Read the two Institute of Medicine Reports “To Err is Human” and “Crossing the Quality Chasm.” Discuss the effect that these reports could have in the Kingdom of Saudi Arabia’s healthc

March 2001 I N S T I T U T E OF M E D I C I N E Shaping the Future for Health C ROSSING THE Q UALITY C HASM : A NEW HEALTH SYSTEM FOR THE 21ST CE NTURY T he U.S. health care delivery system does not provide consistent, high- quality medical care to all people. Americans should be able to count on receiving care that meets their needs and is based on the best scie n tific knowledge--yet there is strong evidence that this frequently is no\ t the case. Health care harms patients too frequently and routinely fails to deliver\ its potential benefits. Indeed, between the health care that we now have and the health care that we could have lies not just a gap, but a chasm.

A number of factors have combined to create this chasm. Medical sci ence and technology have advanced at an unprecedented rate during the pa\ st half-century. In tandem has come growing complexity of health care, which today is characterized by more to know, more to do, more to manage, more\ to watch, and more people involved than ever before. Faced with such rapid changes, the nation’s health care delivery system has fallen far shor\ t in its ability to translate knowledge into practice and to apply new technology\ safely and appropriately. And if the system cannot consistently deliver t o- day’s science and technology, it is even less prepared to respond to \ the e x traordinary advances that surely will emerge during the coming decades. \ The public’s health care needs have changed as well. Americans are living longer, due at least in part to advances in medical science and technol ogy, and with this aging population comes an increase in the incidence a\ nd prevalence of chronic conditions. Such conditions, including heart disease, diabetes, and asthma, are now the leading cause of illness, disability, \ and death. But today’s health system remains overly devoted to dealing with acute, episodic care needs. There is a dearth of clinical programs with the multidisciplinary infrastructure required to provide the full complement\ of services needed by people with common chronic conditions.

The health care delivery system also is poorly organized to meet the challenges at hand. The delivery of care often is overly complex and uncoo r dinated, requiring steps and patient “handoffs” that slow down car\ e and d e- crease rather than improve safety. These cumbersome processes waste r e- sources; leave unaccountable voids in coverage; lead to loss of informat\ ion; Faced with such rapid changes, the nation’s health care delivery system has fallen far short in its ability to translate knowledge into practice and to a p ply new technology safely and appro priately. CARE SYSTEM Supportive payment and regulatory en vironment Organizations that facilitate the work of patient- centered teams High perfor m ing patient- centered teams Outcomes:

• Safe • Effective • Efficient • Personalized • Timely • Equitable REDESIGN IMPERATIVES: SIX CHALLENGES • Reengineered care processes • Effective use of information technologies • Knowledge and skills management • Development of effective teams • Coordination of care across patient- conditions, services, sites of care over time Making change possible. and fail to build on the strengths of all health professionals involved to ensure that care is appropriate, timely, and safe. Organizational problems are pa rticularly apparent regarding chronic conditions. The fact that more than 40 percent of people with chronic conditions have more than one such condition argues strongly for more sophisticated mechanisms to coordinate care. Yet health care organizations, hospitals, and physician groups typically operate as separate “silos,” acting wit hout the benefit of complete information about the patient’s condition, medical history, services provided in other settings, or medications provided by other cl inicians. Strategy for Reinventing the Sys tem Bringing state-of-the-art care to all Americans in every community will \ require a fundamental, sweeping redesign of the entire health system, according to\ a report by the Institute of Medicine (IOM), an arm of the National Academy of \ Sciences.

Crossing the Quality Chasm: A New Health System for the 21st Century , prepared by the IOM’s Committee on the Quality of Health Care in America and released\ in March 2001, concludes that merely making incremental improvements in \ cu r- rent systems of care will not su ffice. The committee already has spoken to one urgent care problem--patient safety--in a 1999 report titled To Err is Human: Building a Safer Health System .

Concluding that tens of thousands of Americans die each year as a result\ of pr e ventable mistakes in their care, the report lays out a comprehensive str\ ategy by which government, health care providers, industry, and consumers can red\ uce medical errors.

Crossing the Quality Chasm focuses more broadly on how the health sy s tem can be reinvented to foster innovation and improve the delivery of care. To- ward this goal, the committee presents a comprehensive strategy and acti\ on plan for the coming decade. Six Aims for Improvement Advances must begin with all health care constituencies--health professi\ onals, federal and state policy makers, public and private purchasers of care, \ regulators, organization managers and governing boards, and consumers--committing to\ a 2 Advances must begin with all health care con stituencies… committing to a national statement of pur pose… national statement of purpose for the health care system as a whole. In making this commitment, the parties would accept as their explicit purpose “\ to continually reduce the burden of illness, injury, and disability, and to improve the\ health and functioning of the people of the United States.” The parties also would adopt a shared vision of six specific aims for improvement. These aims are built around the core need for health care to be: • Safe : avoiding injuries to patients from the care that is intended to help them.

• Effective : providing services based on scientific knowledge to all who could benefit, and refraining from providing services to those not likel\ y to benefit.

• Patient-centered: providing care that is respectful of and responsive to i n dividual patient preferences, needs, and values, and ensuring that patie\ nt values guide all clinical decisions. • Timely : reducing waits and sometimes harmful delays for both those who receive and those who give care.

• Efficient : avoiding waste, including waste of equipment, supplies, ideas, and energy.

• Equitable : providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and soci\ oeconomic status. A health care system that achieves major gains in these six areas would \ be far better at meeting patient needs. Patients would experience care that is safer, more reliable, more responsive to their needs, more integrated, and more\ available, and they could count on receiving the full array of preventive, acute, a\ nd chronic services that are likely to prove beneficial. Clinicians and other health workers also would benefit through their increased satisfaction at being better able \ to do their jobs and thereby bring improved health, greater longevity, less pain and\ suffering, and increased personal productivity to those who receive their care. Ten Rules for Redesign To help in achieving these improvement aims, the committee deemed that i\ t would be neither useful nor possible to specify a blueprint for 21st-cen\ tury health care delivery systems. Imagination abounds at all levels, and all promising routes for innovation should be encouraged. At the same time, the committee formu lated a set of ten simple rules, or general principles, to inform effort\ s to redesign the health system. These rules are: 1. Care is based on continuous healing relationships . Patients should r e ceive care whenever they need it and in many forms, not just face-to-fac\ e visits.

This implies that the health care system must be responsive at all times\ , and a c cess to care should be provided over the Internet, by telephone, and by \ other means in addition to in-person visits.

2. Care is customized according to patient needs and values. The system should be designed to meet the most common types of needs, but should ha\ ve the capability to respond to individual patient choices and preferences.

3. The patient is the source of control. Patients should be given the nec- A health care sys tem that achieves major gains in these six areas would be far better at meeting patient needs.

…the health care system must be responsive at all times, and access to care should be provided over the Internet, by tel e phone, and by other means in addition to in- person visits. 3 Reducing risk and ensuring safety require greater at tention to systems that help prevent and mitigate e r rors.

To initiate the pr o cess of change, Congress should establish a Health Care Quality Inno vation Fund essary information and opportunity to exercise the degree of control the\ y choose over health care decisions that affect them. The system should be able to accom modate differences in patient preferences and encourage shared decision \ making. 4. Knowledge is shared and information flows freely . Patients should have unfettered access to their own medical information and to clinical \ know l edge. Clinicians and patients should communicate effectively and share inform a tion.

5. Decision making is evidence-based. Patients should receive care based on the best available scientific knowledge. Care should not vary illogically from clinician to clinician or from place to place.

6. Safety is a system property . Patients should be safe from injury caused by the care system. Reducing risk and ensuring safety require greater attention to systems that help prevent and mitigate errors.

7. Transparency is necessary. The system should make available to pa tients and their families information that enables them to make informed\ decisions when selecting a health plan, hospital, or clinical practice, or when ch\ oosing among alternative treatments. This should include information describing the system’s performance on safety, evidence-based practice, and patient \ satisfaction.

8. Needs are anticipated. The system should anticipate patient needs, rather than simply react to events.

9. Waste is continuously decreased . The system should not waste r e- sources or patient time.

10. Cooperation among clinicians is a priority . Clinicians and institutions should actively collaborate and communicate to ensure an appropriate exc\ hange of information and coordination of care. Taking the First Steps To initiate the process of change, Congress should establish a Health Ca\ re Quality Innovation Fund--roughly $1 billion for use over three to five years to \ help pr o duce a public-domain portfolio of programs, tools, and technologies of w\ id e- spread applicability, and to help communicate the need for rapid and sig\ nificant change throughout the health system. Some of the projects funded should be ta r geted at achieving the six aims of improvement. The committee also calls for immediate attention on developing care proc esses for the common health conditions, most of them chronic, that afflict great numbers of people. The federal Agency for Healthcare Research and Quality (AHRQ) should identify 15 or more common priority conditions. (The agency has requested guidance from the IOM on selection of these conditions, an\ d the Institute expects to issue its report in September 2002.) The AHRQ then should work with various stakeholders in the health community to develop strate\ gies and action plans to improve care for each of these priority conditions over \ a five-year period. 4 Changing the Environment Redesigning the health care delivery system also will require changing t\ he struc tures and processes of the environment in which health professionals and\ organ i zations function. Such changes need to occur in four main areas: • Applying evidence to health care delivery. Scientific knowledge about best care is not applied systematically or expeditiously to clinical pra\ ctice. It now takes an average of 17 years for new knowledge generated by randomized c\ o n- trolled trails to be incorporated into practice, and even then applicati\ on is highly uneven. The committee therefore recommends that the Department of Health and Human Services establish a comprehensive program aimed at making scienti\ fic evidence more useful and more accessible to clinicians and pa tients.

It is critical that leadership from the private sector, both professiona\ l and other health care leaders and consumer representatives, be involved in all aspects of this effort to ensure its applicability and acceptability to clinicia\ ns and patients.

The infrastructure developed through this public-private partnership sho\ uld focus initially on priority conditions. Efforts should include analysis and synthesis of the medical evidence, delineation of specific practice guidelines, ident\ ification of best practices in the design of care processes, dissemination of the evi\ dence and guidelines to the professional communities and the general public, devel\ opment of support tools to help clinicians and patients in applying evidence an\ d making decisions, establishment of goals for improvement in care processes and \ ou t- comes, and development of measures for assessing quality of care.

• Using information technology. Information technology, including the Internet, holds enormous potential for transforming the health care deli\ very sy s tem, which today remains relatively untouched by the revolution that has\ swept nearly every other aspect of society. Central to many information technology a p plications is the automation of patient-specific clinical information. Such infor mation typically is dispersed in a collection of paper records, which of\ ten are poorly organized, illegible, and not easy to retrieve, making it nearly \ impossible to manage various illnesses, especially chronic conditions, that require\ frequent monitoring and ongoing patient support. Many patients also could have their needs met more quickly and at a lower cost if they could communicate wit\ h health professionals through e-mail. In addition, the use of automated systems for o r dering medications can reduce errors in prescribing and dosing drugs, an\ d co m puterized reminders can help both patients and clinicians identify neede\ d services. The challenges of applying information technology should not be unde r- estimated, however. Health care is undoubtedly one of the most, if not the most, complex sectors of the economy. Sizable capital investments and multiyear commitments to building systems will be needed. Widespread adoption of many information technology applications also will require behavioral adaptat\ ions on the part of large numbers of clinicians, organizations, and patients. Thus, the committee calls for a nationwide commitment of all stakeholders to build\ ing an information infrastructure to support health care delivery, consumer hea\ lth, qua l ity measurement and improvement, public accountability, clinical and hea\ lth services research, and clinical education. This commitment should lead to the elimination of most handwritten clinical data by the end of the decade. \ It is critical that leadership from the private sector, both professional and other health care leaders and consumer repre sentatives, be i n volved in all a s pects of this e f fort… Information tech nology…holds enormous poten tial for transform ing the health care delivery sys tem… 5 Clinicians should be adequately compensated for taking good care of all types of pa tients… …the importance of adequately pre - paring the workforce to make a smooth transi tion into a thor oughly revamped health care sys tem cannot be u n deresti mated.

Now is the right time to begin work on reinventing the nation’s health care delivery sys tem. • Aligning payment policies with quality improvement . Although pa y ment is not the only factor that influences provider and patient behavio\ r, it is an important one. The committee calls for all purchasers, both public and private, to carefully reexamine their payment policies to remove barriers that imped\ e quality improvement and build in stronger incentives for quality enhancement. Clinicians should be adequately compensated for taking good care of all types of pa\ tients, neither gaining nor losing financially for caring for sicker patients or\ those with more complicated conditions. Payment methods also should provide an opport u nity for providers to share in the benefits of quality improvement, prov\ ide an op portunity for consumers and purchasers to recognize quality differences \ in health care and direct their decisions accordingly, align financial incentives \ with the i m plementation of care processes based on best practices and the achieveme\ nt of better patient outcomes, and enable providers to coordinate care for pat\ ients across se ttings and over time.

To assist purchasers in their redesign of payment policies, the federal \ go v ernment, with input from the private sector, should develop a program to\ identify, pilot test, and evaluate various options for better aligning payment met\ hods with quality improvement goals. Examples of possible means of achieving this end include blended methods of payment designed to counter the disadvantages\ of one payment method with the advantages of another, multiyear contracts, paym\ ent modifications to encourage use of electronic interaction among clinician\ s and between clinicians and patients, and bundled payments for priority condi\ tions.

• Preparing the workforce. Health care is not just another service i n dustry. Its fundamental nature is characterized by people taking care of other people in times of need and stress. Stable, trusting relationships between a patient and the people providing care can be critical to healing or managing an \ illness.

Therefore, the importance of adequately preparing the workforce to make \ a smooth transition into a thoroughly revamped health care system cannot b\ e u n derestimated.

Three approaches can be taken to support the workforce in this transition.

One approach is to redesign the way health professionals are trained to \ emphasize the six aims for improvement, which will mean placing more stress on tea\ ching evidence-based practice and providing more opportunities for interdiscip\ linary training. Second is to modify the ways in which health professionals are reg u lated and accredited to facilitate needed changes in care delivery. Third is to use the liability system to support changes in care delivery while preservin\ g its role in ensuring accountability among health professionals and organizations. All of these approaches likely will prove valuable, but key questions remain ab\ out each.

The federal government and professional associations need to study these\ a p proaches to better ascertain how they can best contribute to ensuring th\ e strong workforce that will be at the center of the health care system of the 21\ st century. No Better Time Now is the right time to begin work on reinventing the nation’s healt\ h care deliv ery system. Technological advances are making it possible to accomplish things today that were impossible only a few years ago. Health professionals and or- 6 �� ganizations, policy makers, and patients are becoming all too painfully \ aware of the shortcomings of the nation’s current system and of the importance\ of finding radically new and better approaches to meeting the health care needs of \ all Americans. Although Crossing the Quality Chasm does not offer a simple pre scription--there is none--it does provide a vision of what is possible a\ nd the path that can be taken. It will not be an easy road, but it will be most worthwhile.

For More Information… Copies of Crossing the Quality Chasm: A New Health System for the 21st Century are available for sale from the National Acad emy Press; call (800) 624-6242 or (202) 334- 3313 (in the Washington metropolitan area), or visit the NAP home page\ at www.nap.edu. The full text of this report is available at http://www.nap.edu/books/0309072808/html/ Support for this project was provided by: the Institute of Medicine; the\ National Research Council; The Robert Wood Johnson Foundation; the California Health Care \ Foundation; the Commonwealth Fund; and the Department of Health and Human Services’\ Health Care Finance Administration, Public Health Service, and Agency for Healt\ hcare Re- search and Quality. The views presented in this report are those of the Institute of Med i cine Committee on the Quality of Health Care in America and are not nece\ ssarily those of the funding age ncies.

The Institute of Medicine is a private, nonprofit organization that prov\ ides health policy advice under a congressional charter granted to the National Academy of \ Sciences. For more information about the Institute of Medicine, visit the IOM home pag\ e at www.iom.edu.

Permission is granted to reproduce this document in its entirety, with n\ o additions or a l terations COMMITTEE ON QUALITY OF HEALTH CARE IN AMERICA WILLIAM C. RICHARDSON ( Chair), President and CEO, W.K. Kellogg Foundation, Battle Creek, MI DONALD M. BERWICK, President and CEO, Institute for Healthcare Improvement, Boston, MA J. CRIS BISGARD, Director, Health Services, Delta Air Lines, Inc., Atlanta, GA LONNIE R. BRISTOW, Former President, American Medical Association, Walnut Creek, CA CHARLES R. BUCK, Program Leader, Health Care Quality and Strategy Initiatives, General Electric Company, Fairfield, CT CHRISTINE K. CASSEL, Professor and Chairman, Department of Geriatrics and Adult Development, The Mount Sinai School of Medicine, New York, NY 7 �� MARK R. CHASSIN, Professor and Chairman, Department of Health Policy, The Mount Sinai School of Medicine, New York, NY MOLLY JOEL COYE, Senior Fellow, Institute for the Future, and President, Health Technology Center, San Francisco, CA DON E. DETMER, Dennis Gillings Professor of Health Management, University of Cambridge, UK JEROME H. GROSSMAN, Chairman and CEO, Lion Gate Management Corporation, Boston, MA BRENT JAMES, Executive Director, Intermountain Health Care Institute for Health Care Delivery Research, Salt Lake City, UT DAVID McK. LAWRENCE, Chairman and CEO, Kaiser Foundation Health Plan, Inc., Oakland, CA LUCIAN L. LEAPE, Adjunct Professor, Harvard School of Public Health, Bo ston, MA ARTHUR LEVIN, Director, Center for Medical Consumers, New York, NY RHONDA ROBINSON-BEALE, Executive Medical Director, Managed Care Manag e ment and Clinical Programs, Blue Cross Blue Shield of Michigan, Southfie\ ld JOSEPH E. SCHERGER, Associate Dean for Primary Care, University of California, Irvine College of Medicine ARTHUR SOUTHAM, President and CEO, Health Systems Design, Oakland, CA MARY WAKEFIELD, Director, Center for Health Policy, Research, and Ethics, George Mason University, Fairfax, VA GAIL L. WARDEN, President and CEO, Henry Ford Health System, Detroit, MI Study Staff JANET M. CORRIGAN, Director, Quality of Health Care in America Project Director, Board on Health Care Services, MOLLA S. DONALDSON, Project Codirector LINDA T. KOHN, Project Codirector SHARI K. MAGUIRE, Research Assistant KELLY C. PIKE, Senior Project Assistant Auxiliary Staff MIKE EDINGTON, Managing Editor JENNIFER CANGCO, Financial Advisor Consultant RONA BRIER, Brier Associates, Inc.