From The New England Journal of Medicine
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The Institute of Medicine's Committee on Quality of
Care in America has issued its second and final report,
Crossing the Quality Chasm: A New System for the 21st
Century. The committee has done an excellent job, but its report
is as noteworthy for what it omits as for what it says. It
identifies and analyzes with great in and clarity
deficiencies in the quality of our present medical care delivery
system, and it is persuasive in outlining how the system ought to
work. But it does not say much about the fundamental causes of
those deficiencies. Nor does it address the central question: Can
we really ``cross the quality chasm'' in medical care without
major reform of the whole system?
The committee's earlier report, To Err Is Human: Building a
Safer System (Linda T. Kohn, Janet M. Corrigan, and Molla
S. Donaldson, eds. Washington, D.C.: National Academy Press,
1999), was released in the fall of 1999. The report created an
immediate sensation with its estimate of 44,000 to 98,000 deaths
annually due to errors in hospital care, which it said were due
more to error-prone institutional systems than to mistakes by
individual care workers. Predictably, the report launched
a spate of governmental and private projects to study the cause
and reporting of such events and the means of preventing them.
The committee's second report moves beyond the initial focus on
medical mishaps and takes a broader look at other problems with
the quality of care. It suggests, in general terms, a
variety of ways in which the effectiveness and efficiency of
care should be improved. The report is thoughtful,
painstaking, and totally reasonable, and yet it has attracted
much less attention than its predecessor.
Why hasn't Crossing the Quality Chasm had more impact? I think
there are several reasons. First, it contains nothing nearly so
sensational as the cl made in the first report that tens of
thousands of deaths are caused by medical errors. Second, most of
the problems in our care system that are identified in the
second report have been widely recognized for some time. For
example, as important causes of reduced quality, the report cites
fragmentation of responsibility and lack of continuity in the
care of individual patients. It describes the lack of
coordination and communication among providers and between
providers and patients. And it faults the system for not
sufficiently employing electronic-information technology. It
criticizes the system's failure to rely on evidence-based
guidelines as standards for practice and faults providers for
failing systematically to record and report outcomes. It also
finds the current care delivery system insufficiently
responsive to the needs of patients and not sufficiently
accountable to payers or patients. All these problems are
certainly important. But they have been described before, and
this report offers little that is substantive in the way of new
and practical ways to solve them. This omission is probably the
chief reason for the lukewarm reception given this study.
Granted, the study calls for greater attention to the need for
improving the quality of care. It calls for workshops, more
research and education, a reexamination of current payment
methods, and many other general initiatives of this kind. It
urges Congress to establish a `` Care Quality Innovation
Fund'' to support projects on the improvement of quality, and it
estimates that something ``on the order of $1 billion over 3 to 5
years'' would be needed. The report also suggests that the Agency
for care Research and Quality should identify ``not fewer
than 15 priority conditions'' and should convene a meeting to
``develop strategies, goals, and action plans for achieving
substantial improvements in quality in the next 5 years for each
of the priority conditions.'' But these recommendations, however
well intended, do not go to the heart of the matter, and they
offer little in the way of fundamental solutions.
In fairness to the committee's meticulous and scholarly work, I
should acknowledge that it did not set out to ``recommend
specific organizational approaches to achieve the s set
forth.'' The committee was no doubt asked instead to concentrate
on general s, to suggest principles and guidelines for
improving the quality of care, rather than confront the
controversies that would result from suggesting basic reforms in
the organization of the system.
So, what is wrong with the organization of our present
care system that accounts for its problems with quality? In my
view, the central problem is that the system is being directed
mainly by market forces, which are as ill suited to the
achievement of the quality goals envisioned in this report as
they are to the attainment of the equally important goals of cost
control and universal access. The notion that care is
basically an economic commodity represents a radical change from
earlier assumptions about the social purpose of care. It
has gained currency only during the past 10 to 20 years, but it
has already produced public policies that are rapidly converting
our care system into a vast competitive marketplace. We
now have a large and growing sector of care delivery
controlled by private business, to a degree unmatched in any
other nation.
As is the case with other markets in the U.S. economy, the part
of medical service that is privately insured is distributed
primarily according to the ability to pay. The multiple
independent private insurers (mostly investor-owned) constantly
seek to reduce their payments to providers and their financial
obligations to patients. Similar economic pressures and
incentives are at work in the governmental half of the system. In
all parts of the system, the providers of care (i.e., hospitals
and physicians) see themselves as competing businesses struggling
to survive in a hostile economic climate, and they act
accordingly. The predictable result is a fragmented, inefficient,
and expensive system that neglects those who cannot pay, scrimps
on the support of public services and medical education,
and has all of the deficiencies in quality that are so well
described and analyzed in this report. It is a system that
responds more to the financial interests of investors, managers,
and employers than to the medical needs of patients.
The best way to achieve substantial improvements in the quality
of care, I believe, would be to change the system. Unfortunately,
the committee does not say that. It concentrates instead on
suggestions for modifying behavior in the current system.
However, the prospects for persuading participants caught up in
the present commercially dominated system to behave in a more
socially responsible way are not very good. I suspect most
members of the committee know that but that they felt constrained
by the terms of their charge to focus on incremental improvements
in the quality of the present system. Given those constraints,
they have done all that could have been expected, and they have
done it very well. A more definitive approach to the problems
they address must await major reforms in the care system.
Arnold S. Relman, M.D.
Copyright © 2001 Massachusetts Medical Society. All rights
reserved. The New England Journal of Medicine is a registered
trademark of the MMS.
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Review
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"...Committees strong findings and bold vision will
give new momentum to the processes of change in American
care." -- Institute for care Improvement website
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