In 1996, after releasing America's Health in Transition: Protecting and Improving Quality, the IOM launched a concerted, ongoing effort focused on assessing and improving the nation's quality of care.
The first phase of this Quality Initiative documented the serious and pervasive nature of the nation's overall quality problem, concluding that "the burden of harm conveyed by the collective impact of all of our health care quality problems is staggering" (Chassen et al., 1998).
IOM Definition of Quality
The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.
This phase built on an intensive review of the literature conducted by RAND to understand the scope of this issue (Schuster) and a framework was established that defined the nature of the problem as one of overuse, misuse and underuse of health care services (Chassen et al). More specifically, the report Ensuring Quality Cancer Care (1999) documented the wide gulf that exists between ideal cancer care and the reality many Americans with cancer experience.
During the second phase, spanning 1999-2001, the Committee on Quality of Health Care in America, laid out a vision for how the health care system and related policy environment must be radically transformed in order to close the chasm between what we know to be good quality care and what actually exists in practice. The reports released during this phase—To Err is Human: Building a Safer Health System (1999) and Crossing the Quality Chasm: A New Health System for the 21st Century (2001)—stress that reform around the margins is inadequate to address system ills.
The series of IOM quality reports have included a number of metrics that illustrate how wide the quality chasm is and how important it is to close this gulf, between what we know is good quality care and what the norm is in practice.
To Err is Human put the spotlight on how tens of thousands of Americans die each year from medical errors and effectively put the issue of patient safety and quality on the radar screen of public and private policymakers. The Quality Chasm report described broader quality issues and defines six aims—care should be safe, effective, patient-centered, timely, efficient and equitable—and 10 rules for care delivery redesign.
Phase three of the IOM's Quality Initiative focuses on operationalizing the vision of a future health system described in the Quality Chasm report. In addition to the IOM, many others are working to create a more patient responsive 21st century health system, including clinicians/ health care organizations, employers/consumers, foundations/research, government agencies, and quality organizations. This collection of efforts focus reform at three different overlapping levels of the system: the environmental level, the level of the health care organization, and the interface between clinicians and patients.
Recent and ongoing IOM efforts, mostly addressing the environmental level, are multifaceted and include the following.
Fostering Rapid Advances in Health Care: Learning from Systems Demonstrations
As problems in the health care system became more pronounced, the Secretary of the Department on Health and Human Services asked the IOM to develop some bold ideas that could be enacted at the state and community level to respond to system ills and guide future larger scale reform.
Over a five month period, the Committee on Rapid Advance Demonstration Projects developed and released in a report a recommended portfolio of demonstrations. Fostering Rapid Advances in Health Care: Learning from System Demonstrations (2002) focuses on redesigning primary care and care for those with chronic conditions, creating an information and communications technology infrastructure, making health insurance coverage available and affordable at the state level, and reforming malpractice to make it patient-centered, safety focused and nonjudicial.
The demonstration ideas are shaped by the strategic direction set out in the Quality Chasm report and seek to operationalize and test many of the ideas offered in the study.
Redesigning Care Delivery
The Quality Chasm report recommends that common conditions serve as a starting point for restructuring care delivery and, at the behest of the Agency for Health Care Research and Quality, an IOM effort recommended 20 such priority areas for national action in a report issued in January 2003. As a follow up to that report, an IOM committee held a Quality Chasm Summit in January 2004 where leaders from exemplary communities and national organizations designed community-focused strategic plans to be implemented at the community level for a subset of the priority areas. A report from that summit was released in September 2004.
Keeping Patients Safe: Transforming the Work Environment of Nurses (2004) identifies solutions to problems in hospital, nursing home, and other health care organization work environments that threaten patient safety through their effect on nursing care. The report puts forth a blueprint of actions that all health care organizations which rely on nurses should take.
The report's findings and recommendations address the related issues of management practices, workforce capability, work design, and organizational safety culture. Actions needed from the federal and state governments, as well as from coalitions of parties involved in shaping the work environments of nurses also are specified. The report presents evidence from health services, behavioral, and organizational research, and human factors and engineering to address pressing public policy questions including nurse staffing levels, nurse work hours, and mandatory overtime.
Furthering Measurement and Informed Purchasing
The IOM report Leadership by Example: Coordinating Government Roles in Improving Health Care Quality (2002) encourages the federal government to take full advantage of its influential position as purchaser, regulator and provider of health care services to determine quality for the health care sector. The vision for each of these distinct federal roles is very much in concert with ideas laid out in the Quality Chasm report. Other efforts in this area include Envisioning the National Healthcare Quality Report (2001) and Guidance for the National Healthcare Disparities Report (2002).
Reforming Health Professions Education
Operationalizing the agenda set out in the Quality Chasm report has important implications for current and future health professionals. Health Professions Education: A Bridge to Quality (2003) sets out a vision for all programs and institutions engaged in clinical education, recommending the implementation of a core set of competencies and targeting a mix of approaches including leveraging oversight organizations, fostering enhanced training environments, and initiating public reporting. This report benefited greatly from the ideas of 150 interdisciplinary experts who attended an IOM summit on health professions education and contributed ideas about educational reform.
Encouraging Information Technology Implementation
Authors of the Quality Chasm report underscore the importance of a dramatically improved information technology infrastructure to support a 21st century health system. Building blocks for such a system include an electronic health record system and national standards. Key Capabilities of an Electronic Health Record (2003) identifies eight care delivery functions that are essential for such records to promote greater safety, quality and efficiency.
Patient Safety: Achieving a New Standard for Care (2003) provides a detailed plan to facilitate the development of data standards applicable to the collection, coding, and classification of patient safety information.
This report addresses key areas related to the establishment of a national health information infrastructure, including: a process for the ongoing promulgation of data standards; the status of current standards-setting activities in health data interchange, terminologies, and medical knowledge representation; as well as the need for comprehensive patient safety programs in health care organizations.
Quality of Care in Rural America
Rural America is home to 20 percent of the nation's population, but struggles to maintain physicians, hospitals, and other critical points of access to health care services. The principles of Crossing the Quality Chasm have been difficult to calibrate to rural needs and resources.
Quality Through Collaboration: The Future of Rural Health Care (2004) proposes a comprehensive strategy for meeting the health challenges that rural communities face. Many of the challenges stem from lack of access to core health care services, such as primary care in the community, hospital and emergency services, long term care, and mental health. Overcoming these barriers will require an integrated approach to meet personal and population needs at the community level; assist health systems professionals to acquire the knowledge and tools to improve quality; and enhance education and training to increase the supply of health professionals in rural areas.
Quality of Care for Mental and Substance-Use Conditions
Health care for mental and substance-use conditions has a number of characteristics that distinguish it from overall health care, such as the greater use of coercion into treatment, separate care delivery systems, a less developed quality measurement infrastructure, and a differently structured marketplace. These and other differences raised questions about whether the Quality Chasm approach is applicable to health care for mental and substance-use conditions and, if so, how it should be applied.
Improving the Quality of Health Care for Mental and Substance-Use Conditions: Quality Chasm Series (2006) examines those differences and finds that the Quality Chasm framework is applicable to health care for mental and substance-use conditions, and describes a multifaceted and comprehensive strategy to do so.
Preventing Medication Errors
Most of the time the medications that people take are beneficial, or at least they cause no harm, but on occasion they do injure those taking them. Some of these “adverse drug events [ADEs],” as injuries due to medication are generally called, are inevitable--the more powerful a drug is, the more likely it is to have harmful side effects, for instance--but sometimes the harm is caused by an error in prescribing or taking the medication, and these damages are not inevitable. These errors can be prevented.
Preventing Medication Errors (2006) finds that medication errors are surprisingly common and costly to the nation, and it outlines a comprehensive approach to decreasing the prevalence of these errors.
Pathways to Quality Health Care
In September 2004, the IOM launched the Redesigning Health Insurance Performance Measures, Payment, and Performance Improvement Project in response to two congressional mandates in the Medicare Prescription Drug, Improvement, and Modernization Improvement Act of 2003 (Public Law 108-173, section 109).
The study committee is producing three reports on strategies for accelerating the diffusion and pace of quality improvement efforts in the United States.
Each of these reports, known collectively as the Pathways to Quality Health Care series, is focused on a specific policy approach to improving the quality of health care:
Performance Measurement: Accelerating Improvement was released in December 2005 and addresses measurement and reporting of performance data.
Medicare's Quality Improvement Organization Program: Maximizing Potential was released in March 2006 and addresses quality improvement initiatives.
Rewarding Provider Performance: Aligning Incentives in Medicare was released in September 2006 and analyzes the promise and risks of instituting a pay-for-performance program within Medicare to encourage a more effective health care system.