Crossing the Quality Chasm

Janet Corrigan

Institute of Medicine

The Quality of Care in America Project was started about three years ago. The final report, Crossing the Quality Chasm, is a comprehensive review of the overall quality of the health care system, including an assessment of its safety and effectiveness and recommendations for a comprehensive strategy for improvement (IOM, 2001).

The first step in the project was a review of the literature by RAND. About 70 RAND studies have documented serious deficiencies and large gaps between the care people should receive and the care they actually do receive. Deficiencies were observed in all health care settings, in all age groups, and in all geographic areas. In other words, the problems are systemic and permeate the health care industry; problems are just as prevalent in traditional indemnity, or less managed, settings as in managed care settings.

Two factors influence how we approach this problem. The first is the expanding knowledge base, which has clearly overwhelmed physicians and made it all but impossible for an individual physician to provide high quality care on his or her own. A tremendous number of publications now report the results of randomized controlled trials, and the number of new drugs and medical devices and the amount of information flowing into the marketplace has increased exponentially.

The second major factor is the need to care for people with chronic conditions. A very limited number of chronic conditions, 15 or 20, account for the bulk of health care problems. If we targeted those conditions, we could make tremendous progress and affect a sizable proportion of the health care delivery system, as well as of the general population.

The models that are most useful in caring for the chronically ill are very different from our current delivery system models. Providing high-quality care to chronically ill individuals requires well designed care processes focused on information that meets the self-management needs of patients and their families. Patients with chronic illnesses require multidisciplinary care from teams of physicians, nurses, social workers, aides, and others. Team care is essential for high quality care.

Our current health care delivery system, which is organized around professionals and types of institutions, grew out of a need to provide primarily acute care rather than chronic care. This is one kind of chasm we have to cross. The health care delivery system must be reorganized to meet the real needs of patients.

Few clinical programs have the infrastructure to provide a full complement of services to chronically ill patients. Some institutions have well defined programs for particular chronic conditions, but few institutions or systems provide high quality care for the full range of chronic conditions. In addition, we have a problem in “scaling up”—exemplary programs are not replicated throughout the industry.

The lack of standardized performance measures has made it difficult if not impossible to make cross-institutional comparisons. For example, we have no standardized performance or outcome measures that enable us to identify which providers deliver exemplary care for diabetes. This creates two problems. First, we do not know where the best performers are. Second, the best performers are not rewarded for their excellent work. We need much better systems for managing knowledge and for using information technology to help people make decisions, and we need unfettered, timely access to clinical information.

Today, physician groups often operate as “silos” (i.e., in isolation) without benefit of the kind of information, infrastructure, and support they need to provide high quality care. On the one hand, we can no longer deliver health care through a collection of silos. On the other hand, we do not have the organizational support that can, for example, pull together the latest knowledge and make it readily available to providers and patients. If one looks on the Web, one finds 42,000 sites on lupus and 75,000 sites on breast cancer. Individual patients and individual professionals are overloaded with huge amounts of undigestible, disorganized information.

The Committee on Quality of Health Care in America recommended that the redesign process be initiated by focusing on priority areas. Specifically, the Agency for Healthcare Research and Quality should identify 15 priority areas and define them clearly so that everyone involved can work toward the same goals. The committee also recommended that Congress establish a $1 billion innovation fund to seed improvement projects and that purchasers, health care organizations, and professional groups begin to develop action plans immediately for each priority area. The goal should be a 50-percent improvement in quality and safety in the next five years.

Meaningful innovation in the health care delivery system will require some significant changes in the overall health system environment. The Chasm report describes changes in four key areas: (1) the use of information technology; (2) payment policies; (3) the development of best practices, decision support tools, and an accountability system; and (4) professional education and training (IOM, 2001).

We have many examples of how information technology can improve quality. For instance, we know that computerized order entry by physicians can reduce adverse drug events by 50 to 60 percent—an enormous improvement in safety. Reminder systems for physicians or patients and their families have been found to be effective in getting people the right services at the right time. The Institute of Medicine is working on a strategic plan for an information technology initiative that should be ready soon.

Second, current payment policies are complex, contradictory, and often work against improving quality. For example, current payment systems do not reward investments in information technology. Unlike investments in medical technology, investments in information technology do not directly generate billable services under Medicare or third-party-payer, fee-for-service systems. Hence, providers may realize a faster return on investments in a new surgical suite than they will on investments in an automated order entry system. Unfortunately, errors in clinical care contribute to rising health care expenditures because patients injured as a result of errors typically require more services and readmissions.

The problem is compounded because the marketplace typically cannot discern differences in quality. Because we do not have good comparative data for measuring quality and performance in medical care and patient outcomes, health care organizations, medical groups, and hospital systems that have better outcomes do no better in the marketplace than providers with poorer outcomes. We must move very aggressively to address these payment concerns before they stifle the adoption of information technologies critical to improving the safety and quality of care.

Third, we need to translate the evidence base into best practices that can be implemented in care delivery and then communicate this information to health care professionals and patients. In addition, we must develop and implement decision-support tools to assist clinicians and patients in using the clinical knowledge base effectively. Last but not least, the Chasm report calls for “transparency”—an accountability system that emphasizes the release of comparative data.

Fourth, we must make major changes in the medical education system. Currently, many providers are trained in environments that are not “wired.” Students are not exposed to technology and decision-support systems, evidence-based practices are not emphasized, and learning is not focused on multidisciplinary teams. In other words, we are not training individuals to practice or acquire the kinds of skills they will need to be effective in the health care delivery system we are attempting to create. Changing the medical education system will require the active participation of professional associations, educational leaders, and professional licensing and certification groups.