrease waste. We recommend a fu- ture system much more mindful of pure waste as poor quality and far better able to cease wasteful activities and habits rather than allow them to accrue like barnacles on the hull of care. This includes an almost en- tirely wasteful and dysfunctional medical records system, long overdue for a major overhaul. We need a thoroughly redesigned medical record, and we need to avoid handwritten records whenever we can. Tenth, we want to place cooperation at the highest level of priority. I like the prior wording before the final edit on this recommendation. It was that the role trumps the team; the new rule is: the team trumps the role. We find today that too often status, role, and discipline trump coop- eration in the system. By habit and tradition, for example, some physi- cians and specialists can insist on prerogatives in scheduling, supplies, and procedures that may help them locally in the short run but that in the long run hurt a lot of other people in the system. We think cooperation needs to be the trump. Health care Microsystems need to place a much higher priority on shared aims, cooperative acts, and teamwork than they currently do. This recommendation has very profound implications, by the way, for profes- sional preparation. The framework of the ten simple rules we think offers a fine starting place for the redesign of health care delivery in the United States. Our fourth recommendation is that these rules be adopted. Our fifth is that they apply first to fifteen of the most common conditions in our popula- tion, mainly chronic illnesses. If we could adopt the strategy as a nation of applying these principles to the care of just those fifteen conditions, which

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OVERVIEW 19 we now call for identification of, we think we can make tremendous progress against the burden of chronic illness in our population. For that, we need to make some investments in innovation about how best to take care of those conditions and redesign our systems. This framework is a good starting place. We find that the current sys- tem, designed according to current rules, is incapable of achieving the improvement aims we are recommending. Those new rules, the ten rules, aren't just nice. They are a solution to a very deep set of problems and, without adopting them, we just don't see another way out. But the new rules at level two are not sufficient. The IOM Chasm report finds problems at two other levels, levels beyond the microsystems that give the care. The level of organization, level three, in which the microsystems generally are embedded and in the level of the outside environment of payment, regu- lations, professional development, accreditation, liability level four- which shapes and channels the activities of the organizations that channel the activities of the microsystems. More bluntly, we think that the broken microsystems lie within and depend upon broken organizations that cannot help them very much, and that those organizations are, in this country, often working in an environ- ment that is broken, one that is toxic to productive change. lust as we recommend changes in care according to the ten rules, we recommend some changes at the organization and environmental level that can help increase the probability that these newly conceived microsystems can in fact emerge into daylight. I am running short on time, so I cannot review in any detail the de- sign ideas we have at these other two levels the organization and the environment. I guess that is not too bad because, given the wide varia- tions in organizations and environments from area to area, the changes at level three and level four, as opposed to the more generalizable changes at level two, require very strong customization in local systems of care. But to make things a little clearer, let me show you what we recommended and give you a couple of examples of needed changes at those other two levels. At the organization level, many of our new simple rules require as- sets and supports to microsystems that the microsystems cannot arrange themselves. For example, if we want to urge a more proactive system- recommendation number nine, anticipatory it has to have a memory, rather than a current reactive system. And that probably depends on the capacity to establish and maintain good patient registries, lists of patients with chronic illnesses, for example, that can help the clinicians reach out to the patients in timely and reliable ways. Has the diabetic patient had an eye examination lately? Is the patient with heart failure gaining weight? Similarly, our recommendation that patients be able to access their

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20 CROSSING THE QUALITY CHASM own medical records without any restrictions whatsoever no restric- tions, no costs, no barriers or to use e-mail to reach the physician, which we think it is high time to offer as a national standard, require changes in institutional policies and procedures in training and, again, information systems. If we map our recommendations into the next level, beyond the orga- nization as with the recommendation on e-mail care we find at the next level that few American environmental systems, few payments systems in this case, would pay doctors to give care through the Internet. Most payment systems today define productivity purely in terms of face-to- face encounters. Yet our first recommendation is to shift the concept of care from encounter to healing relationships. A doctor in such a system who tried to behave as rule one recommends would suffer criticism and income loss, not just from the organization, but from the environment, if he or she tried to substitute, let's say, an hour of patient visits with an hour of tending to patients on the Internet. So in the Chasm report we find it entirely insufficient to call for changes in aims or even in aims and care systems alone. We think and we recommend that everyone must have solutions to the quality problems, and the redesigns that get us there will require nothing less than a re- building of our industry. Our recommendations on changing the environment are quite broad. We recognize the strong need to reform payment to ally with the kind of microsystem performance that we imagine. There are strong needs for social experimentation on how to align payment, because it is not a solved problem. We ask for new requirements of the workforce, able to function in the system we describe, which is an environmental issue related to training and education and educational strategies. And we think the tort system needs to be tackled. No one has an answer yet to how we can configure the tort system in this country to better encourage these kinds of changes, but we think it is high time for social experimentation at that level also. All of this is bold, and yet our committee concluded, over a wide spec- trum of initial positions, that this is worth the effort. Modern science, modern information systems, modern consumerism, and modern aspira- tions now give us a wonderful and unprecedented chance to craft a care system that our patients deserve and that we want to give them. The changes ahead are daunting. We don't minimize them. Many are un- solved, they are not easy, but they are the right changes; this is the right time and it is the right reason. I have seen that realization emerge in our country at a level I have never before experienced, first around the safety report. I have seen it not just in the United States with the IOM report, but there is a dawning pub-

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OVERVIEW 21 kc and professional sense of just how good it could be on a worldwide level. It is going to take people who know that the reality is not as it should be, who are not afraid to say so, who know how impoverished blame is as a remedy, and who not only hope for, but intend to, change systems until they can make the promises that they ought to and keep them every single day.