The second recommendation calls on HCOs to “implement proven medication safety practices” (IOM, 2000:157).

Crossing the Quality Chasm further addresses patient safety as one of six highlighted aims for U.S. health care: that it be safe, effective, patient-centered, timely, efficient, and equitable. To achieve these six aims, the report specifies actions that HCOs and other entities should take to improve all aspects of health care quality—not just patient safety. The report’s recommendations call on HCOs to (1) redesign care processes; (2) make effective use of information technologies; (3) manage clinical knowledge and skills; (4) develop effective teams; (5) coordinate care across patient conditions, services, and settings over time; and (6) incorporate performance and outcome measurements for improvement and accountability.

The authors of Crossing the Quality Chasm identify four different levels for intervening in the delivery of health care: (1) the experience of patients; (2) the functioning of small units of care delivery (“microsystems”), such as surgical teams or nursing units; (3) the functioning of organizations that house the microsystems; and (4) the environment of policy, payment, regulation, accreditation, and similar external factors that shape the environment in which health care delivery organizations deliver care. Whereas To Err Is Human speaks mainly to the fourth level, Crossing the Quality Chasm addresses primarily the first and second levels—how the experiences of patients and the work of microsystems of care, such as health care teams, nursing units, or individual health care workers delivering care to patients, should be changed (Berwick, 2002). Both of these reports direct less attention to the third level above—the organizations (HCOs) that house the microsystems.

This report emphasizes this level of the HCO. HCOs—by virtue of their employment of health care providers, establishment of work processes, and management of the resources used to deliver health care—are the primary developers of the structures and processes used by health care workers to deliver care. For purposes of this study, the committee defines these internal HCO structures and processes as the “work environment.” We recognize that organizations and factors external to HCOs also shape work environments, but note that these external elements have been strongly addressed in the two prior IOM reports.

This report, with its focus on HCOs and the work environments they contain, therefore complements the work of the two prior IOM reports in three ways:

  • It provides greater detail on how HCOs can and should implement key recommendations of To Err Is Human and Crossing the Quality Chasm in such areas as cultures of safety and work design.



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