21st Century

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QMHC Book Review

QUALITY MANAGEMENT IN HEALTH CARE/SUMMER 2002

Crossing the Quality Chasm: A New Health System for the 21st Century

Reviewed by Jean Gayton Carroll, PhD Editor Quality Management in Health Care Chicago, Illinois

Quality Management in Health Care, 2002, 10(4), 60–61 © 2002 Aspen Publishers, Inc.

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Crossing the Quality Chasm: A New Health System for the 21st Century, by the Committee on Quality of Health Care in America of the Institute of Medicine. Washington, DC: Institute of Medicine. National Academy Press, 2001. 335 pages, hardcover, $44.95. In 1998 the Institute of Medicine formed its Committee on the Quality of Health Care. The committee’s mission was to identify strategies for achieving a substantial improvement in the quality of health care delivered to Americans. The committee’s first report, To Err is Human: Building a Safer Health System, released in 1999, generated widespread interest and spurred a great deal of follow-up research and discussion on patient safety issues. This, the second and final report of the committee, addresses strategies for change not only in the health care delivery system per se but also in the structures and processes of the environment in which health care organizations and their workforces function. This expansive project was planned and carried out under the leadership of a blue ribbon committee chaired by William C. Richardson, President and CEO of the Kellogg Foundation. Execution of the project was the work of another stellar group, the study staff, directed by Janet Corrigan and supported by the auxiliary staff. The report was reviewed by a panel of expert specialists. Thanks to its good organization, starting with the table of contents, what could have been a cumbersome document turns out to be an easy read. A helpful feature in the table of contents is the display, within each chapter reference, of the page numbers on which major topics are addressed. Organizing and guiding the report’s content are 13 committee recommendations, couched in fairly general terms. These recommendations are operationalized through more

QMHC Book Review

concretely phrased “aims” and “rules” in the course of the report. In savvy journalistic style, the writers lay out six aims for improvement in the system: that health care be safe, effective, patient-oriented, timely, efficient, and equitable. The need for the specific improvements is illustrated with a case history. Then they formulate 10 “rules”—the observance of which should help to resolve the perceived problems. To get the resolution process started, they propose that the Agency for Healthcare Research and Quality identify and focus on a list of common chronic health conditions (the “priority conditions”) for which state-ofthe-art care and treatment processes will be developed and disseminated. The committee recognizes that implementing system redesign requires developing effective organizational structures and processes. The reengineering principles of system design used in other industries and how they could be applied to health care are wellpresented. The role of the leader in planning and implementing change is thoughtfully addressed. Especially well done is the chapter on “Applying Evidence to Health Care Delivery.” The authors go into detail on such aspects of evidence-based practice as synthesizing clinical findings, using computer-based clinical decision support systems, making information available on the Internet, and defining quality measures. In another chapter, the related subject of the role of information technology in the twenty-first century delivery system is discussed. The authors argue for the development of a comprehensive national health information infrastructure, while acknowledging the related need for a reliable apparatus to protect pri-

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vacy. However, their critical comment that, “Only a fraction of clinicians offer e-mail as a communication option to patients,” seems to ignore the weakness of current privacy safeguards and the fact that access to computers is by no means universal. In a chapter that could serve well as one of the readings for a graduate course in health system finance or organizational analysis, the committee analyzes payment policies, past and present, and their impact on the quality of care. Mechanisms to improve the way payment methods reward quality care are presented and evaluated. In the final chapter, the committee addresses the subject of preparing the health care workforce for the future. The authors make the point that health care workforce planning must become comprehensive in scope, rather than focused on such subjects as discipline-specific ratios or existing organizational models. Their agenda on workforce planning would address key issues in training and education, legal and regulatory processes, and workforce supply. The report of the Technical Panel on the State of Quality to the Quality of Health Care in America Committee is included as Appendix A. Appendix B is a chapter by Paul Plsek entitled, “Redesigning Health Care with Insights from the Science of Complex Adaptive Systems,” a fascinating discussion of how applying the basic principles of complexity thinking might aid in the redesigning effort. Each chapter of the book has an ample bibliography. This valuable and well-written report can be recommended to anyone, whether clinician or nonclinician, who is involved in the development of health care delivery system strategy.