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To err is human, to improve divine:
A New Health System for the 21st Century
From the March 7, 2001 issue
Last week, the Institute of Medicine's (IOM) Committee on
the Quality of Health Care in America took center stage again
after releasing its report, Crossing the Quality Chasm:
A New Health System for the 21st Century, which outlines
a set of performance expectations for health care. The IOM
Committee's first report, To Err is Human: Building a Safer
Health System, was a clear call to improve patient safety.
This second report unfolds as a larger story and urges a strong
national commitment to improve health care across six broad
dimensions of quality: safety, effectiveness, responsiveness
to patients, timeliness, efficiency, and equity. The authors
suggest that the current health care system is failing to
provide safe, high-quality care consistently to all Americans
because it is poorly designed and relies on outdated systems.
The report envisions a revamped system which is centered on
patient needs and preferences, encourages teamwork among health
care providers, and makes greater use of evidence-based approaches
to care and information technology. To spur an overhaul, the
authors recommend that Congress create an innovation fund
of $1 billion over the next 3-5 years.
Although the report does not specify in detail the future
design of health care, it establishes a framework for innovation
on a local level by providing ten rules to promote the design
of systems that are safe, effective, patient-centered, interdisciplinary,
and efficient. For example, the authors say that patients
should be able to count on receiving care based on the best
available scientific knowledge, but there is strong evidence
that this is frequently not the case. Thus, one rule covers
the need for evidence-based decision making and suggests
that care should not vary illogically from clinician to clinician.
The report notes that clinicians operate in silos without
the benefit of complete information about the patient's conditions,
medical history, treatment received in other settings, or
medications prescribed by other clinicians. So, another rule
encourages cooperation among clinicians to exchange
appropriate information and coordinate care.
The report stresses the need for all health care stakeholders
to work together to redesign how care is delivered, with emphasis
on chronic conditions and effective use of care teams and
information technology. Health care remains relatively untouched
by information technology that has transformed so many other
aspects of society. Patient information is still dispersed
on paper, poorly organized, often illegible, and difficult
to retrieve. The authors recommend a renewed national commitment
to building an information infrastructure to support health
care and eliminate most handwritten clinical data (including
prescriber's orders) by the end of decade. The report also
calls for the Agency for Healthcare Research and Quality to
convene workshops to identify and implement state-of the art
approaches to effective team development, use of information
technology, coordination of care, and other health care challenges.
The IOM Committee members recognized that, if organizations
are expected to change the processes of care, broader environmental
changes are also needed. They recommend a federal program
to make scientific evidence more useful and accessible to
providers and patients, examination of current payment methods
(e.g., fee for service, capitation, etc.) to remove barriers
to innovation and quality, and testing of options to better
align payment methods with quality goals. The report also
suggests that the workforce will need new skills as well as
innovation in the use of various types of clinicians to achieve
the best patient outcomes. Evaluation of how regulations,
practice acts, and the legal system help or hinder needed
changes, and the restructure of clinical education using multidisciplinary
approaches (rather than isolated by discipline) is recommended
to better prepare our workforce for the 21st century. For
the full report, go to http://www4.nas.edu/onpi/webextra.nsf/web/chasm?OpenDocument.
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