Executive Summary Assignment | Essay Help Services

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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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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
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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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EXECUTIVE SUMMARY
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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
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EXECUTIVE SUMMARY
11
integration of the five competencies into
practice. There are a number of different
options that could serve as models for these
payment experiments, including capitation,
bundled payments, bonuses, withholds, and
various ways to share risk and responsibility
between clinicians and payers (Bailit Health
Purchasing, 2002; Guyatt et al., 2000). The
committee encourages other payers to follow
suit.
Recommendation 7: Through Medicare
demonstration projects, the Centers for
Medicare and Medicaid Services (CMS)
should take the lead in funding
experiments that will enable and create
incentives for health professionals to
integrate interdisciplinary approaches
into educational or practice settings, with
the goal of providing a training ground
for students and clinicians that
incorporates the five core competencies.
Research and Information
Along with oversight changes and
supportive training environments, the
committee believes that evidence of the efficacy
of an educational intervention can be a catalyst
for change. To this end, evidence related to the
link between clinical education and health care
quality needs to be better developed, as does
evidence about various teaching approaches.
In a review of 117 trials in continuing
education, fewer than 20 percent were found to
use health care outcomes as their measure of
effectiveness (Davis et al., 2000), and a review
of 2,000 papers on continuing education showed
that only about 5 percent assessed the
relationship between course content and clinical
outcomes (Jordan, 2000). Teaching itself is
dominated by intuition and tradition, which do
not always hold up when submitted to empirical
verification (Tanenbaum, 1994; van der Vleuten
et al., 2000). For example, studies have shown
that lecture-based teaching of isolated
components, the most common means of
imparting information in both academic and
continuing education settings, fails in that it
does not provide a way for students to integrate
or apply the information provided (Wass et al.,
2001).
Although there is significant public funding
of health professions education, limited public
and private resources are available for research
that could help in determining whether the
dollars are being well spent. In addition, much
of the research that does exist is disciplinespecific
and therefore does not reflect the
current practice environment.
The committee believes the time has come
to focus energy and resources on developing a
more robust and compelling evidence base
about what educational content matters for
patient care and what works in teaching
clinicians so that educators, payers, and
regulators can assess objectively what needs to
be emphasized in the health professions
curricula and what should be eliminated. The
research should also span disciplines.
Recommendation 8: The Agency for
Healthcare Research and Quality
(AHRQ) and private foundations should
support ongoing research projects
addressing the five core competencies and
their association with individual and
population health, as well as research
related to the link between the
competencies and evidence-based
education. Such projects should involve
researchers across two or more
disciplines.
The committee believes that incorporation
of education-related measures into qualityreporting
efforts and ongoing monitoring will be
required to realize the vision articulated in this
report. The lack of standardized information
about the quality of clinical education makes the
job of leaders seeking to reform such education
more difficult. The lack of standardized
measures also sets clinical education apart from
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HEALTH PROFESSIONS EDUCATION
12
the broader health care quality movement. A
rankingóby NCQA regarding health plan
quality or by U.S. News and World Report
regarding hospitals, for exampleóforces
leaders to focus their attention on improving
performance on a given set of comparable
metrics (National Committee for Quality
Assurance, 2002; U.S. News and World Report,
2002). The National Healthcare Quality Report
Card, anticipated for release by AHRQ in 2003
and annually thereafter, will likely further
standardize quality measurement and focus
attention on the strengths and weaknesses of the
current system. Yet no education-related
measures are anticipated for inclusion in this
first annual report (Agency for Health Care
Research Quality, 2002).
A focused effort to develop educationrelated
measures must begin now, given the
amount of time required to develop and test
prospective measures before they can be
incorporated into report cards. The committee
recognizes that initially there will be a small
number of measures ready for public reporting.
Recommendation 9: AHRQ should work
with a representative group of health
care leaders to develop measures
reflecting the core set of competencies, set
national goals for improvement, and issue
a report to the public evaluating progress
toward these goals. AHRQ should issue
the first report, focused on clinical
educational institutions, in 2005 and
produce annual reports thereafter.
Providing Leadership
Significant reform in health professions
education is a challenge to say the least. The
oversight framework is a morass of different
organizations with differing requirements and
philosophies, now under considerable pressure
to demonstrate greater accountability (Batalden
et al., 2002; Finocchio et al., 1998; Leach, 2002;
O’Neil and the Pew Health Professions
Commission, 1998). In academia, deans,
department chairs, residency directors, and
other leaders face a stream of requests for
adding new elements to a curriculum that is
already overcrowded. Shortages of key
professionals, such as nurses and pharmacists,
are another significant challenge. Moreover,
funding for some academic health centers has
been under pressure, and states are facing
budget shortfalls that are causing them to trim
education budgets, including funding for
universities and community colleges (Griner
and Danoff, 2000).
When change happens in health professions
education, it does not happen overnight.
Multiyear processes are required to develop,
review, and achieve consensus on new
requirements or methods before they can be
implemented. Given this environment, the
committee believes that reform of clinical
education will be possible only with the skill
and commitment of a broad range of health care
leaders. A recent analysis and synthesis of 44
curriculum reform efforts revealed that
leadership is the factor most often cited as
affecting curriculum change (Bland et al.,
2000).
Consequently, the committee believes that
to maintain momentum for reform in clinical
education, there will need to be biennial
summits at which leaders who have
demonstrated a real commitment to
implementing the committeeís overarching
vision can gather. These summits should serve
as a forum for leaders to take stockññincluding
review of education-related performance
measures and, over time, related trends against
goalsññand to define future plans. There should
be a written report issued from the summit that
captures such information and communicates it
more broadly to the field.
Recommendation 10: Beginning in 2004,
a biennial interdisciplinary summit
should be held involving health care
leaders in education, oversight processes,
practice, and other areas. This summit
Health Professions Education: A Bridge to Quality
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EXECUTIVE SUMMARY
13
should focus on both reviewing progress
against explicit targets and setting goals
for the next phase with regard to the five
competencies and other areas necessary
to prepare professionals for the 21stcentury
health system.
Conclusion
The committee has set forth 10 major
recommendations for reforming health
professions education to enhance quality and
meet the evolving needs of patients. Each of
these recommendations focuses on ways of
integrating a core set of competencies into
health professions education. Taken together,
they represent a mix of approaches related to
oversight processes, the practice environment,
research, public reporting, and leadership.
The staging of these recommendations is
important. The first step is to articulate
common terms so that shared definitions can
inform interdisciplinary discussions about core
competencies. Once the disciplines have agreed
on a core set of competencies, public and
private oversight bodies can consider how to
incorporate such competencies into their
processesóproviding a catalyst for many
educational institutions and professional
associations, as well as support for those who
have already moved toward adopting a
competency-based approach. The committee
believes that the development of common
language and definition of core competencies
should happen as rapidly as possible and by no
later than 2004, given that the integration of
core competencies into oversight processes will
take considerable time, perhaps a decade or
more if the efforts of ACGME and ACPE are
any guide.
As the work of integrating core
competencies into oversight processes proceeds,
the efforts of leading practice organizations to
integrate the core competencies into care
delivery should be fostered through regional
demonstration learning centers and Medicare
demonstration projects. Simultaneously with
these efforts, AHRQ and private foundations
should provide support for research focused on
the efficacy of the competencies and
competency education and, most important,
develop a set of measures reflecting the core set
of competencies, along with national goals for
improvement. Given that the committee calls
upon AHRQ to issue a first report on health
professions educational institutions by 2005,
albeit with a limited number of initial measures,
efforts related to reporting must begin
immediately. Finally, the committee believes
that biennial summits of health care leaders who
control and shape educationóstarting in
2004ówill be an important mechanism for
integrating and furthering the efforts of those
developing measures, practice and education
innovators, researchers, and leaders from
oversight organizations.
The committee is confident that its
recommendations are both sound and feasible to
implement because they are supported by a
literature review, and informed by a broad range
of leaders who shape education both directly
and indirectly (see appendix C). Building a
bridge to cross the quality chasm in health care
cannot be done in isolation. The committee
hopes that this report will jump start other
efforts to reform clinical education, both
individually and collectively, so that it focuses
on continually reducing the burden of illness,
injury, and disability, with the ultimate aim of
improving the health status, functioning, and
satisfaction of the American people (President’s
Advisory Commission on Consumer Protection
and Quality in the Health Care Industry, 1998b).
The public deserves nothing less.
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Chassin, M.R., R.W. Galvin, and the National
Health Professions Education: A Bridge to Quality
Copyright National Academy of Sciences. All rights reserved.

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
Copyright National Academy of Sciences. All rights reserved.
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
Copyright National Academy of Sciences. All rights reserved.
4 CROSSING THE QUALITY CHASM
expenditures (Hoffman et al., 1996; The Robert Wood Johnson Foundation,
1996). As the need for community-based acute and long-term care services has
grown, the portion of health care resources devoted to hospital care has declined,
while that expended on pharmaceuticals has risen dramatically (Copeland, 1999).
Yet there remains a dearth of clinical programs with the infrastructure required to
provide the full complement of services needed by people with heart disease,
diabetes, asthma, and other common chronic conditions (Wagner et al., 1996).
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
communicate and coordinate care (The Robert Wood Johnson Foundation, 1996).
Yet physician groups, hospitals, and other health care organizations operate as
silos, often providing care without the benefit of complete information about the
patient’s condition, medical history, services provided in other settings, or medications
prescribed by other clinicians. For those without insurance, care is often
unobtainable except in emergencies. It is not surprising, then, that studies of
patient experience document that the health system for some is a “nightmare to
navigate” (Picker Institute and American Hospital Association, 1996).
QUALITY AS A SYSTEM PROPERTY
The committee is confident that Americans can have a health care system of
the quality they need, want, and deserve. But we are also confident that this
higher level of quality cannot be achieved by further stressing current systems of
care. The current care systems cannot do the job. Trying harder will not work.
Changing systems of care will.
The committee’s report on patient safety offers a similar conclusion in its
narrower realm. Safety flaws are unacceptably common, but the effective remedy
is not to browbeat the health care workforce by asking them to try harder to
give safe care. Members of the health care workforce are already trying hard to
do their jobs well. In fact, the courage, hard work, and commitment of doctors,
nurses, and others in health care are today the only real means we have of
stemming the flood of errors that are latent in our health care systems.
Health care has safety and quality problems because it relies on outmoded
systems of work. Poor designs set the workforce up to fail, regardless of how
hard they try. If we want safer, higher-quality care, we will need to have redesigned
systems of care, including the use of information technology to support
clinical and administrative processes.
Throughout this report, the committee offers a strategy and action plan for
building a stronger health system over the coming decade, one that is capable of
delivering on the promise of state-of-the-art health care to all Americans. In
some areas, achieving this ideal will require crossing a large chasm between
today’s system and the possibilities of tomorrow.
Crossing the Quality Chasm: A New Health System for the 21st Century
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EXECUTIVE SUMMARY 5
AN AGENDA FOR CROSSING THE CHASM
The need for leadership in health care has never been greater. Transforming
the health care system will not be an easy process. But the potential benefits are
large as well. Narrowing the quality chasm will make it possible to bring the
benefits of medical science and technology to all Americans in every community,
and this in turn will mean less pain and suffering, less disability, greater longevity,
and a more productive workforce. To this end, the committee proposes the
following agenda for redesigning the 21st-century health care system:
• That all health care constituencies, including policymakers, purchasers,
regulators, health professionals, health care trustees and management,
and consumers, commit to a national statement of purpose for the health
care system as a whole and to a shared agenda of six aims for improvement
that can raise the quality of care to unprecedented levels.
• That clinicians and patients, and the health care organizations that
support care delivery, adopt a new set of principles to guide the redesign of
care processes.
• That the Department of Health and Human Services identify a set of
priority conditions upon which to focus initial efforts, provide resources to
stimulate innovation, and initiate the change process.
• That health care organizations design and implement more effective
organizational support processes to make change in the delivery of care
possible.
• That purchasers, regulators, health professions, educational institutions,
and the Department of Health and Human Services create an environment
that fosters and rewards improvement by (1) creating an infrastructure
to support evidence-based practice, (2) facilitating the use of information
technology, (3) aligning payment incentives, and (4) preparing the workforce
to better serve patients in a world of expanding knowledge and rapid change.
The committee recognizes that implementing this agenda will be a complex
process and that it will be important to periodically evaluate progress and reassess
strategies for overcoming barriers.
Establishing Aims for the 21st-Century Health Care System
The committee proposes six aims for improvement to address key dimensions
in which today’s health care system functions at far lower levels than it can
and should. Health care should be:
• Safe—avoiding injuries to patients from the care that is intended to help
them.
Crossing the Quality Chasm: A New Health System for the 21st Century
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6 CROSSING THE QUALITY CHASM
• Effective—providing services based on scientific knowledge to all who
could benefit and refraining from providing services to those not likely to benefit
(avoiding underuse and overuse, respectively).
• Patient-centered—providing care that is respectful of and responsive to
individual patient preferences, needs, and values and ensuring that patient 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 socioeconomic
status.
A health care system that achieved major gains in these six dimensions
would be far better at meeting patient needs. Patients would experience care that
was safer, more reliable, more responsive, more integrated, and more available.
Patients could count on receiving the full array of preventive, acute, and chronic
services from which they are likely to benefit. Such a system would also be better
for clinicians and others who would experience the satisfaction of providing care
that was more reliable, more responsive to patients, and more coordinated than is
the case today.
The entire enterprise of care would ideally be united across these aims by a
single, overarching purpose for the American health care system as a whole. For
this crucial statement of purpose, the committee endorses and adopts the phrasing
of the Advisory Commission on Consumer Protection and Quality in the Health
Care Industry (1998).
Recommendation 1: All health care organizations, professional
groups, and private and public purchasers should adopt 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.
Recommendation 2: All health care organizations, professional
groups, and private and public purchasers should pursue six major
aims; specifically, health care should be safe, effective, patient-centered,
timely, efficient, and equitable.
Additionally, without ongoing tracking to assess progress in meeting the six
aims, policy makers, leaders within the health professions and health organizations,
purchasers, and consumers will be unable to determine progress or understand
where improvement efforts have succeeded and where further work is most
needed. The National Quality Report has the potential to play an important role
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EXECUTIVE SUMMARY 7
in continuing to raise the awareness of the American public about the quality-ofcare
challenges facing the health care system. Public awareness of shortcomings
in quality is critical to securing public support for the steps that must be taken to
address these concerns.
Recommendation 3: Congress should continue to authorize and
appropriate funds for, and the Department of Health and Human
Services should move forward expeditiously with the establishment
of, monitoring and tracking processes for use in evaluating the
progress of the health system in pursuit of the above-cited aims of
safety, effectiveness, patient-centeredness, timeliness, efficiency, and
equity. The Secretary of the Department of Health and Human
Services should report annually to Congress and the President on
the quality of care provided to the American people.
The committee applauds Congress and the Administration for their current
efforts to establish a National Quality Report for tracking the quality of care.
Ongoing input from the many public- and private-sector associations, professional
groups, and others involved in quality measurement and improvement will
contribute to the success of these efforts. The establishment of specific goals for
each of the six aims could further enhance the usefulness of this monitoring and
tracking system as a stimulus for performance improvement. Continued funding
for this activity should be ensured, as well as regular reports that communicate
progress to all concerned. It should be noted that although this report focuses
only on health care for individuals, the above overarching statement of purpose
and six aims for improvement are sufficiently robust that they can be applied
equally to decisions and evaluations at the population–health level.
Formulating New Rules to Redesign and Improve Care
As discussed earlier, improved performance will depend on new system
designs. The committee believes it would be neither useful nor possible for us to
specify in detail the design of 21st-century health care delivery systems. Imagination
and valuable pluralism abound at the local level in the nation’s health care
enterprise. At the same time, we believe local efforts to implement innovation
and achieve improvement can benefit from a set of simple rules to guide the
redesign of the health care system.
In formulating these rules, the committee has been guided by the belief that
care must be delivered by systems that are carefully and consciously designed to
provide care that is safe, effective, patient-centered, timely, efficient, and equitable.
Such systems must be designed to serve the needs of patients, and to
ensure that they are fully informed, retain control and participate in care delivery
whenever possible, and receive care that is respectful of their values and preferences.
Such systems must facilitate the application of scientific knowledge to
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8 CROSSING THE QUALITY CHASM
practice, and provide clinicians with the tools and supports necessary to deliver
evidence-based care consistently and safely.
Recommendation 4: Private and public purchasers, health care
organizations, clinicians, and patients should work together to redesign
health care processes in accordance with the following rules:
1. Care based on continuous healing relationships. Patients
should receive care whenever they need it and in many forms, not
just face-to-face visits. This rule implies that the health care system
should be responsive at all times (24 hours a day, every day) and
that access to care should be provided over the Internet, by telephone,
and by other means in addition to face-to-face visits.
2. Customization based on patient needs and values. The system
of care should be designed to meet the most common types of needs,
but have the capability to respond to individual patient choices and
preferences.
3. The patient as the source of control. Patients should be given
the necessary information and the opportunity to exercise the degree
of control they choose over health care decisions that affect
them. The health system should be able to accommodate differences
in patient preferences and encourage shared decision making.
4. Shared knowledge and the free flow of information. Patients
should have unfettered access to their own medical information and
to clinical knowledge. Clinicians and patients should communicate
effectively and share information.
5. Evidence-based decision making. 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 as 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. The need for transparency. The health care system should
make information available to patients and their families that allows
them to make informed decisions when selecting a health plan,
hospital, or clinical practice, or choosing among alternative treatments.
This should include information describing the system’s
performance on safety, evidence-based practice, and patient satisfaction.
8. Anticipation of needs. The health system should anticipate
patient needs, rather than simply reacting to events.
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EXECUTIVE SUMMARY 9
9. Continuous decrease in waste. The health system should not
waste resources or patient time.
10. Cooperation among clinicians. Clinicians and institutions
should actively collaborate and communicate to ensure an appropriate
exchange of information and coordination of care.
The above rules will lead the redesign effort in the right direction, guiding
the innovation required to achieve the aims for improvement outlined earlier.
Widespread application of these ten rules, each grounded in both logic and varying
degrees of evidence, will represent a new paradigm for health care delivery.
As the redesign effort moves forward, it will be important to assess not only
progress toward meeting the aims, but also the specific effects attributable to the
new rules and to adapt the rules as appropriate.
Design ideas are not enough, however. To initiate the process of change,
both an action agenda and resources are needed.
Taking the First Steps
The committee recognizes the enormity of the change that will be required to
achieve a substantial improvement in the nation’s health care system. Although
steps can be taken immediately to apply the ten rules set forth above to the
redesign of health care, widespread application will require commitment to the
provision of evidence-based care that is responsive to individual patients’ needs
and preferences. Well-designed and well-run systems of care will be required as
well. These changes will occur most rapidly in an environment in which public
policy and market forces are aligned and in which the change process is supported
by an appropriate information technology infrastructure.
To initiate the process of change, the committee believes the health care
system must focus greater attention on the development of care processes for the
common conditions that afflict many people. A limited number of such conditions,
about 15 to 25, account for the majority of health care services (Centers for
Disease Control and Prevention, 1999; Medical Expenditure Panel Survey, 2000;
Ray et al., 2000). Nearly all of these conditions are chronic. By focusing
attention on a limited number of common conditions, the committee believes it
will be possible to make sizable improvements in the quality of care received by
many individuals within the coming decade.
Health care for chronic conditions is very different from care for acute episodic
illnesses. Care for the chronically ill needs to be a collaborative, multidisciplinary
process. Effective methods of communication, both among caregivers
and between caregivers and patients, are critical to providing high-quality care.
Personal health information must accompany patients as they transition from
home to clinical office setting to hospital to nursing home and back.
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10 CROSSING THE QUALITY CHASM
Carefully designed, evidence-based care processes, supported by automated
clinical information and decision support systems, offer the greatest promise of
achieving the best outcomes from care for chronic conditions. Some efforts are
now under way to synthesize the clinical evidence pertaining to common chronic
conditions and to make this information available to consumers and clinicians on
the Web and by other means (Lindberg and Humphreys, 1999). In addition,
evidence-based practice guidelines have been developed for many chronic conditions
(Eisenberg, 2000). Yet studies of the quality of care document tremendous
variability in practice for many such conditions. Given these variations and the
prevalence of chronic conditions, these conditions represent an excellent starting
point for efforts to better define optimum care or best practices, and to design
care processes to meet patient needs. Moreover, such efforts to improve quality
must be supported by payment methods that remove barriers to integrated care
and provide strong incentives and rewards for improvement.
To facilitate this process, the Agency for Healthcare Research and Quality
should identify a limited number of priority conditions that affect many people
and account for a sizable portion of the national health burden and associated
expenditures. In identifying these priority conditions, the agency should consider
using the list of conditions identified through the Medical Expenditure Panel
Survey (2000). According to the most recent survey data, the top 15 priority
conditions are cancer, diabetes, emphysema, high cholesterol, HIV/AIDS, hypertension,
ischemic heart disease, stroke, arthritis, asthma, gall bladder disease,
stomach ulcers, back problems, Alzheimer’s disease and other dementias, and
depression and anxiety disorders. Health care organizations, clinicians, purchasers,
and other stakeholders should then work together to (1) organize evidencebased
care processes consistent with best practices, (2) organize major prevention
programs to target key health risk behaviors associated with the onset or progression
of these conditions, (3) develop the information infrastructure needed to
support the provision of care and the ongoing measurement of care processes and
patient outcomes, and (4) align the incentives inherent in payment and accountability
processes with the goal of quality improvement.
Recommendation 5: The Agency for Healthcare Research and Quality
should identify not fewer than 15 priority conditions, taking into
account frequency of occurrence, health burden, and resource use.
In collaboration with the National Quality Forum, the agency should
convene stakeholders, including purchasers, consumers, health care
organizations, professional groups, and others, to develop strategies,
goals, and action plans for achieving substantial improvements
in quality in the next 5 years for each of the priority conditions.
Redirecting the health care industry toward the implementation of welldesigned
care processes for priority conditions will require significant resources.
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EXECUTIVE SUMMARY 11
Capital will be required to invest in enhancing organizational capacity, building
an information infrastructure, and training multidisciplinary care teams, among
other things. The committee believes it is appropriate for the public sector to take
the lead in establishing an innovation fund to seed promising projects, but not to
shoulder the full burden of the transition. Private-sector organizations, including
foundations, purchasers, health care organizations, and others, should also make
investments. High priority should be given to projects that are likely to result in
making available in the public domain new programs, tools, and technologies that
are broadly applicable throughout the health care sector.
Recommendation 6: Congress should establish a Health Care Quality
Innovation Fund to support projects targeted at (1) achieving the
six aims of safety, effectiveness, patient-centeredness, timeliness, efficiency,
and equity; and/or (2) producing substantial improvements
in quality for the priority conditions. The fund’s resources should
be invested in projects that will produce a public-domain portfolio
of programs, tools, and technologies of widespread applicability.
Americans now invest annually $1.1 trillion, or 13.5 percent, of the nation’s
gross domestic product (GDP) in the health care sector (Health Care Financing
Administration, 1999). This figure is expected to grow to more than $2 trillion,
or 16 percent of GDP, by 2007 (Smith et al., 1998). The committee believes a
sizable commitment, on the order of $1 billion over 3 to 5 years, is needed to
strongly communicate the need for rapid and significant change in the health care
system and to help initiate the transition. Just as a vigorous public commitment
has led to the mapping of human DNA, a similar commitment is needed to help
the nation’s health care system achieve the aims for improvement outlined above.
Building Organizational Supports for Change
Supporting front-line teams that deliver care are many types of health care
organizations. Today, these are hospitals, physician practices, clinics, integrated
delivery systems, and health plans, but new forms will unquestionably emerge.
Whatever those forms, care that is responsive to patient needs and makes consistent
use of the best evidence requires far more conscious and careful organization
than we find today.
Organizations will need to negotiate successfully six major challenges. The
first is to redesign care processes to serve more effectively the needs of the
chronically ill for coordinated, seamless care across settings and clinicians and
over time. The use of tools to organize and deliver care has lagged far behind
biomedical and clinical knowledge. A number of well-understood design principles,
drawn from other industries as well as some of today’s health care organizations,
could help greatly in improving the care that is provided to patients.
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12 CROSSING THE QUALITY CHASM
A second challenge is making effective use of information technologies to
automate clinical information and make it readily accessible to patients and all
members of the care team. An improved information infrastructure is needed to
establish effective and timely communication among clinicians and between patients
and clinicians.
A third challenge is to manage the growing knowledge base and ensure that
all those in the health care workforce have the skills they need. Making use of
new knowledge requires that health professionals develop new skills or assume
new roles. It requires that they use new tools to access and apply the expanding
knowledge base. It also requires that training and ongoing licensure and certification
reflect the need for lifelong learning and evaluation of competencies.
A fourth challenge for organizations is coordination of care across patient
conditions, services, and settings over time. Excellent information technologies
and well-thought-out and -implemented modes of ongoing communication can
reduce the need to craft laborious, case-by-case strategies for coordinating patient
care.
A fifth challenge is to continually advance the effectiveness of teams. Team
practice is common, but the training of health professionals is typically isolated
by discipline. Making the necessary changes in roles to improve the work of
teams is often slowed or stymied by institutional, labor, and financial structures,
and by law and custom.
Finally, all organizations—whether or not health care related—can improve
their performance only by incorporating care process and outcome measures into
their daily work. Use of such measures makes it possible to understand the
degree to which performance is consistent with best practices, and the extent to
which patients are being helped.
Recommendation 7: The Agency for Healthcare Research and Quality
and private foundations should convene a series of workshops
involving representatives from health care and other industries and
the research community to identify, adapt, and implement state-ofthe-
art approaches to addressing the following challenges:
• Redesign of care processes based on best practices
• Use of information technologies to improve access to clinical
information and support clinical decision making
• Knowledge and skills management
• Development of effective teams
• Coordination of care across patient conditions, services, and
settings over time
• Incorporation of performance and outcome measurements for
improvement and accountability
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EXECUTIVE SUMMARY 13
Establishing a New Environment for Care
To enable the profound changes in health care recommended in this report,
the environment of care must also change. The committee believes the current
environment often inhibits the changes needed to achieve quality improvement.
Two types of environmental change are needed:
• Focus and align the environment toward the six aims for improvement.
To effect this set of changes, purchasers and health plans, for example, should
eliminate or modify payment practices that fragment the care system, and should
establish incentives designed to encourage and reward innovations aimed at improving
quality. Purchasers and regulators should also create precise streams of
accountability and measurement reflecting achievements in the six aims. Moreover,
efforts should be made to help health care consumers understand the aims,
why they are important, and how to interpret the levels of performance of various
health care systems.
• Provide, where possible, assets and encouragement for positive change.
For example, national funding agencies could promote research on new designs
for the care of priority conditions, state and national activities could be undertaken
to facilitate the exchange of best practices and shared learning among
health care delivery systems, and a national system for monitoring progress toward
the six aims for improvement could help improvement efforts remain on
track.
Such environmental changes need to occur in four major areas: the infrastructure
that supports the dissemination and application of new clinical knowledge
and technologies, the information technology infrastructure, payment policies,
and preparation of the health care workforce.
Changes will also be needed in the quality oversight and accountability
processes of public and private purchasers. This issue is not addressed here. The
IOM will be issuing a separate report on federal quality measurement and improvement
programs in Fall 2002. In addition, the National Quality Forum has an
extensive effort under way to develop a national framework for quality measurement
and accountability and will be issuing a report in Summer 2001.
Applying Evidence to Health Care Delivery
In the current health care system, scientific knowledge about best care is not
applied systematically or expeditiously to clinical practice. An average of about
17 years is required for new knowledge generated by randomized controlled trials
to be incorporated into practice, and even then application is highly uneven
(Balas and Boren, 2000). The extreme variability in practice in clinical areas in
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14 CROSSING THE QUALITY CHASM
which there is strong scientific evidence and a high degree of expert consensus
about best practices indicates that current dissemination efforts fail to reach many
clinicians and patients, and that there are insufficient tools and incentives to
promote rapid adoption of best practices. The time has come to invest in the
creation of a more effective infrastructure for the application of knowledge to
health care delivery.
Recommendation 8: The Secretary of the Department of Health
and Human Services should be given the responsibility and necessary
resources to establish and maintain a comprehensive program
aimed at making scientific evidence more useful and accessible to
clinicians and patients. In developing this program, the Secretary
should work with federal agencies and in collaboration with professional
and health care associations, the academic and research communities,
and the National Quality Forum and other organizations
involved in quality measurement and accountability.
It is critical that leadership from the private sector, both professional and
other health care leaders and consumer representatives, be involved in all aspects
of this effort to ensure its applicability and acceptability to clinicians and patients.
The infrastructure developed through this public- and private-sector partnership
should focus initially on priority conditions and include:
• Ongoing analysis and synthesis of the medical evidence
• Delineation of specific practice guidelines
• Identification of best practices in the design of care processes
• Enhanced dissemination efforts to communicate evidence and guidelines
to the general public and professional communities
• Development of decision support tools to assist clinicians and patients in
applying the evidence
• Establishment of goals for improvement in care processes and outcomes
• Development of quality measures for priority conditions
More systematic approaches are needed to analyze and synthesize medical
evidence for both clinicians and patients. Far more sophisticated clinical decision
support systems will be required to assist clinicians and patients in selecting
the best treatment options and delivering safe and effective care. Many promising
private- and public-sector activities now under way can serve as excellent
models and building blocks for a more expanded effort. In particular, the Cochrane
Collaboration and the Agency for Healthcare Research and Quality’s
Evidence-Based Practice Centers represent important efforts to synthesize medical
evidence. The growth of the Internet has also opened up many new opportunities
to make evidence more accessible to clinicians and consumers. The efforts
of the National Library of Medicine to facilitate access to the medical literature
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EXECUTIVE SUMMARY 15
by both consumers and health care professionals and to design Web sites that
organize large amounts of information on particular health needs are particularly
promising.
The development of a more effective infrastructure to synthesize and organize
evidence around priority conditions would also offer new opportunities to
enhance quality measurement and reporting. A stronger and more organized
evidence base should facilitate the adoption of best practices, as well as the
development of valid and reliable quality measures for priority conditions that
could be used for both internal quality improvement and external accountability.
Using Information Technology
Health care delivery has been relatively untouched by the revolution in information
technology that has been transforming nearly every other aspect of society.
The majority of patient and clinician encounters take place for purposes of
exchanging clinical information: patients share information with clinicians about
their general health, symptoms, and concerns, and clinicians use their knowledge
and skills to respond with pertinent medical information, and in many cases
reassurance. Yet it is estimated that only a small fraction of physicians offer email
interaction, a simple and convenient tool for efficient communication, to
their patients (Hoffman, 1997).
The meticulous collection of personal health information throughout a patient’s
life can be one of the most important inputs to the provision of proper care.
Yet for most individuals, that health information is dispersed in a collection of
paper records that are poorly organized and often illegible, and frequently cannot
be retrieved in a timely fashion, making it nearly impossible to manage many
forms of chronic illness that require frequent monitoring and ongoing patient
support.
Although growth in clinical knowledge and technology has been profound,
many health care settings lack basic computer systems to provide clinical information
or support clinical decision making. The development and application of
more sophisticated information systems is essential to enhance quality and improve
efficiency.
The Internet has enormous potential to transform health care through information
technology applications in such areas as consumer health, clinical care,
administrative and financial transactions, public health, professional education,
and biomedical and health services research (National Research Council, 2000).
Many of these applications are currently within reach, including remote medical
consultation with patients in their homes or offices; consumer and clinician access
to the medical literature; creation of “communities” of patients and clinicians
with shared interests; consumer access to information on health plans,
participating providers, eligibility for procedures, and covered drugs in a formulary;
and videoconferencing among public health officials during emergency
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16 CROSSING THE QUALITY CHASM
situations. Other applications are more experimental, such as simulation of surgical
procedures; consultation among providers involving manipulation of digital
images; and control of experimental equipment, such as electron microscopes.
The Internet also supports rising interest among consumers in information
and convenience in all areas of commerce, including health care. The number of
Americans who use the Internet to retrieve health-related information is estimated
to be about 70 million (Cain et al., 2000). Consumers access health-related
Web sites to research an illness or disease; seek information on nutrition and
fitness; research drugs and their interactions; and search for doctors, hospitals,
and online medical support groups.
The committee believes information technology must play a central role in
the redesign of the health care system if a substantial improvement in quality is to
be achieved over the coming decade. Automation of clinical, financial, and
administrative transactions is essential to improving quality, preventing errors,
enhancing consumer confidence in the health system, and improving efficiency.
Central to many information technology applications is the automation of
patient-specific clinical information. A fully electronic medical record, including
all types of patient information, is not needed to achieve many, if not most, of the
benefits of automated clinical data. Sizable benefits can be derived in the near
future from automating certain types of data, such as medication orders. Efforts
to automate clinical information date back several decades, but progress has been
slow (Institute of Medicine, 1991), in part because of the barriers and risks
involved. An important constraint is that consumers and policy makers share
concerns about the privacy and confidentiality of these data (Cain et al., 2000;
Goldman, 1998). The United States also lacks national standards for the capture,
storage, communication, processing, and presentation of health information
(Work Group on Computerization of Patient Records, 2000).
The challenges of applying information technology to health care should not
be underestimated. Health care is undoubtedly one of the most, if not the most,
complex sector of the economy. The number of different types of transactions
(i.e., patient needs, interactions, and services) is very large. Sizable capital
investments and multiyear commitments to building systems will be required.
Widespread adoption of many information technology applications will require
behavioral adaptations on the part of large numbers of patients, clinicians, and
organizations. Yet, the Internet is rapidly transforming many aspects of society,
and many health-related processes stand to be reshaped as well.
In the absence of a national commitment and financial support to build a
national health information infrastructure, the committee believes that progress
on quality improvement will be painfully slow. The automation of clinical,
financial, and administrative information and the electronic sharing of such information
among clinicians, patients, and appropriate others within a secure environment
are critical if the 21st-century health care system envisioned by the
committee is to be realized.
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EXECUTIVE SUMMARY 17
Recommendation 9: Congress, the executive branch, leaders of
health care organizations, public and private purchasers, and health
informatics associations and vendors should make a renewed national
commitment to building an information infrastructure to support
health care delivery, consumer health, quality measurement
and improvement, public accountability, clinical and health services
research, and clinical education. This commitment should lead to
the elimination of most handwritten clinical data by the end of the
decade.
Aligning Payment Policies with Quality Improvement
Current payment methods do not adequately encourage or support the provision
of quality health care. Although payment is not the only factor that influences
provider and patient behavior, it is an important one.
All payment methods affect behavior and quality. For example, fee-forservice
payment methods for physicians and hospitals raise concerns about potential
overuse of services—the provision of services that may not be necessary
or may expose the patient to greater potential harm than benefit. On the other
hand, capitation and per case payment methods for physicians and hospitals raise
questions about potential underuse—the failure to provide services from which
the patient would likely benefit. Indeed, no payment method perfectly aligns
financial incentives with the goal of quality improvement for all health care
decision makers, including clinicians, hospitals, and patients. This is one reason
for the widespread interest in blended methods of payment designed to counter
the disadvantages of one payment method with the advantages of another.
Too little attention has been paid to the careful analysis and alignment of
payment incentives with quality improvement. The current health care environment
is replete with examples of payment policies that work against the efforts of
clinicians, health care administrators, and others to improve quality. The following
example, presented at an Institute of Medicine workshop on payment and
quality held on April 24, 2000,2 illustrates how payment policies can work against
the efforts of clinicians, health care administrators, and others to improve quality:
A physician group paid primarily on a fee-for-service basis instituted a new
program to improve blood sugar control for diabetic patients. Specifically, pilot
studies suggested that tighter diabetic management could decrease hemoglobin
A1c levels by 2 percentage points for about 40 percent of all diabetic patients
managed by the physician group. Data from two randomized controlled trials
demonstrated that better sugar controls should translate into lower rates of retinopathy,
nephropathy, peripheral neurological damage, and heart disease. The
2 This case study has been excerpted from a paper prepared by and presented at the IOM workshop
by Brent James, Intermountain Health Care, Salt Lake City, Utah, April 2000.
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18 CROSSING THE QUALITY CHASM
savings in direct health care costs (i.e., reduced visits and hospital episodes)
from avoided complications have been estimated to generate a net savings of
about $2,000 per patient per year, on average, over 15 years. Across the more
than 13,000 diabetic patients managed by the physician group, the project had
the potential to generate over $10 million in net savings each year. The project
was costly to the medical group in two ways. First, expenses to conduct the
project, including extra clinical time for tighter management, fell to the physician
group. Second, over time, as diabetic complication rates fell, the project
would reduce patient visits and, thus, revenues as well. But the savings from
avoided complications would accrue to the insurer or a self-funded purchaser.
The committee believes that all purchasers, both public and private, should carefully
reexamine their payment policies.
Recommendation 10: Private and public purchasers should examine
their current payment methods to remove barriers that currently
impede quality improvement, and to build in stronger incentives
for quality enhancement.
Payment methods should:
• Provide fair payment for good clinical management of the types of patients
seen. Clinicians should be adequately compensated for taking good care of
all types of patients, neither gaining nor losing financially for caring for sicker
patients or those with more complicated conditions. The risk of random incidence
of disease in the population should reside with a larger risk pool, whether
that be large groups of providers, health plans, or insurance companies.
• Provide an opportunity for providers to share in the benefits of quality
improvement. Rewards should be located close to the level at which the reengineering
and process redesign needed to improve quality are likely to take
place.
• Provide the opportunity for consumers and purchasers to recognize quality
differences in health care and direct their decisions accordingly. In particular,
consumers need to have good information on quality and the ability to use that
information as they see fit to meet their needs.
• Align financial incentives with the implementation of care processes based
on best practices and the achievement of better patient outcomes. Substantial
improvements in quality are most likely to be obtained when providers are highly
motivated and rewarded for carefully designing and fine-tuning care processes to
achieve increasingly higher levels of safety, effectiveness, patient-centeredness,
timeliness, efficiency, and equity.
• Reduce fragmentation of care. Payment methods should not pose a
barrier to providers’ ability to coordinate care for patients across settings and
over time.
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EXECUTIVE SUMMARY 19
To assist purchasers in the redesign of payment policy based on these fundamental
principles, a vigorous program of pilot testing and evaluating alternative
design options should be pursued.
Recommendation 11: The Health Care Financing Administration
and the Agency for Healthcare Research and Quality, with input
from private payers, health care organizations, and clinicians,
should develop a research agenda to identify, pilot test, and evaluate
various options for better aligning current payment methods with
quality improvement goals.
Examples of possible means of achieving this end include blended methods
of payment for providers, multiyear contracts, payment modifications to encourage
use of electronic interaction among clinicians and between clinicians and
patients, risk adjustment, bundled payments for priority conditions, and alternative
approaches for addressing the capital investments needed to improve quality.
Preparing the Workforce
A major challenge in transitioning to the health care system of the 21st
century envisioned by the committee is preparing the workforce to acquire new
skills and adopt new ways of relating to patients and each other. At least three
approaches can be taken to support the workforce in this transition. One is to
redesign the way health professionals are trained to emphasize the aims for
improvement set forth earlier, including teaching evidence-based practice and
using multidisciplinary approaches. Second is to modify the ways in which
health professionals are regulated to facilitate the needed changes in care delivery.
Scope-of-practice acts and other workforce regulations need to allow for
innovation in the use of all types of clinicians to meet patient needs in the most
effective and efficient way possible. Third is to examine how the liability system
can constructively support changes in care delivery while remaining part of an
overall approach to accountability for health care professionals and organizations.
All three approaches are important and require additional study.
Recommendation 12: A multidisciplinary summit of leaders within
the health professions should be held to discuss and develop strategies
for (1) restructuring clinical education to be consistent with the
principles of the 21st-century health system throughout the continuum
of undergraduate, graduate, and continuing education for
medical, nursing, and other professional training programs; and
(2) assessing the implications of these changes for provider credentialing
programs, funding, and sponsorship of education programs
for health professionals.
Crossing the Quality Chasm: A New Health System for the 21st Century
Copyright National Academy of Sciences. All rights reserved.
20 CROSSING THE QUALITY CHASM
Recommendation 13: The Agency for Healthcare Research and
Quality should fund research to evaluate how the current regulatory
and legal systems (1) facilitate or inhibit the changes needed for
the 21st-century health care delivery system, and (2) can be modified
to support health care professionals and organizations that seek
to accomplish the six aims set forth in Chapter 2.
SUMMARY
The changes needed to realize a substantial improvement in health care
involve the health care system as a whole. The new rules set forth in this report
will affect the role, self-image, and work of front-line doctors, nurses, and all
other staff. The needed new infrastructures will challenge today’s health care
leaders—both clinical leaders and management. The necessary environmental
changes will require the interest and commitment of payers, health plans, government
officials, and regulatory and accrediting bodies. New skills will require
new approaches by professional educators. The 21st-century health care system
envisioned by the committee—providing care that is evidence-based, patientcentered,
and systems-oriented—also implies new roles and responsibilities for
patients and their families, who must become more aware, more participative,
and more demanding in a care system that should be meeting their needs. And all
involved must be united by the overarching purpose of reducing the burden of
illness, injury, and disability in our nation.
American health care is beset by serious problems, but they are not intractable.
Perfect care may be a long way off, but much better care is within our
grasp. The committee envisions a system that uses the best knowledge, that is
focused intensely on patients, and that works across health care providers and
settings. Taking advantage of new information technologies will be an important
catalyst to moving us beyond where we are today. The committee believes that
achieving such a system is both possible and necessary.
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Crossing the Quality Chasm: A New Health System for the 21st Century
Copyright National Academy of Sciences. All rights reserved.