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To err is human, to improve divine:
A New Health System for the 21st Century

From the March 7, 2001 issue

Last week, the Institute of Medicine's (IOM) Committee on the Quality of Health Care in America took center stage again after releasing its report, Crossing the Quality Chasm: A New Health System for the 21st Century, which outlines a set of performance expectations for health care. The IOM Committee's first report, To Err is Human: Building a Safer Health System, was a clear call to improve patient safety. This second report unfolds as a larger story and urges a strong national commitment to improve health care across six broad dimensions of quality: safety, effectiveness, responsiveness to patients, timeliness, efficiency, and equity. The authors suggest that the current health care system is failing to provide safe, high-quality care consistently to all Americans because it is poorly designed and relies on outdated systems. The report envisions a revamped system which is centered on patient needs and preferences, encourages teamwork among health care providers, and makes greater use of evidence-based approaches to care and information technology. To spur an overhaul, the authors recommend that Congress create an innovation fund of $1 billion over the next 3-5 years.

Although the report does not specify in detail the future design of health care, it establishes a framework for innovation on a local level by providing ten rules to promote the design of systems that are safe, effective, patient-centered, interdisciplinary, and efficient. For example, the authors say that patients should be able to count on receiving care based on the best available scientific knowledge, but there is strong evidence that this is frequently not the case. Thus, one rule covers the need for evidence-based decision making and suggests that care should not vary illogically from clinician to clinician. The report notes that clinicians operate in silos without the benefit of complete information about the patient's conditions, medical history, treatment received in other settings, or medications prescribed by other clinicians. So, another rule encourages cooperation among clinicians to exchange appropriate information and coordinate care.

The report stresses the need for all health care stakeholders to work together to redesign how care is delivered, with emphasis on chronic conditions and effective use of care teams and information technology. Health care remains relatively untouched by information technology that has transformed so many other aspects of society. Patient information is still dispersed on paper, poorly organized, often illegible, and difficult to retrieve. The authors recommend a renewed national commitment to building an information infrastructure to support health care and eliminate most handwritten clinical data (including prescriber's orders) by the end of decade. The report also calls for the Agency for Healthcare Research and Quality to convene workshops to identify and implement state-of the art approaches to effective team development, use of information technology, coordination of care, and other health care challenges.

The IOM Committee members recognized that, if organizations are expected to change the processes of care, broader environmental changes are also needed. They recommend a federal program to make scientific evidence more useful and accessible to providers and patients, examination of current payment methods (e.g., fee for service, capitation, etc.) to remove barriers to innovation and quality, and testing of options to better align payment methods with quality goals. The report also suggests that the workforce will need new skills as well as innovation in the use of various types of clinicians to achieve the best patient outcomes. Evaluation of how regulations, practice acts, and the legal system help or hinder needed changes, and the restructure of clinical education using multidisciplinary approaches (rather than isolated by discipline) is recommended to better prepare our workforce for the 21st century. For the full report, go to

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