Crossing the Quality Chasm: A New Health System for the 21st Century

Second in a series of publications from the Institute of Medicine's Quality of Health Care in America project

Today's health care providers have more research findings and more technology available to them than ever before. Yet recent reports have raised serious doubts about the quality of health care in America.

Crossing the Quality Chasm makes an urgent call for fundamental change to close the quality gap. This book recommends a sweeping redesign of the American health care system and provides overarching principles for specific direction for policymakers, health care leaders, clinicians, regulators, purchasers, and others. In this comprehensive volume the committee offers:

• A set of performance expectations for the 21st century health care system.
• A set of 10 new rules to guide patient-clinician relationships.
• A suggested organizing framework to better align the incentives inherent in payment and accountability with improvements in quality.
• Key steps to promote evidence-based practice and strengthen clinical information systems.

Analyzing health care organizations as complex systems, Crossing the Quality Chasm also documents the causes of the quality gap, identifies current practices that impede quality care, and explores how systems approaches can be used to implement change.

The Institute of Medicine's Committee on Quality of Health Care in America has issued its second and final report, Crossing the Quality Chasm: A New Health System for the 21st Century. The committee has done an excellent job, but its report is as noteworthy for what it omits as for what it says. It identifies and analyzes with great insight and clarity deficiencies in the quality of our present medical care delivery system, and it is persuasive in outlining how the system ought to work. But it does not say much about the fundamental causes of those deficiencies. Nor does it address the central question: Can we really ``cross the quality chasm'' in medical care without major reform of the whole system?

The committee's earlier report, To Err Is Human: Building a Safer Health System (Linda T. Kohn, Janet M. Corrigan, and Molla S. Donaldson, eds. Washington, D.C.: National Academy Press, 1999), was released in the fall of 1999. The report created an immediate sensation with its estimate of 44,000 to 98,000 deaths annually due to errors in hospital care, which it said were due more to error-prone institutional systems than to mistakes by individual health care workers. Predictably, the report launched a spate of governmental and private projects to study the cause and reporting of such events and the means of preventing them. The committee's second report moves beyond the initial focus on medical mishaps and takes a broader look at other problems with the quality of health care. It suggests, in general terms, a variety of ways in which the effectiveness and efficiency of health care should be improved. The report is thoughtful, painstaking, and totally reasonable, and yet it has attracted much less attention than its predecessor.

Why hasn't Crossing the Quality Chasm had more impact? I think there are several reasons. First, it contains nothing nearly so sensational as the claim made in the first report that tens of thousands of deaths are caused by medical errors. Second, most of the problems in our health care system that are identified in the second report have been widely recognized for some time. For example, as important causes of reduced quality, the report cites fragmentation of responsibility and lack of continuity in the care of individual patients. It describes the lack of coordination and communication among providers and between providers and patients. And it faults the system for not sufficiently employing electronic-information technology. It criticizes the system's failure to rely on evidence-based guidelines as standards for practice and faults providers for failing systematically to record and report outcomes. It also finds the current health care delivery system insufficiently responsive to the needs of patients and not sufficiently accountable to payers or patients. All these problems are certainly important. But they have been described before, and this report offers little that is substantive in the way of new and practical ways to solve them. This omission is probably the chief reason for the lukewarm reception given this study.

Granted, the study calls for greater attention to the need for improving the quality of care. It calls for workshops, more research and education, a reexamination of current payment methods, and many other general initiatives of this kind. It urges Congress to establish a ``Health Care Quality Innovation Fund'' to support projects on the improvement of quality, and it estimates that something ``on the order of $1 billion over 3 to 5 years'' would be needed. The report also suggests that the Agency for Healthcare Research and Quality should identify ``not fewer than 15 priority conditions'' and should convene a meeting to ``develop strategies, goals, and action plans for achieving substantial improvements in quality in the next 5 years for each of the priority conditions.'' But these recommendations, however well intended, do not go to the heart of the matter, and they offer little in the way of fundamental solutions.

In fairness to the committee's meticulous and scholarly work, I should acknowledge that it did not set out to ``recommend specific organizational approaches to achieve the aims set forth.'' The committee was no doubt asked instead to concentrate on general aims, to suggest principles and guidelines for improving the quality of care, rather than confront the controversies that would result from suggesting basic reforms in the organization of the health system.

So, what is wrong with the organization of our present health care system that accounts for its problems with quality? In my view, the central problem is that the system is being directed mainly by market forces, which are as ill suited to the achievement of the quality goals envisioned in this report as they are to the attainment of the equally important goals of cost control and universal access. The notion that health care is basically an economic commodity represents a radical change from earlier assumptions about the social purpose of health care. It has gained currency only during the past 10 to 20 years, but it has already produced public policies that are rapidly converting our health care system into a vast competitive marketplace. We now have a large and growing sector of health care delivery controlled by private business, to a degree unmatched in any other nation.

As is the case with other markets in the U.S. economy, the part of medical service that is privately insured is distributed primarily according to the ability to pay. The multiple independent private insurers (mostly investor-owned) constantly seek to reduce their payments to providers and their financial obligations to sick patients. Similar economic pressures and incentives are at work in the governmental half of the system. In all parts of the system, the providers of care (i.e., hospitals and physicians) see themselves as competing businesses struggling to survive in a hostile economic climate, and they act accordingly. The predictable result is a fragmented, inefficient, and expensive system that neglects those who cannot pay, scrimps on the support of public health services and medical education, and has all of the deficiencies in quality that are so well described and analyzed in this report. It is a system that responds more to the financial interests of investors, managers, and employers than to the medical needs of patients.

The best way to achieve substantial improvements in the quality of care, I believe, would be to change the system. Unfortunately, the committee does not say that. It concentrates instead on suggestions for modifying behavior in the current system. However, the prospects for persuading participants caught up in the present commercially dominated system to behave in a more socially responsible way are not very good. I suspect most members of the committee know that but that they felt constrained by the terms of their charge to focus on incremental improvements in the quality of the present system. Given those constraints, they have done all that could have been expected, and they have done it very well. A more definitive approach to the problems they address must await major reforms in the health care system.

Arnold S. Relman, M.D.
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