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hoped that actions in the external environment will lead to implementation of a specific set of actions within health care organizations. Although some health care organizations are already implementing the recommended actions absent any incentives from the external environment, the external environment can motivate a broader response.

Second, worker safety is often linked with patient safety. If workers are safer in their jobs, patients will be safer also. Sometimes, the actions needed to improve patient safety are ones that would also improve worker safety. Procedures for avoiding needlesticks or limiting long work hours are aimed at protecting workers but can also protect patients. Thus, although worker safety is not the focus of this report, the committee believes that creating a safe environment for patients will go a long way in addressing issues of worker safety as well.

The third issue is that of access to care. This report is focused on making the delivery of care safer for patients who have access to and are using the health care system. Safe care is an important part of quality care. Although safe care does not guarantee quality, it is a necessary prerequisite for the delivery of high-quality care. However, the committee also recognizes the relationship that exists between access and quality. When someone needs medical care, the worst quality is no care at all.

Access continues to be threatened in today's health care marketplace. For many people the lack of insurance creates a significant barrier to access. The uninsured typically use fewer services than the insured, are more likely to report having cost and access problems, and are less likely to believe that they receive excellent care.3 However, access is not just a concern of the uninsured. Even people with insurance are growing uneasy about their access to care. Employers are reducing coverage for workers and their dependents.4 Inadequate coverage compromises access and creates inequities between those who have complete coverage and full access and those who have partial coverage and partial access. Insufficient coverage also creates concerns about the affordability of care, either because services are not covered at all or because significant out-of-pocket payments, such as copayments and deductibles, are involved. Although financial burden is a significant barrier to access, other factors interfere as well, such as poor transportation, language, and cultural barriers.5

When access to care is threatened, the ability to make a threshold change in quality is also threatened. Although it is not being addressed in this report, those dealing with overall quality concerns will also have to consider problems of access.



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