Description
Read the Executive Summary of all three reports. Reflect on the following questions: 1. What are the key points that should be remembered from these reports? 2.How far do you think we have progressed over the past decades? 3.Relate quality experiences you have had as an intern, technician, or as another employee in a pharmacy. 4.What do you see as the role of the pharmacist in these processes? Grading This assignment will be graded on your discovery skills, critical thinking, reflective abilities, relevance to the subject matter, completeness, depth of reflection, and originality. The course grading rubric will be used as a guide to determine the level of reflection and other factors
Executive Summary
Education for the health professions is in need of a major overhaul. Clinical education simply
has not kept pace with or been responsive enough to shifting patient demographics and desires,
changing health system expectations, evolving practice requirements and staffing arrangements, new
information, a focus on improving quality, or new technologies (Institute of Medicine, 2001):
1
ABSTRACT
The 2001 Institute of Medicine report Crossing the Quality Chasm: A New Health System for
the 21st Century recommended that an interdisciplinary summit be held to develop next steps for
reform of health professions education in order to enhance patient care quality and safety. In June
2002, the IOM convened this summit, which included 150 participants across disciplines and
occupations. This follow-up report focuses on integrating a core set of competenciesópatientcentered
care, interdisciplinary teams, evidence-based practice, quality improvement and
informaticsññinto health professions education.
The reportís recommendations include a mix of approaches related to oversight processes, the
training environment, research, public reporting, and leadership. The recommendations targeting
oversight organizations include integrating core competencies into accreditation, and credentialing
processes across the professions. The goal is an outcome-based education system that better
prepares clinicians to meet both the needs of patients and the requirements of a changing health
system.
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HEALTH PROFESSIONS EDUCATION
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• Health professionals are not adequately
preparedññin either academic or continuing
education venuesññto address shifts in the
nationís patient population (Cantillon and
Jones, 1999; Council on Graduate Medical
Education, 1999; Davis et al., 1999;
Grantmakers in Health, 2001; Halpern et al.,
2001; Health Resources and Services
Administration, 1999; Pew Health
Professions Commission, 1995). Patients in
America are becoming more diverse, are
aging, and are increasingly afflicted by one
or more chronic illnesses, while at the same
time being more likely to seek out health
information (Calabretta, 2002; Frosch and
Kaplan, 1999; Gerteis et al., 1993; Mansell
et al., 2000; Mazur and Hickam, 1997; Wu
and Green, 2000). This changing landscape
requires that clinicians be skilled in
responding to varying patient expectations
and values; provide ongoing patient
management; deliver and coordinate care
across teams, settings, and time frames; and
support patientsí endeavors to change
behavior and lifestyleññtraining for which is
in short supply in todayís clinical education
settings (Calabretta, 2002).
• Once in practice, health professionals are
asked to work in interdisciplinary teams,
often to support those with chronic
conditions, yet they are not educated
together or trained in team-based skills.
• These same clinicians are confronted with a
rapidly expanding evidence baseññupon
which health care decisions should ideally be
madeññbut are not consistently schooled in
how to search and evaluate this evidence
base and apply it to practice (American
Association of Medical Colleges, 1999;
Detmer, 1997; Green, 2000; Shell, 2001).
• Although there is a spotlight on the serious
mismatch between what we know to be good
quality care and the care that is actually
delivered, students and health professionals
have few opportunities to avail themselves of
coursework and other educational
interventions that would aid them in
analyzing the root causes of errors and other
quality problems and in designing
systemwide fixes (Baker et al., 1998;
Buerhaus and Norman, 2001).
• While clinicians are trained to use an array
of cutting-edge technologies related to care
delivery, they often are not provided a basic
foundation in informatics (Gorman et al.,
2000; Hovenga, 2000). Training in this area
would, for example, enable clinicians to
easily access the latest literature on a
baffling illness faced by one of their patients
or to use computerized order entry systems
that automatically flag pharmaceutical
contraindications and errors.
While there are notable pockets of innovationññ
settings in which clinicians are being trained for
a 21st-century health care systemññthese are by
and large exceptions to the rule.
Building a Bridge to Cross the
Quality Chasm
Numerous recent studies have led to the
conclusion that ìthe burden of harm conveyed
by the collective impact of all of our health care
quality problems is staggeringî (Chassin et al.,
1998:1005). Errors lead to tens of thousands of
Americans dying each year, and hundreds of
thousands suffering or becoming sick as a result
of nonfatal injuries. Other studies have
documented pervasive overuse, misuse, and
underuse of services (Chassin et al., 1998;
Institute of Medicine, 2000; President’s
Advisory Commission on Consumer Protection
and Quality in the Health Care Industry, 1998a;
Schuster et al., 1998).
Crossing the Quality Chasm: A New Health
System for the 21st Century (Institute of
Medicine, 2001) emphasizes that safety and
quality problems exist largely because of system
problems, and that browbeating health
professionals to just try harder is not the answer
to addressing the system’s flaws and future
challenges. Quality problems are occurring in
the hands of health professionals highly
dedicated to doing a good job, but working
within a system that does not adequately
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EXECUTIVE SUMMARY
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prepare them, or support them once they are in
practice, to achieve the best for their patients.
The Quality Chasm report concludes that
reform around the edges will not solve the
quality problem, and sets forth an ambitious
agenda for redesign of the broken health care
system to achieve six national quality aims:
safety, effectiveness, patient-centeredness,
timeliness, efficiency, and equity.
Implementing such an agenda has important
implications for current and future health
professionals. The Quality Chasm report
provides initial guidance on what kinds of
competencies clinicians would need to carry out
this agenda, and emphasizes further study to
better understand how the workforce should be
educated for practice, how it should be
deployed, and how it should be held
accountable.
Health Professions Education
Summit
The Quality Chasm report recommends that
a multidisciplinary summit of leaders within the
health professions be held to discuss and
develop strategies for restructuring clinical
education across the full continuum of
education. The Committee on the Health
Professions Education Summit was convened to
plan and hold this summitññwhich was held on
June 17ñ18, 2002ññand to produce this followup
report.
The committee organized a
multidisciplinary summit involving allied
health, nursing, medical, and pharmacological
educators and students; health professional and
industry association representatives; regulators
and representatives of certifying organizations;
providers; consumers; innovators in education
and practice settings; and influential policy
makers. Participants were asked to develop
proposed strategies and actions for addressing
the five competency areas recommended by the
committee (described below) in health
professions education: patient-centered care,
interdisciplinary teams, evidence-based
practice, quality improvement, and informatics.
Summit participants worked in small
interdisciplinary groups using the Hoshin
method (Counsell et al., 1999; Hyde and
Vermillion, 1996; Platt and Laird, 1995), a
structured facilitation process for gathering
expert opinion and identifying, prioritizing, and
implementing strategies. The ideas generated at
the summit are included in this report in
Appendix B. The committee conducted a
literature review related to the core
competencies and various recommendations that
were considered. The committee also reviewed
the over 200 ideas proposed by summit
participants as part of its deliberations.
A New Vision for Health Professions
Education
With the ideal 21st-century health care
system described in the Quality Chasm report as
a backdrop, the committee developed a new
vision for clinical education in the health
professions that is centered on a commitment to,
first and foremost, meeting patientsí needs. The
committee believes that the following should
serve as an overarching vision for all programs
and institutions engaged in the clinical
education of health professionals, and further
that such organizations should develop
operating principals that will allow this vision to
be achieved.
All health professionals should be educated
to deliver patient-centered care as members
of an interdisciplinary team, emphasizing
evidence-based practice, quality
improvement approaches, and informatics.
The committeeís vision is apparent in
selected institutionsññboth academic and
practice settingsññaround the country, but is not
incorporated into the basic fabric of health
professions education, nor is it supported by
oversight processes or financing arrangements.
Accordingly, the committee proposes a set of
five core competencies that all clinicians should
possess, regardless of their discipline, to meet
the needs of the 21st-century health system.
Competencies are defined here as the habitual
and judicious use of communication,
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HEALTH PROFESSIONS EDUCATION
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knowledge, technical skills, clinical reasoning,
emotions, values, and reflection in daily practice
(Hundert et al., 1996).
• Provide patient-centered careññidentify,
respect, and care about patientsí differences,
values, preferences, and expressed needs;
relieve pain and suffering; coordinate
continuous care; listen to, clearly inform,
communicate with, and educate patients;
share decision making and management; and
continuously advocate disease prevention,
wellness, and promotion of healthy
lifestyles, including a focus on population
health.
• Work in interdisciplinary teamsññcooperate,
collaborate, communicate, and integrate care
in teams to ensure that care is continuous and
reliable.
• Employ evidence-based practiceññintegrate
best research with clinical expertise and
patient values for optimum care, and
participate in learning and research activities
to the extent feasible.
• Apply quality improvementññidentify errors
and hazards in care; understand and
implement basic safety design principles,
such as standardization and simplification;
continually understand and measure quality
of care in terms of structure, process, and
outcomes in relation to patient and
community needs; and design and test
interventions to change processes and
systems of care, with the objective of
improving quality.
• Utilize informaticsññcommunicate, manage
knowledge, mitigate error, and support
decision making using information
technology.
Many efforts have arisen in response to the need
to prepare clinicians for a changing practice
environment (ABIM Foundation, 2002;
Accreditation Council for Graduate Medical
Education, 1999; American Association of
Medical Colleges, 2001; Brady et al., 2001;
Center for the Advancement of Pharmaceutical
Education [CAPE] Advisory Panel on
Educational Outcomes, 1998; Halpern et al.,
2001; O’Neil and the Pew Health Professions
Commission, 1998). To formulate the above
core competencies, the committee examined the
skills outlined in the Quality Chasm report,
reviewed other efforts to define core
competencies within and across the health
professions, and reviewed the relevant
literature.
The five competencies are meant to be core,
but should not be viewed as an exhaustive list.
The committee recognizes that there are many
other competencies that health professionals
should possess, such as a commitment to
lifelong learning, but believes those listed above
are the most relevant across the clinical
disciplines; advance the vision in the Quality
Chasm report; and overlap with recent, existing
efforts to define competencies (Accreditation
Council for Graduate Medical Education, 1999;
Accreditation Council on Pharmaceutical
Education, 2000). The committee also
acknowledges that the core competencies will
differ in application across the disciplines.
Next Steps
With some notable exceptions (O’Neil and
the Pew Health Professions Commission, 1998;
Pew Health Professions Commission, 1995),
most current and past reform efforts have
focused within a particular profession (Bellack
and O’Neil, 2000; Christakis, 1995; Harmening,
1999; Jablonover et al., 2000). The committee
believes the time has come for leaders across
the professions to work together on the crosscutting
changes that must occur to effect reform
in clinical education and related training
environments, and that they should carefully
consider the cultural changes necessary to
support such reform efforts.
The committee believes that integrating a
core set of competenciesññone that is shared
across the professionsññinto the health
professions oversight spectrum would provide
the most leverage in terms of reform of health
professions education. A recent article
synthesizing nine major reports on physician
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EXECUTIVE SUMMARY
5
competencies, focused on the important role
oversight organizations can play, concluded that
ìwithout data about medical-education quality,
accreditation is the most potent lever for
curricula reform in our decentralized medical
education systemî (Halpern et al., 2001). Many
participants at the IOM summit concurred with
this conclusion. The two levers for change most
often cited by the 150 participants were
oversight approaches and changes to financing.
The committee also recommends pursing
other leverage pointsññsuch as the use of report
cards that incorporate education-related
measures and innovations in financial
incentivesññbut the preponderance of its
recommendations are directed at oversight
organizations. This is the case in part because
of the lack of education measures and the
charge to this committee, which is focused on
clinical education.1 Also, health professions
oversight processes, such as accreditation and
certification, function at the national level,
thereby affording a leverage point for
systemwide change. The committee believes
that such an approach will stimulate efforts on
the part of educational institutions and
professional associations.
The committee would like to highlight its
definition of ìoversight processesî and
underscore that it includes the efforts of both
private ñ and public ñ sector organizations:
Oversight processes include accreditation,
certification, and licensure. Educational
accreditation serves as a leverage point for
the inclusion of particular educational
content in a curriculum. Licensure assesses
that a student has understood and mastered
formal curricula. Certification seeks to
ensure that a practitioner maintains
competence in a given area over time.
Organizational accreditation also may
influence practitionersí ongoing
competency.
The call for accrediting and certifying
organizations to move toward a competencybased
approach to education is in response to
growing concerns about patient safety (Institute
of Medicine, 2000), the persistent and
substantial variation in patient care across
geographic settings that does not relate to
patient characteristics (O’Connor et al., 1996;
Wennberg, 1998), and the related desire on the
part of public payers and consumers for
increased accountability (Leach, 2002; Lenburg
et al., 1999). Competency-based education
focuses on making the learning outcomes for
courses explicit and on evaluating how well
students have mastered these outcomes or
competencies (Harden, 2002). The evidence
base on the efficacy of various educational
approaches is slim. However, the limited
evidence that does exist points to
improvements, such as better performance on
licensing exams, associated with the use of
competencyñ or outcome-based educational
approaches (Carraccio et al., 2002).
A competency-based approach to education
could result in better quality because educators
would begin to have information on outcomes,
which could ultimately lead to better patient
care. Defining a core set of competencies
across educational oversight processes could
also reduce costs as a result of better
communication and coordination, with
processes being streamlined and redundancies
reduced. Integrating core competencies into
oversight processes would likely provide the
impetus for faculty development, curricular
reform, and leadership activities.
Common Language and Adoption of Core
Competencies
Before steps can be taken to integrate a core
set of competencies into oversight processes, an
interdisciplinary group that includes leaders
from the professions, educational institutions,
and oversight organizations will need to define
common terms. A number of studies have
shown that any collective movement to reform
education must begin by defining a shared
1 A current Institute of Medicine study addressing academic health centers is considering financing questions.
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language (Halpern et al., 2001; Harden, 2002).
Such an effort can help set in motion a process
focused on achieving a threshold level of
consensus across the disciplines around a core
set of competencies.
The lack of consensus across the
professions around language and terms related
to the core competencies may be undermining
their integration into oversight processes. For
example, with respect to evidence-based
practice, leaders in the field have worked to
expand the definition of evidence so it includes
qualitative research and to dispel the myth that
such practice ignores clinical experience and
expertise (Guyatt, 1992). Despite these efforts,
a review of the literature suggests that
misconceptions regarding the definition of
evidence persist (Ingersoll, 2000; Marwick,
2000; Mazurek, 2002; Mitchell, 1999; Satya-
Murti, 2000; Woolf, 2000). A review of the
literature related to teaching interdisciplinary
team skills reveals differing terminologies as an
obstacle: faculty struggle to understand other
professionsí core concepts and content, which
leads to conflict when they teach
interdisciplinary courses (Lavin et al., 2001;
Pomeroy and Philp, 1994). The committee
believes that an interdisciplinary group, created
under the auspices of the Department of Health
and Human Services (DHHS), should be
charged with developing a common language
across the health disciplines and achieving
consensus around a core set of competencies.
Recommendation 1: DHHS and leading
foundations should support an
interdisciplinary effort focused on
developing a common language, with the
ultimate aim of achieving consensus
across the health professions on a core set
of competencies that includes patientcentered
care, interdisciplinary teams,
evidence-based practice, quality
improvement, and informatics.
Integrating competencies into oversight
processes
The extent of integration of competencies
into existing oversight processes varies. Any
effort at further integration would be
strengthened if predicated on a core a set of
competenciesócompetencies with universal
definitions shared across the professions. The
committee recognizes that these competencies
are by no means exhaustive, but represent an
important core of what health professionals
need to know to practice in a 21st-century health
system.
During the last decade, competencies have
begun to redefine accreditation, particularly in
pharmacy and medicine. The competencies that
these disciplines have defined overlap with the
core competencies recommended by the
committee. In 1997, the American Council on
Pharmaceutical Education (ACPE) adopted
accreditation standards focused on 18
professional competencies (American Council
on Pharmaceutical Education, 2002). In 1999,
the Accreditation Council for Graduate Medical
Education (ACGME) and the organization of
certifying boards, the American Board of
Medical Specialties (ABMS), endorsed six
general competencies as the foundation for all
graduate medical education, and these
competencies are currently being phased in
(Accreditation Council for Graduate Medical
Education, 2002). Until they are fully
incorporated and evaluated, it remains to be
seen what effect these competencies will have
on pharmacological and medical education. In
nursing, the two accrediting organizations also
have defined competenciesññwhich do not fully
overlap with the core competencies defined
hereññbut differ in whether they require
demonstration of such competencies
(Commission on Collegiate Nursing Education,
2002; National League for Nursing Accrediting
Commission, 2002). Finally, the curricula for
the selected allied health professions examined
in this report vary in the extent to which they
incorporate the five competencies outlined
above (Collier, 2002).
The competency movement, however, does
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EXECUTIVE SUMMARY
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not have as much of a foothold in licensure and
certification processes. Requirements for
maintaining a license vary considerably, as do
requirements for those who pursue recognition
of clinical excellence. Further, research has
raised questions about the efficacy of continuing
education courses, the most common way to
demonstrate ongoing competency (Cantillon
and Jones, 1999; Davis et al., 1999).
Efforts to incorporate a core set of
competencies across the professions into the full
oversight frameworkññaccreditation, licensing,
and certificationññwould need to occur on the
national, state, and local levels; coordinate both
public- and private-sector oversight
organizations; and solicit broad input. Again,
the involvement of DHHS, and specifically the
Health Resources and Services Administration,
would be important in getting this effort off the
ground, in helping to establish a process for
soliciting input from professional associations
and the education community, and in
identifying linkages and synergies across the
various oversight groups within and across
professions.
It is imperative to have such linkages
among accreditation, certification, and
licensure; it would mean very little, for
example, if accreditation standards set
requirements for educational programs, and
these requirements were not then reinforced
through testing on the licensing exam. All
processes must be linked so they are focused on
the same outcomeóthe ability of professionals
to provide the highest quality of care.
Recommendation 2: DHHS should
provide a forum and support for a series
of meetings involving the spectrum of
oversight organizations across and within
the disciplines. Participants in these
meetings would be charged with
developing strategies for incorporating a
core set of competencies into oversight
activities, based on definitions shared
across the professions. These meetings
would actively solicit the input of health
professions associations and the
education community.
Strategies for incorporating the
competencies into oversight processes would
necessarily differ across the oversight
framework based on history, regulatory
approach, and structure. In all cases, the
oversight bodies should proceed with
deliberation, with efforts made to solicit
comments on draft language, and initial testing
of new requirements, such as through the use of
provisional standards. Processes should also be
established to monitor and evaluate new
requirements to ensure that they are useful and
not overly burdensome.
The experiences of ACPE and ACGME
provide some guidance on how accrediting
bodies could incorporate competencies into
their processes. Both ACPE and ACGME
undertook an intensive, decade-long process of
rethinking how they were preparing
professionals for practice. They concluded that
fundamental change was necessary, and that
they needed to move away from approaches that
had become increasingly precise, prescriptive,
and burdensome (Byrd, 2002; Batalden et al.,
2002, Leach, 2002).
What has not yet occurred is coordination
across accrediting bodies of the various
professions in defining a core set of
competencies and related standards and
measures. Such coordination would obviate the
need for each accrediting body to reinvent the
wheel, promote synergies, and enable better
communication and working relationships, as
well as more consistent integration of the core
competencies across schools. This sort of
coordinated effort would also help ensure that
educational innovators would not be stifled by
outdated accreditation requirements.
Organizational accreditorsññsuch as the Joint
Commission on Accreditation of Healthcare
Organizations (JCAHO) and the National
Committee for Quality Assurance (NCQA)ññ
should likewise consider more fully how
clinicians maintain competency in the core set
of competencies outlined above.
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Recommendation 3: Building upon
previous efforts, accreditation bodies
should move forward expeditiously to
revise their standards so that programs
are required to demonstrateóthrough
process and outcome measuresóthat
they educate students in both academic
and continuing education programs in
how to deliver patient care using a core
set of competencies. In so doing, these
bodies should coordinate their efforts.
With the exception of patient-centered care,
which is consistently included in examinations
across the professions, licensing exams for
health professionals vary considerably in
whether they test for competency in the core
areas (National Association of Boards of
Pharmacy, 2002; National Council of State
Boards of Nursing, 2001; United States Medical
Licensing Exam, 2002). This situation also
needs to be addressed and could be the focus of
a subset of the oversight organizations described
in recommendation 2.
In addition, geographic restrictions on
licensure and separate and sometimes
conflicting scope-of-practice acts need to be
examined to determine whether they are a
serious barrier to the full integration of the core
competencies into practice, and if so, how to
modify them so that all clinicians can practice to
the fullest extent of their technical training and
ability. Although beyond the scope of this
report, the committee believes that this matter
deserves further examination because licensure
and scope of practice influence how clinicians
are deployed, which in turn affects decisions
about education. For example, licensure
restrictions might hamper a rural hospitalís
ability to consult a specialist because she
happened to be located in another state and
licensed to practice only there (Phillips et al.,
2002). Similarly, scope-of-practice restrictions
in one state might prohibit a nurse practitioner
who was part of an interdisciplinary diabetes
care management team from prescribing
medications, while another state might allow
such activityññeven though both practitioners
worked for the same national health plan
(Phillips et al., 2002). These restrictions make
less and less sense as health care organizations
and health professionals cross state lines.
Finally, the committee believes that there
should be a focused effort to integrate a core set
of competencies into oversight processes
focused on practicing clinicians. Such an effort
would require coordination among an array of
public- and private-sector licensing and
certification organizations, within which there is
currently little uniformity in approach across the
professions or within a given profession across
the states. At present, many boards require only
a fee for license renewal (Swankin, 2002b;
Yoder-Wise, 2002), and many others view
continuing education courses as evidence of
competence, even though, as noted above, this
has not been shown to be a reliable measure of
such ability (Davis et al., 2000; O’Brien et al.,
2001).
To begin with, state legislatures would need
to require state licensing boards to insist that
their licensees demonstrate competence, not just
pay a license renewal fee, to maintain their
authority to practice. To date, state legislators
have not insisted upon such a requirement, in
part because there is disagreement about what
constitutes evidence of competency, how often
it should be demonstrated, and who should
judge. Licensing boards also would need to
consider clinician competency at varying career
stages. For example, a veteran intensive care
nurse or physician subspecialist should be
expected to have a higher level of competence
than a new graduate in either profession.
The committee believes that all health
professions boards need to require
demonstration of continued competency, and
that they should move toward adopting rigorous
tests for this purpose. Beyond licensure
examinations, there is evidence to suggest that
structured direct observation using standardized
patients, peer assessments, and caseñ and essaybased
questions are reliable ways to assess
competency (Epstein and Hundert, 2002;
Murray et al., 2000).
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Recommendation 4: All health
professions boards should move toward
requiring licensed health professionals to
demonstrate periodically their ability to
deliver patient careóas defined by the
five competencies identified by the
committeeóthrough direct measures of
technical competence, patient assessment,
evaluation of patient outcomes, and other
evidence-based assessment methods.
These boards should simultaneously
evaluate the different assessment
methods.
There is more uniformity among certifying
organizations as compared with professional
boards, in that nearly all require some means of
demonstrating continuing competence. The vast
majority allow for two or more approaches, and
many also consider competency at various
career stages. Moreover, in response to the
paucity of evidence that taking continuing
education courses improves practice outcomes,
some certifying organizations are beginning to
emphasize alternative measures that are more
evidence based (American Board of Medical
Specialties, 2000; American Nurses
Association/NursingWorld.Org, 2001; Bashook
et al., 2000; Board of Pharmaceutical
Specialties, 2002; Federation of State Medical
Boards, 2002; Finocchio et al., 1998; National
Council of State Boards of Nursing, 1997-2000;
Swankin, 2002a). Although such efforts are
challenging to implement and often costly,
certification bodies should only recognize
continuing education courses as a valid method
of maintaining competence if there is an
evidence-based assessment of such courses; if
clinicians select courses based on an assessment
of their individual skills and knowledge; and if
clinicians then demonstrate, through testing or
other methods, that they have learned the course
content.
The committee recognizes that there is a
monetary and human resource cost to moving to
evidence-based assessment, whether it is related
to licensure or certification. Consequently, such
assessments may need to be phased in, or less
costly assessment methods identified. The
committee also recognizes that increased
investment in computer-based clinical records
would provide the kind of rich clinical data
necessary to fully realize this approach.
Recommendation 5: Certification bodies
should require their certificate holders to
maintain their competence throughout
the course of their careers by periodically
demonstrating their ability to deliver
patient care that reflects the five
competencies, among other requirements.
Training Environments
Education does not occur in a vacuum;
indeed, much of what is learned lies outside of
formal academic coursework. A ìhidden
curriculumî of observed behavior, interactions,
and the overall norms and culture of a studentís
training environments are extremely powerful in
shaping the values and attitudes of future health
professionals. Often, this hidden curriculum
contradicts what is taught in the classroom
(Ferrill et al., 1999; Hafferty, 1998; Maudsley,
2001).
Consequently, the committee believes that
initial support should be provided for existing
exemplary practice organizations that partner
with educational institutions, and are already
providing the interdisciplinary education and
training necessary for staff to consistently
deliver care that incorporates the core
competencies. Further, the committee believes
that these leading organizations should be
identified as training models for other
organizations, and should be given the resources
necessary to open their doors to students,
clinicians, and faculty from other organizations,
as well as support for testing alternative
approaches to providing curricula that integrate
the core competencies. Given that faculty
shortages and lack of preparedness are a barrier
to implementing some of the core competencies
(Griner and Danoff, 2000; Halpern, 1996; Weed
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HEALTH PROFESSIONS EDUCATION
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and Weed, 1999) attention should be given to
faculty development as well as instruction of
students.
These learning centers could test various
approaches for incorporating the core
competencies into education for students,
clinicians, and faculty, and provide guidance to
practice and educational organizations about
key operational issues. Is problem-based
learning the best approach to teaching these
competencies? Should the teaching of these
competencies be infused into other courses, or
should they be stand-alone? In terms of staging,
when should these competencies be taught?
These learning centers should also consider
how, after an initial investment, they could
become selfñsustaining in 3ñ5 years. Such a
model might include provision of health care
services or require outside clinicians and faculty
to pay for training.
There is precedence for focusing on
learning centers that span occupations. For
example, in health care there are selected
examples of area health education centers
(AHECs) training a broad range of professionals
with support from the HRSA, while in other
sectors, such as the airline industry, there are
more comprehensive interdisciplinary training
efforts (O’Neil and the Pew Health Professions
Commission, 1998). Such organizations could
provide centralized locations for information
technology infrastructure, which would be an
efficient way of aggregating costs across many
organizations.
Recommendation 6: Foundations, with
support from education and practice
organizations, should take the lead in
developing and funding regional
demonstration learning centers,
representing partnerships between
practice and education. These centers
should leverage existing innovative
organizations and be state-of-the art
training settings focused on teaching and
assessing the five core competencies.
There are many barriers to incorporating the
five competencies into the practice
environment, where medical residents and new
graduates in allied health, nursing, and
pharmacology obtain initial training that leaves
an important imprint on their future practice
(Partnership for Solutions, 2002). In addition to
the barriers of time constraints, oversight
restrictions, resistance from the professions, and
absence of political will, the overall health care
financing system is a large impediment to
integrating the core competencies into practice
settings. Therefore, the committee believes
steps must be taken to explore alternative ways
of paying clinicians so as to foster such
integration.
The lack of a supportive financial incentives
structure becomes abundantly clear when one
considers, for example, the kinds of services
from which the chronically ill elderly would
benefit and what Medicare fee-for-service pays
for. Currently, Medicare fee-for-service does
not generally pay for clinician time spent
providing education that enables, for example,
patients with diabetes and heart disease to make
necessary lifestyle and behavioral changes, or
for time spent helping such patients by teaching
them how to actively manage their condition
with the support of technology. Medicare feefor-
service also does not pay for the work
involved in coordinating and integrating the
various services such patients need across teams
and settings (Institute of Medicine, 2002).
Consequently, the financing system often
undermines integration of the five competencies
into practice, despite evidence that patients who
are actively involved in managing and making
decisions about their care have better quality
and functional status outcomes at lower cost
(Gifford et al., 1998; Superio-Cabuslay et al.,
1996; Von Korff et al., 1998; Wagner et al.,
2001).
As the largest payer, Medicare has a major
effect on the system when it innovates (Institute
of Medicine, 2002). Moreover, the committee
believes that patients with chronic conditionsññ
a sizable proportion of whom are covered by
Medicareññwould benefit greatly from
Health Professions Education: A Bridge to Quality
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Executive Summary
The American health care delivery system is in need of fundamental change.
Many patients, doctors, nurses, and health care leaders are concerned that the care
delivered is not, essentially, the care we should receive (Donelan et al., 1999;
Reed and St. Peter, 1997; Shindul-Rothschild et al., 1996; Taylor, 2001). The
frustration levels of both patients and clinicians have probably never been higher.
Yet the problems remain. Health care today harms too frequently and routinely
fails to deliver its potential benefits.
Americans should be able to count on receiving care that meets their needs
and is based on the best scientific knowledge. Yet there is strong evidence that
this frequently is not the case.1 Crucial reports from disciplined review bodies
document the scale and gravity of the problems (Chassin et al., 1998; Institute of
Medicine, 1999; Advisory Commission on Consumer Protection and Quality in
the Health Care Industry, 1998). Quality problems are everywhere, affecting
many patients. Between the health care we have and the care we could have lies
not just a gap, but a chasm.
The Committee on the Quality of Health Care in America was formed in
June 1998 and charged with developing a strategy that would result in a substantial
improvement in the quality of health care over the next 10 years. In carrying
out this charge, the committee commissioned a detailed review of the literature
on the quality of care; convened a communications workshop to identify strategies
for raising the awareness of the general public and key stakeholders of
quality concerns; identified environmental forces that encourage or impede ef-
1See Appendix A of this report for a review of the literature on the quality of care.
Crossing the Quality Chasm: A New Health System for the 21st Century
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2 CROSSING THE QUALITY CHASM
forts to improve quality; developed strategies for fostering greater accountability
for quality; and identified important areas of research that should be pursued to
facilitate improvements in quality. The committee has focused on the personal
health care delivery system, specifically, the provision of preventive, acute,
chronic, and end-of-life health care for individuals. Although the committee
recognizes the critical role of the public health system in protecting and improving
the health of our communities, this issue lies beyond the purview of the
present study.
The committee has already spoken to one urgent quality problem—patient
safety. In our first report, To Err Is Human: Building a Safer Health System, we
concluded that tens of thousands of Americans die each year from errors in their
care, and hundreds of thousands suffer or barely escape from nonfatal injuries
that a truly high-quality care system would largely prevent (Institute of Medicine,
2000b).
As disturbing as the committee’s report on safety is, it reflects only a small
part of the unfolding story of quality in American health care. Other defects are
even more widespread and, taken together, detract still further from the health,
functioning, dignity, comfort, satisfaction, and resources of Americans. This
report addresses these additional quality problems. As the patient safety report
was a call for action to make care safer, this report is a call for action to improve
the American health care delivery system as a whole, in all its quality dimensions,
for all Americans.
WHY ACTION IS NEEDED NOW
At no time in the history of medicine has the growth in knowledge and
technologies been so profound. Since the first contemporary randomized controlled
trial was conducted more than 50 years ago, the number of trials conducted
has grown to nearly 10,000 annually (Chassin, 1998). Between 1993 and
1999, the budget of the National Institutes of Health increased from $10.9 to
$15.6 billion, while investments by pharmaceutical firms in research and development
increased from $12 to $24 billion (National Institutes of Health, 2000;
Pharmaceutical Research and Manufacturers of America, 2000). Genomics and
other new technologies on the horizon offer the promise of further increasing
longevity, improving health and functioning, and alleviating pain and suffering.
Advances in rehabilitation, cell restoration, and prosthetic devices hold potential
for improving the heath and functioning of many with disabilities. Americans are
justifiably proud of the great strides that have been made in the health and
medical sciences.
As medical science and technology have advanced at a rapid pace, however,
the health care delivery system has floundered in its ability to provide consistently
high-quality care to all Americans. Research on the quality of care reveals
Crossing the Quality Chasm: A New Health System for the 21st Century
Copyright National Academy of Sciences. All rights reserved.
EXECUTIVE SUMMARY 3
a health care system that frequently falls short in its ability to translate knowledge
into practice, and to apply new technology safely and appropriately. During the
last decade alone, more than 70 publications in leading peer-reviewed journals
have documented serious quality shortcomings (see Appendix A). The performance
of the health care system varies considerably. It may be exemplary, but
often is not, and millions of Americans fail to receive effective care. If the health
care system cannot consistently deliver today’s science and technology, we may
conclude that it is even less prepared to respond to the extraordinary scientific
advances that will surely emerge during the first half of the 21st century. And
finally, more than 40 million Americans remain without health insurance, deprived
of critically important access to basic care (U.S. Census Bureau, 2000).
The health care system as currently structured does not, as a whole, make the
best use of its resources. There is little doubt that the aging population and
increased patient demand for new services, technologies, and drugs are contributing
to the steady increase in health care expenditures, but so, too, is waste. Many
types of medical errors result in the subsequent need for additional health care
services to treat patients who have been harmed (Institute of Medicine, 2000b).
A highly fragmented delivery system that largely lacks even rudimentary clinical
information capabilities results in poorly designed care processes characterized
by unnecessary duplication of services and long waiting times and delays. And
there is substantial evidence documenting overuse of many services—services
for which the potential risk of harm outweighs the potential benefits (Chassin et
al., 1998; Schuster et al., 1998).
What is perhaps most disturbing is the absence of real progress toward
restructuring health care systems to address both quality and cost concerns, or
toward applying advances in information technology to improve administrative
and clinical processes. Despite the efforts of many talented leaders and dedicated
professionals, the last quarter of the 20th century might best be described as the
“era of Brownian motion in health care.” Mergers, acquisitions, and affiliations
have been commonplace within the health plan, hospital, and physician practice
sectors (Colby, 1997). Yet all this organizational turmoil has resulted in little
change in the way health care is delivered. Some of the new arrangements have
failed following disappointing results. Leaders of health care institutions are
under extraordinary pressure, trying on the one hand to strategically reposition
their organizations for the future, and on the other to respond to today’s challenges,
such as reductions in third-party payments (Guterman, 1998), shortfalls in
nurse staffing (Egger, 2000), and growing numbers of uninsured patients seeking
uncompensated care (Institute of Medicine, 2000a).
For several decades, the needs of the American public have been shifting
from predominantly acute, episodic care to care for chronic conditions. Chronic
conditions are now the leading cause of illness, disability, and death; they affect
almost half of the U.S. population and account for the majority of health care
Crossing the Quality Chasm: A New Health System for the 21st Century
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