1

Crossing the Quality Chasm

Second ReportSecond Report

Committee onCommittee onQuality of Health Care Quality of Health Care

in Americain America

To order: www.nap.eduTo order: www.nap.edu

2

Studies Documenting the “Quality Gap”

Literature reviews conducted by RANDLiterature reviews conducted by RAND Over 70 studies documenting quality Over 70 studies documenting quality

shortcomingsshortcomings Large gaps between the care people should receive Large gaps between the care people should receive

and the care they do receiveand the care they do receive true for preventive, acute and chronictrue for preventive, acute and chronic across all health care settingsacross all health care settings all age groups and geographic areas all age groups and geographic areas

(Schuster et.al., MMFQ,1998 ;updated 2000)(Schuster et.al., MMFQ,1998 ;updated 2000)

3

Medical Errors are a Serious Problem

Over 35 studies documenting patient Over 35 studies documenting patient safety concernssafety concerns

Tens of thousands of Americans are Tens of thousands of Americans are seriously harmedseriously harmed

Most errors occur because of system Most errors occur because of system failures failures

4

Major Forces Influencing Health Care

Expanding Knowledge BaseExpanding Knowledge Base

““Current practice depends upon the clinical Current practice depends upon the clinical decision-making capacity and reliability of decision-making capacity and reliability of autonomous individual practitioners, for classes of autonomous individual practitioners, for classes of problems that routinely exceed the bounds of problems that routinely exceed the bounds of unaided human cognition.”unaided human cognition.”

Daniel R. Masys, M.D.Daniel R. Masys, M.D. 2001 IOM Annual Meeting2001 IOM Annual Meeting

5

Major Forces Influencing Health Care

Chronic Care NeedsChronic Care Needs

40% of population have one or more chronic 40% of population have one or more chronic conditionsconditions

Chronic conditions account for more than two-Chronic conditions account for more than two-thirds of health care expenditures thirds of health care expenditures (RWJF, 1996)(RWJF, 1996)

80/20 Rule: Limited number of conditions account 80/20 Rule: Limited number of conditions account for most of these health care expendituresfor most of these health care expenditures

6

Delivery System Increasingly Inadequate

Dearth of clinical programs with necessary infrastructure Dearth of clinical programs with necessary infrastructure

Chronic Care Delivery Model (Wagner, 1996)Chronic Care Delivery Model (Wagner, 1996)

Systematic approachSystematic approach

Attention to information and self-management needs of Attention to information and self-management needs of patientspatients

Multi-disciplinary teamsMulti-disciplinary teams

Coordination across settings and clinicians, and over timeCoordination across settings and clinicians, and over time

Unfettered and timely access to clinical information Unfettered and timely access to clinical information

7

Committee’s Conclusion

The American health care delivery system The American health care delivery system is in need of fundamental change. The is in need of fundamental change. The current care systems cannot do the job. current care systems cannot do the job. Trying harder will not work. Changing Trying harder will not work. Changing systems of care will. systems of care will.

8

Five Part Agenda for Change

Commit to six aims for improvement Commit to six aims for improvement

Adopt “10 rules” to guide the redesign of careAdopt “10 rules” to guide the redesign of care

Implement effective organizational supportsImplement effective organizational supports

Focus efforts on “priority conditions”Focus efforts on “priority conditions”

Create environment that fosters improvementCreate environment that fosters improvement

9

Aims For Improvement

SafeSafe

EffectiveEffective

Patient-centeredPatient-centered

TimelyTimely

EfficientEfficient

EquitableEquitable

10

10 Simple Rules

Continuous Healing Continuous Healing RelationshipsRelationships

Evidence-based Evidence-based DecisionsDecisions

Customized CareCustomized Care Patient is the Source Patient is the Source

of Controlof Control Shared KnowledgeShared Knowledge

TransparencyTransparency Safety is a System Safety is a System

PropertyProperty Cooperation Among Cooperation Among

Clinicians Clinicians Needs are AnticipatedNeeds are Anticipated Waste is Continuously Waste is Continuously

DecreasedDecreased

11

Organizational Supports to…

-- redesign care processesredesign care processes

-- invest in information technologyinvest in information technology

- - management of knowledge and skillsmanagement of knowledge and skills

- - develop effective multidisciplinary teamsdevelop effective multidisciplinary teams

- - coordinate carecoordinate care

-- measure and improve performance and measure and improve performance and outcomes outcomes

12

Focus on Priority Conditions

AHRQ should identify 15 priority conditionsAHRQ should identify 15 priority conditions

Congress should establish $1B Innovation Congress should establish $1B Innovation Fund Fund

There should be substantial improvements in There should be substantial improvements in quality for priority conditions over the next 5 quality for priority conditions over the next 5 yearsyears

13

Align Environmental Forces

Four Critical Forces: Four Critical Forces:

1. 1. Information TechnologyInformation Technology

2. 2. PaymentPayment

3.3. Clinical Knowledge Clinical Knowledge

4.4. Professional WorkforceProfessional Workforce

14

Align Environmental Forces

Information TechnologyInformation Technology

Call for renewed national commitment to building an Call for renewed national commitment to building an information infrastructure to support care delivery, information infrastructure to support care delivery, consumer health, public accountability, public consumer health, public accountability, public health, research, and clinical educationhealth, research, and clinical education. .

Goal: elimination of most handwritten clinical data Goal: elimination of most handwritten clinical data by 2010by 2010

15

Aligning Environmental Forces

PaymentPayment

Current payment policies are complex and Current payment policies are complex and contradictory, and often work contradictory, and often work againstagainst efforts to efforts to improve quality. improve quality.

Payment methods should provide an opportunity for Payment methods should provide an opportunity for providers to share in the benefits of quality providers to share in the benefits of quality improvementimprovement

16

Aligning Environmental Forces

Clinical KnowledgeClinical Knowledge

Focusing on priority conditions, a public - private partnership Focusing on priority conditions, a public - private partnership should:should:- synthesize evidence - synthesize evidence - identify best practices in care delivery- identify best practices in care delivery- communicate evidence to public and professionals - communicate evidence to public and professionals - develop and apply decision support tools- develop and apply decision support tools- establish goals for improvement in care processes- establish goals for improvement in care processes- develop core sets of quality measures- develop core sets of quality measures

17

Aligning Environmental Forces

Professional WorkforceProfessional Workforce

A multidisciplinary summit of leaders within the A multidisciplinary summit of leaders within the health professions should be held to discuss and health professions should be held to discuss and develop strategies for develop strategies for

-- restructuring clinical education at all levelsrestructuring clinical education at all levels

-- assessing the implications of change for assessing the implications of change for credentialing programscredentialing programs

18

Crossing the Quality Chasm: Next Steps

2001 - 2003 2001 - 2003 Project AreasProject Areas

Priority Conditions Priority Conditions Reports to Monitor and Track QualityReports to Monitor and Track Quality Health Professions SummitHealth Professions Summit Nursing Work Environment and Patient SafetyNursing Work Environment and Patient Safety 11stst Annual Chasm Summit Annual Chasm Summit Related IT InitiativeRelated IT Initiative