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This PDF is available at http://nap.nationalacademies.org/10027

Crossing the Quality Chasm: A New Health System for the 21st Century (2001)

360 pages | 6 x 9 | HARDBACK

ISBN 978-0-309-07280-9 | DOI 10.17226/10027

Committee on Quality of Health Care in America; Institute of Medicine

Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. https://doi.org/10.17226/10027.

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

Copyright National Academy of Sciences. All rights reserved.

Crossing the Quality Chasm

A New Health System for the 21st Century

Committee on Quality of Health Care in America

INSTITUTE OF MEDICINE

NATIONAL ACADEMY PRESS Washington, D.C.

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

Copyright National Academy of Sciences. All rights reserved.

NATIONAL ACADEMY PRESS • 2101 Constitution Avenue, N.W. • Washington, DC 20418

NOTICE: The project that is the subject of this report 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 members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance.

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 Com- monwealth Fund; and the Department of Health and Human Services’ Health Care Financing Admin- istration and Agency for Healthcare Research and Quality. The views presented in this report are those of the Institute of Medicine Committee on the Quality of Health Care in America and are not necessarily those of the funding agencies.

Library of Congress Cataloging-in-Publication Data

Crossing the quality chasm : a new health system for the 21st century / Committee on Quality Health Care in America, Institute of Medicine. p. ; cm. Includes bibliographical references and index. ISBN 0-309-07280-8 1. Medical care—United States. 2. Health care reform—United States. 3. Medical care—United States—Quality control. I. Institute of Medicine (U.S.). Committee on Quality of Health Care in America. [DNLM: 1. Health Care Reform—methods—United States. 2. Quality of Health Care—United States. WA 540 AA1 C937 2001] RA395.A3 C855 2001 362.1′0973—dc21

2001030775

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For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu.

Copyright 2001 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 serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin.

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

Copyright National Academy of Sciences. All rights reserved.

Shaping the Future for Health

“Knowing is not enough; we must apply. Willing is not enough; we must do.” —Goethe

INSTITUTE OF MEDICINE

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

Copyright National Academy of Sciences. All rights reserved.

The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Bruce M. Alberts is president of the National Academy of Sciences.

The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achieve- ments of engineers. Dr. William A. Wulf is president of the National Academy of Engi- neering.

The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Kenneth I. Shine is president of the Institute of Medicine.

The National Research Council was organized by the National Academy of Sci- ences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Func- tioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Bruce M. Alberts and Dr. William A. Wulf are chairman and vice chairman, respectively, of the National Research Council.

National Academy of Sciences National Academy of Engineering Institute of Medicine National Research Council

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

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v

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

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, Senior Fellow, Center for Business and Government, John F. Kennedy School of Government, Harvard University, 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, Boston, MA

ARTHUR LEVIN, Director, Center for Medical Consumers, New York, NY RHONDA ROBINSON-BEALE, Executive Medical Director, Managed Care

Management and Clinical Programs, Blue Cross Blue Shield of Michigan, Southfield

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

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

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vi

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

ANTHONY BURTON, Administrative Assistant MIKE EDINGTON, Managing Editor JENNIFER CANGCO, Financial Advisor

Consultant/Editor

RONA BRIERE, Briere Associates, Inc.

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

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vii

Reviewers

The report was reviewed by individuals chosen for their diverse perspectives and technical expertise in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments to assist the authors and the Institute of Medicine in making the published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The content of the review comments and the draft manuscript remain confidential to protect the integrity of the deliberative process. The committee wishes to thank the following individuals for their par- ticipation in the report review process:

TERRY CLEMMER, Intermountain Health Care, Salt Lake City, UT SUSAN EDGMAN-LEVITAN, The Picker Institute, Boston, MA ANN GREINER, Center for Studying Health System Change, Washington, D.C. DAVID LANSKY, The Foundation for Accountability, Portland, OR DAVID MECHANIC, Rutgers, The State University of New Jersey,

New Brunswick, NJ L. GORDON MOORE, Brighton Family Medicine, Rochester, NY DAVID G. NATHAN, Dana-Farber Cancer Institute (Emeritus), Boston, MA VINOD K. SAHNEY, Henry Ford Health System, Detroit, MI WILLIAM STEAD, Vanderbilt University, Nashville, TN EDWARD WAGNER, Group Health Center for Health Studies, Seattle, WA

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

Copyright National Academy of Sciences. All rights reserved.

viii REVIEWERS

Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommenda- tions nor did they see the final draft of the report before its release. The review of this report was overseen by WILLIAM H. DANFORTH, Washington Univer- sity, St. Louis, Missouri, and EDWARD B. PERRIN, University of Washington and VA Puget Sound Health Care System, Seattle, Washington. Appointed by the National Research Council and the Institute of Medicine, they were respon- sible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review com- ments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.

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

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ix

Preface

This is the second and final report of the Committee on the Quality of Health Care in America, which was appointed in 1998 to identify strategies for achieving a substantial improvement in the quality of health care delivered to Americans. The committee’s first report, To Err Is Human: Building a Safer Health System, was released in 1999 and focused on a specific quality concern—patient safety. This second report focuses more broadly on how the health care delivery system can be designed to innovate and improve care.

This report does not recommend specific organizational approaches to achieve the aims set forth. Rather than being an organizational construct, rede- sign refers to a new perspective on the purpose and aims of the health care system, how patients and their clinicians should relate, and how care processes can be designed to optimize responsiveness to patient needs. The principles and guidance for redesign that are offered in this report represent fundamental changes in the way the system meets the needs of the people it serves.

Redesign is not aimed only at the health care organizations and professionals that comprise the delivery system. Change is also required in the structures and processes of the environment in which those organizations and professionals function. Such change includes setting national priorities for improvement, cre- ating better methods for disseminating and applying knowledge to practice, fos- tering the use of information technology in clinical care, creating payment poli- cies that encourage innovation and reward improvement in performance, and enhancing educational programs to strengthen the health care workforce.

The Quality of Health Care in America project is supported largely by the income from an endowment established within the Institute of Medicine by the

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

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x PREFACE

Howard Hughes Medical Institute and income from an endowment established for the National Research Council by the W. K. Kellogg Foundation. Generous support was provided by the Commonwealth Fund for a workshop on applying information technology to improve the quality of clinical care, by the Health Care Financing Administration for a workshop aimed at exploring the relationship between payment policy and quality improvement, by the Robert Wood Johnson Foundation for a survey of exemplary systems of care, by the California Health Care Foundation for a workshop to explore methods for communicating with the public about quality in health care, and by the Agency for Healthcare Research and Quality for a workshop on the relationship between patient outcomes and provider volume.

Although the committee takes full responsibility for the content of this re- port, many people have made important contributions. The Subcommittee on Designing the Health System of the 21st Century, under the direction of Donald Berwick, combined a depth of knowledge and creativity to propose a vision on how health care could be delivered in the 21st century. The Subcommittee on Creating an External Environment for Quality, under the direction of J. Cris Bisgard and Molly Joel Coye, provided expert guidance and a wealth of experi- ence on how the external environment could support improved delivery of care. Lastly, the IOM staff, under the direction of Janet Corrigan, have provided excel- lent research, analysis and writing.

Now is the right time for the changes proposed in this report. Technological advances make it possible to accomplish things today that were impossible only a few years ago. Patients, health care professionals, and policy makers are becoming all too painfully aware of the shortcomings of our current care delivery systems and the importance of finding better approaches to meeting the health care needs of all Americans. The committee does not offer a simple prescription, but a vision of what is possible and the path that can be taken. It will not be an easy road, but it will be most worthwhile.

William C. Richardson, Ph.D. Chair March 2001

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

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xi

Foreword

This is the second and final report of the Committee on the Quality of Health Care in America. Response to the committee’s first report, To Err is Human: Building a Safer Health System, has been swift, positive, and ongoing from many health care organizations, practitioners, researchers, and policy makers.

The present report addresses quality-related issues more broadly, providing a strategic direction for redesigning the health care delivery system of the 21st century. Fundamental reform of health care is needed to ensure that all Ameri- cans receive care that is safe, effective, patient centered, timely, efficient, and equitable.

As this report is being released, we are reflecting on the recent loss of a great 20th-century leader in the field of health care quality. Avedis Donabedian, member of the Institute of Medicine, leaves behind a rich body of work on the conceptualization and measurement of quality. His extraordinary intellectual con- tributions will continue to guide efforts to improve quality well into the coming century.

The Quality of Health Care in America project continues the Institute of Medicine’s long-standing focus on quality-of-care issues. The Institute’s Na- tional Roundtable on Health Care Quality has described the variability of the quality of health care in the United States and highlighted the urgent need for improvement. The report Ensuring Quality Cancer Care issued by the Institute’s National Cancer Policy Board, offers the conclusion that there is a wide gulf between ideal cancer care and the reality experienced by many Americans. And a forthcoming report from the Institute’s Committee on the National Quality

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

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xii FOREWORD

Report on Health Care Delivery will offer a framework for periodic reporting to the nation on the state of quality of care.

This report reinforces the conviction of these and other concerned groups that we cannot wait any longer to address the serious quality-of-care challenges facing our nation. A comprehensive and strong response is needed now.

Kenneth I. Shine, M.D. President, Institute of Medicine March 2001

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

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xiii

Acknowledgments

The Committee on the Quality of Health Care in America first and foremost acknowledges the tremendous contribution by the members of two subcommit- tees, both of which spent many hours working on exceedingly complex issues. Although individual subcommittee members put forth differing perspectives on a variety of issues, there was no disagreement on the ultimate goal of providing the leadership, strategic direction, and analytic tools needed to achieve a substantial improvement in health care quality during the next decade. We take this oppor- tunity to thank each subcommittee member for his or her contribution.

Subcommittee on Creating an Environment for Quality in Health Care: J. Cris Bisgard (Cochair), Delta Air Lines, Inc.; Molly Joel Coye, (Cochair), Institute for the Future; Phyllis C. Borzi, The George Washington University; Charles R. Buck, General Electric Company; Jon Christianson, University of Minnesota; Mary Jane England, Washington Business Group on Health; George J. I

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