ments. Both reports underscore that the vast majority of problems in the quality of health care are not the result of poorly motivated, uncaring, or unintelligent health care personnel but instead result from numerous barriers to high-quality health care imposed by the delivery systems in which clinicians work. Some of these barriers occur at the level of the patient’s interaction with the clinician (e.g., not having sufficient time during the patient visit to talk with the clinician); some at the level of interactions among different clinicians serving the patient (e.g., poor communication, collaboration, and coordination of care); some within the organization in which care is delivered (e.g., poor decision support for clinicians); and some in the environment external to the delivery of care (e.g., the arenas of policy, payment, and regulation) (Berwick, 2002).

Crossing the Quality Chasm speaks to all of these barriers to quality health care15 and has gained considerable traction in the health care community since its publication. As the subject of more than 50 peer-reviewed articles in the medical literature and hundreds of lay publications and coverage in other media, it has attracted the attention of many health care leaders. In the M/SU sector, the American College of Mental Health Administration (ACMHA), for example, focused on the report at its 2002 summit meeting of leaders from public and private behavioral health care systems. Summit meeting participants reached strong consensus that the Quality Chasm framework is immediately relevant and applicable to the concerns of behavioral health systems of care and policy. Attendees also endorsed the IOM paradigm as a strategic planning blueprint for the redesign of the behavioral health care system. However, because the Quality Chasm report did not separately address the unique characteristics of health care for mental and substance-use conditions (e.g., the use of coercion into treatment; the delivery of care through non-health care sectors, such as schools), attendees also agreed on the need to develop a strategy for applying the framework and recommendations of the Quality Chasm to address the unique characteristics of M/SU health care (ACMHA, undated).

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Crossing the Quality Chasm identifies 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 context in which health care 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 that house the microsystems.



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