A New Health System and Its Quality Agenda / Commentaries / Reply

SUMMARY * THIS ARTICLE reviews recent work on healthcare quality, highlights findings and recommendations of the Institute of Medicine (IOM) reports on medical errors and quality, and describes response to the reports to date. In it, Detmer, chair of the roll's Board of Health Care Services and a member of its Committee on Quality of Health Care in America, identifies implications of the reports for healthcare delivery organizations and professionals and outlines ways organizations and professionals can improve the six dimensions of patient quality defined by the iom. Sustained efforts at the point of care and in policy development are needed to overcome cultural inertia, realign incentives, support innovation, and address technical and human resource issues. Success requires that healthcare executives embrace the goal of transforming the healthcare sector into a true system and provide leadership for their organizations and communities in this most fundamental of challenges for twenty-first century healthcare. [W]e cannot wait any longer to address the serious quality of care challenges facing our nation. A comprehensive and strong approach is needed now. -Kenneth I. Shine, M.D., President, Institute of Medicine You must be the change you wish to see. -M. Chandi IT IS TIME for profound changes in healthcare. Despite the good results that the U.S. health system produces for many individual patients, it could and should do better. Given available knowledge and technology as well as the vast resources devoted to the health sector in this country, patients may reasonably expect to receive consistently high-level performance from healthcare organizations and professionals. Yet, we observe large quality variations across providers, a lower population health status than other nations despite higher spending per capita, long lag times in dissemination of new knowledge, and missed opportunities for critically ill patients to participate in clinical trials (thereby reducing potential gain for individuals as well as for contributions to medical knowledge) (Anderson 1997; Balas and Boran 2000; Chassin et al. 1986; Lara et al. 2001; Schuster, McGlynn, and Brook 1998; Weiner et al. 1995). Moreover, the healthcare sector faces growing pressures that will further tax its capabilities and inhibit its ability to meet growing consumer demands. For example, recent workforce shortages among some health professional disciplines (e.g., pharmacists and nurses) are forcing provider organizations in some markets to subject patients to long waiting times or to curtail services (Appleby 2001; Jaklevic and Lovern 2000). Healthcare organizations were designed to serve and health professionals were trained to treat acute care, but today chronic care is the predominant need, with population health management not far behind. Obtaining and using information technology continues to be problematic for healthcare organizations, despite success with this area in other industries. In the name of privacy, taking full advantage of information technology may be hampered by restrictive regulation and legislation that limits access to patient data for legitimate research. In addition, reimbursement and other incentive mechanisms have not kept pace with the changing practice of medicine. Fundamental changes are needed in healthcare delivery processes, payment mechanisms, information infrastructure, patient communications, and health education of the public. Without such changes, we are likely to experience a mixture of substantial cost escalation, service deterioration, irrational decision making, uneven outcomes in the treatment of individuals, a demoralized health workforce, marginally satisfied patients and loved ones, and little improvement in the health of our population. These factors signal the compelling need to attend to the complicated task of building a true healthcare system. Needless to say, this represents a formidable challenge in light of the existing structure of healthcare resources, the nation's tradition of pluralism and preference for incremental market-based programs blended with an array of internal and external regulations, and the culture of autonomy that has heretofore pervaded the profession of medicine. …