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America's Health in Transition: Protecting and Improving Quality America's Health in Transition Protecting and Improving Quality A Statement of the council of the Institute of Medicine INSTITUTE OF MEDICINE Washington, D.C. 1994
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America's Health in Transition: Protecting and Improving Quality National Academy Press 2101 Constitution Avenue, N.W. Washington, DC 20418 NOTICE: The project that is the subject of this White Paper was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of the appropriate professions in the examination of policy matters pertaining to the health of the public. In this, the Institute acts under both the Academy's 1863 congressional charter responsibility to be an advisor to the federal government and its own initiative to identify issues of medical care, research, and education. Dr. Kenneth I. Shine is president of the Institute of Medicine. Support for this White Paper was provided by the National Research Council, NAS/NAE independent funds, and IOM independent funds. Additional copies of this White Paper are available from: Division of Health Care Services Institute of Medicine 2101 Constitution Avenue, N.W. Washington, DC 20418 Copyright 1994 by the National Academy of Sciences. All rights reserved. Printed in the United States of America. The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The image adopted as a logotype by the Institute of Medicine is based on a relief carving from ancient Greece, now held at the Staatlichemuseen in Berlin.
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America's Health in Transition: Protecting and Improving Quality COUNCIL OF THE INSTITUTE OF MEDICINE KENNETH I. SHINE, M.D. (Chair), * President, Institute of Medicine, Washington, D.C. LINDA H. AIKEN, Ph.D., * Trustee Professor of Nursing and Sociology, and Director, Center for Health Services and Policy Research, University of Pennsylvania, Philadelphia JOEL J. ALPERT, M.D., * Professor of Pediatrics and Public Health, Department of Pediatrics, Boston University School of Medicine, Boston, Massachusetts J. MICHAEL BISHOP, M.D., * † Director, The G.W. Hooper Foundation, and Professor of Microbiology and Immunology, Biochemistry and Biophysics, University of California at San Francisco BARRY R. BLOOM, Ph.D., * † Investigator, Howard Hughes Medical Institute, Albert Einstein College of Medicine, Yeshiva University, Hastings-on-Hudson, New York FLOYD E. BLOOM, M.D., * † Chairman, Department of Neuropharmacology, The Scripps Research Institute, La Jolla, California JOSEPH A. CALIFANO, JR., LL.B., * Chairman and President, The Center on Addiction and Substance Abuse, Columbia University, New York, New York DAVID R. CHALLONER, M.D., * Vice President for Health Affairs, J. Hillis Miller Health Center, University of Florida, Gainesville BARBARA J. CULLITON, * Deputy Editor, NATURE, Washington, D.C. BERNARD N. FIELDS, M.D., * † Adele Lehman Professor and Chairman, Department of Microbiology and Molecular Genetics, Harvard Medical School, Boston, Massachusetts * Member of the Institute of Medicine † Member of the National Academy of Sciences
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America's Health in Transition: Protecting and Improving Quality SUZANNE W. FLETCHER, M.D., * Professor, Department of Ambulatory Care and Prevention, Harvard Medical School, Boston, Massachusetts HENRY W. FOSTER, JR., M.D., * Senior Scholar in Residence, Association of Academic Health Centers, Washington, D.C. DONALD A.B. LINDBERG, M.D., * Director, National Library of Medicine, National Institutes of Health, Bethesda, Maryland HAROLD S. LUFT, Ph.D., * Professor of Health Economics and Acting Director, Institute for Health Policy Studies, University of California at San Francisco BARBARA J. McNEIL, M.D., Ph.D. * (Vice-Chair), Ridley Watts Professor and Head, Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts JOSEPH P. NEWHOUSE, Ph.D., * John D. MacArthur Professor of Health Policy and Management, Division of Health Policy Research and Education, Harvard University, Boston, Massachusetts MITCHELL T. RABKIN, M.D., * President, Beth Israel Hospital, Boston, Massachusetts ARTHUR H. RUBENSTEIN, M.D., * Lowell T. Coggeshall Distinguished Service Professor of Medical Sciences, and Chairman, Department of Medicine, Division of the Biological Sciences, The University of Chicago, Chicago, Illinois CHARLES A. SANDERS, M.D., * Chairman, Glaxo, Inc., Research Triangle Park, North Carolina JEANNE C. SINKFORD, D.D.S., Ph.D., * Director, Office of Women and Minority Affairs, American Association of Dental Schools, Washington, D.C. GAIL L. WARDEN, * President and Chief Executive Officer, Henry Ford Health System, Detroit, Michigan
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America's Health in Transition: Protecting and Improving Quality STEERING COMMITTEE ON AMERICA'S HEALTH IN TRANSITION: PROTECTING AND IMPROVING QUALITY OF HEALTH AND HEALTH CARE WALTER J. McNERNEY, M.H.A. * (Chair), Professor of Health Policy and Consultant, J.L. Kellogg Graduate School of Management, Northwestern University, Evanston, Illinois ROBERT H. BROOK, M.D., Sc.D., * Professor of Medicine and Public Health, UCLA Center for the Health Sciences, and Director, Health Sciences Program, The RAND Corporation, Santa Monica, California CLAIRE FAGIN, Ph.D., * Interim President, University of Pennsylvania, Philadelphia JULIO FRENK, M.D., M.P.H., Ph.D., * Fundacíon Mexicana para La Salud, San Geronimo Lidice, Mexico BERNARD GUYER, M.D., Professor and Chairman, Department of Maternal and Child Health, Johns Hopkins University School of Hygiene and Public Health, Baltimore, Maryland THOMAS S. INUI, Sc.M., M.D., * Professor and Chair, Department of Ambulatory Care and Prevention, Harvard Medical School, Boston, Massachusetts JOSEPH P. NEWHOUSE, Ph.D., * John D. MacArthur Professor of Health Policy and Management, Division of Health Policy Research and Education, Harvard University, Boston, Massachusetts ALFRED SOMMER, M.D., M.H.S., * Dean, Johns Hopkins University School of Hygiene and Public Health, Baltimore, Maryland DAVID N. SUNDWALL, M.D., Vice President and Medical Director, American Healthcare Systems Institute, Washington, D.C. * Member of the Institute of Medicine
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America's Health in Transition: Protecting and Improving Quality GARY L. TISCHLER, M.D., Professor and Chairman, Department of Psychiatry and Biobehavioral Sciences, School of Medicine, University of California at Los Angeles MYRNA M. WEISSMAN, Ph.D., Professor of Epidemiology in Psychiatry, College of Physicians and Surgeons, Columbia University, and Director, Department of Clinical and Genetic Epidemiology, New York State Psychiatric Institute, New York Staff, Division of Health Care Services Kathleen N. Lohr, Ph.D., Director Molla S. Donaldson, M.S., Senior Program Officer Jane S. Durch, M.A., Program Officer H. Donald Tiller, Administrative Assistant
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America's Health in Transition: Protecting and Improving Quality Preface At its best, health care in America is superb. But the very best care—including prevention, early diagnosis of illness, and advanced therapeutic services—is not available to millions of Americans. Many Americans with insurance, including Medicare and Medicaid, do not have access to even adequate care. Some Americans receive too much care in the form of inappropriate or unnecessary procedures. Aggregate health care expenditures in America are too high and threaten to undermine our ability to meet other socially important needs in education, housing, transportation, social services, and economic development. We must control total health care expenditures if we are to have the resources to meet these other needs. In the context of this nation's history of employer-based health insurance, we are currently trying to resolve the issues of access and costs by expanding systems of managed care. Not only are these approaches spreading rapidly for the privately insured, but they are also being extended to Medicaid populations in many states. By its charter, the Institute of Medicine is committed to efforts that will improve health and health care for all Americans. The members of the Institute, like Americans in general, have many individual views on how to accomplish this. But all of its members subscribe to the commitment to achieving the highest quality of health promotion,
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America's Health in Transition: Protecting and Improving Quality disease prevention, and health care for individuals and communities in every part of our nation. During the next few years, as change continues, we cannot lose sight of the urgent need to monitor and improve the quality of health and the effectiveness of health care within our society. This White Paper reiterates the Institute of Medicine's belief that maintaining and indeed enhancing the quality of care is a central element in reform of our health care system—quality can and must be measured, monitored, and improved. Policymakers, whether in the public or the private sector at local, state, or federal levels, must insist that the tools for measuring and improving quality be applied. These approaches require constant modification and reassessment —that is, the continual development of new strategies and the refinement of old ones. Furthermore, credible, objective, and nonpolitical surveillance and reporting of quality in health and health care must be explicitly articulated and vigorously applied as change takes place. The Institute of Medicine, with a membership that includes leaders in public health, nursing, medicine, dentistry, biomedical science, ethics, law, administration, economics, health services research, and numerous other fields, stands ready to participate in this process. As the Institute embarks on its Special Initiative—America's Health in Transition: Protecting and Improving the Quality of Health and Health Care—this White Paper represents the first of many calls for high standards of quality that it will make in the service of good health and health care for all the American people. Kenneth I. Shine, M.D. President, Institute of Medicine