Crossing the Quality Chasm: A New Health System for the 21st Century (2001)
Chapter: Index
Index
A
Access
to care studies, 235
to medical knowledge-base, 31
Accidental injury, IOM definition of, 45
Accreditation Council for Graduate Medical Education, 214
ACP Journal Club, 145
Action steps, 89–110
needed now, 2–4
Actual care and ideal care, gaps between in U.S., 236–238
Acute care. See also Inappropriate acute care;
Priority conditions
hip fractures, 259
otitis media, 259
pregnancy and delivery, 260–264
underuse of, 258–264
urinary tract infections, 259–260
Acute myocardial infarction, 102
Adaptable elements, in complex adaptive systems, 313
Adapting existing payment methods
blended, 200–201
capitation, 200
fee-for-service, 199
shared-risk (budget) arrangements, 201
to support quality improvement, 199–201
Adaptive systems thinking, reconciling with mechanical, 311–312
Adjusted clinical groups (ACGs), 195–196
Administrative management personnel, retraining nonclinical, 212
Administrative transactions, potential benefits of information technology for, 167–168
Adult respiratory distress symptom, 77
Adverse events, misuse leading to, 304–305
Adverse risk selection
adjusted clinical groups (ACGs), 195–196
blocking quality improvement in current payment methods, 195–197
clinical risk groups (CRGs), 196
diagnostic cost groups (DCGs), 196
Advisory Commission on Consumer Protection and Quality in the Health Care Industry, 6, 24, 39, 231
Agency for Health Care Policy and Research. See Agency for Healthcare Research and Quality (AHRQ)
Agency for Healthcare Research and Quality (AHRQ), 10, 105
Center for Organization and Delivery Studies, 105
Evidence-Based Practice Centers, 14, 145, 150–151
Integrated Delivery System Research Network, 105
National Guideline Clearinghouse, 151, 157
recommendations to, 10, 12, 19–20, 90–91, 182, 184, 208
Translating Research into Practice, 155
Agenda for crossing the chasm, 5–20
building organizational supports for change, 11–12
establishing a new environment for care, 13–20
establishing aims for the 21st-century health care system, 5–7
formulating new rules to redesign and improve care, 7–9
taking the first steps, 9–11
Agenda for the future, 33–35
Aging of the population, 26
Aims for the 21st-century health care system, 5–6, 39–54
conflicts among, 53–54
establishing, 5–7
patient-centeredness, 6, 48–51
Alzheimer’s disease and other dementias, 91, 103
American Academy of Physicians, 158
American Association of Colleges of Nursing, 214
American Association of Colleges of Osteopathic Medicine, 214
American Association of Health Plans, 151, 157
American Board of Medical Specialties, 214
American College of Physicians, 150, 158
American College of Physicians’ Journal Club, 150
American Customer Satisfaction Index, 46
American Diabetes Association, 158
American Medical Association, 151, 157, 159, 214
Code of Ethics, 45
American National Standards Institute, Healthcare Informatics Standards Board, 172
American Nurses Association, 214
American Nurses Credentialing Center, 214
American Osteopathic Association, 214
American Society for Testing and Material, 172
American Standards Committee, 172
American Thoracic Society, 192
Annual contracting arrangements, blocking quality improvement in current payment methods , 197
Antibiotic use, inappropriate acute care involving, 292–295
Anticipation of needs, 8, 62, 80–81
current approach—react to needs, 81
new rule—anticipate needs, 81
Anxiety. See also Depression and anxiety disorders
relieving, 50
Applications of priority conditions, 96–103
organize and coordinate care around patient needs, 98–100
provide a common base for the development of information technology, 101
reduce suboptimization in payment, 101–102
simplify quality measurement, evaluation of performance, and feedback, 102–103
synthesize the evidence base and delineate practice guidelines, 97–98
Assets, providing for positive change, 13
Association of American Medical Colleges, 214
chronic care of, 264–265
inappropriate acute care of, 296
Automated clinical information, 170–176
financial requirements, 174–175
human factors issues, 175–176
privacy concerns and need for standards, 171–174
B
Balanced Budget Act, 174
Baldrige Award. See Malcolm Baldrige National Quality Award
Barriers to quality improvement in current payment methods, 191–199
adverse risk selection, 195–197
annual contracting arrangements, 197
perverse payment mechanisms, 191–195
up-front investments required by provider groups, 197–199
“Batch size of one,” 125
Behavioral change, patients’ need for, 28
Benefits of information technology, 166–170
Bill of Rights, 64
Biological approach, 314–315
Biomedical research, increasing investments in, 25
Blended payment methods
adapting, 200–201
incentives of current, 188–189
British Medical Journal, 150
Bronchitis, inappropriate acute care of, 296
Budget approaches, incentives of current, 186– 187
Building organizational supports for change, 11–12
Bureau of Health Professionals, 214
Bureau of Primary Health Care, Quality Center, 91
Buyers Health Care Action Group, 200
C
chronic care, 274–279
screening, 251–253
Cancerfacts.com, 55
Capitation payment, adapting, 200
Cardiac care problems, findings about, 227
Cardiac rehabilitation, 170
Cardiac risk factors, 254–257
Cardiovascular disease
chronic care of, 279–291
inappropriate acute care of, 298–301
Care processes
establishing new environment for, 13–20
Carotid arteries, inappropriate acute care of, 302
Case histories
chronic care (using partnership to improve), 107
Henry L. (HIV positive), 69
hospital emergency department (improving timeliness of services), 107
Mary Chao (diabetes educator), 75
Maureen Waters (care as it could be), 54–56
Ms. Martinez (failed care), 41–44, 49, 51
patient-centered primary care (reorganizing staff), 107–108
Pearl Clayton (mental health), 81
Cataracts, inappropriate acute care of, 302
Center for Organization and Delivery Studies, 105
Centers for Disease Control and Prevention, 156
Centers of Excellence, 100, 106
Change
building organizational supports for, 11–12
in the health care environment, responding to, 138
leadership for managing, 137–140
providing assets and encouragement for positive, 13
providing the resources needed to initiate, 103–108
Changes in Health Care Financing and Organization Program, 105
CHESS database, 55
Chronic care
asthma, 264–265
cancer, 274–279
cardiovascular disease, 279–291
diabetes mellitus, 265–268
hypertension, 269–270
mental/addictive disorder, 272–274
mental health, 270–272
peptic ulcer disease, 269
underuse of, 264–291
Chronic conditions, 3–4.
See also Priority conditions
health care for, 9
increase in, 26–27
Chronic heart failure, 97
Clinical care, potential benefits of information technology for, 167–168
Clinical decision support system (CDSS), 151– 155
Clinical education and training
changes in health professional education required, 210
curricular changes required, 209–210
new or enhanced skills required by health professionals, 209
opportunities for multidisciplinary training, 210–211
reasons for little change in traditional clinical education, 213–214
retooling practicing clinicians, 211–212
retraining nonclinical administrative management personnel, 212
Clinical evidence, synthesizing, 148–152
Clinical Evidence, 150
Clinical expertise, access to necessary, 29
Clinical information, automated, 170–176
Clinical integration, 133
Clinical knowledge and skills, managing, 12, 128–130
Clinical risk groups (CRGs), 196
Clinical Roadmap team, 135
Clinicians
recommendations to, 5, 8–9, 34
retooling practicing, 211–212
Co-evolution, in complex adaptive systems, 314
Cochrane Collaboration, 13, 145, 149–150
Code of Ethics, 45
Collaborative Review Groups, 149
Comfort. See Physical comfort
Committee on the Quality of Health Care in America, 1, 23–24, 31, 225
Technical Advisory Panel on the State of Quality, 24
Communication, 50
enhanced patient and clinician, 31–32
Community health needs, identify and prioritize, 138
Competency, ensuring continuing, 217
Complex adaptive systems (CAS), 309–317
adaptable elements, 313
co-evolution, 314
complexity thinking applied to design of the 21st-century health care system, 314–317
context and embeddedness, 314
emergent behavior, 313
health care organizations as, 63–66
inherent order, 313–314
non-predictable in detail, 313
nonlinearity, 313
novelty, 313
reconciling mechanical and adaptive systems thinking, 311–312
science of complex adaptive systems, 312– 314
simple rules, 313
systems thinking, 309–311
Complex health care conditions, patients with, 122
Complexity thinking applied to design of the 21st-century health care system, 314–317
biological approach and evolutionary design, 314–315
good enough vision, 315–317
simple rules, 315–317
wide space for innovation, 315–317
Comprehensive national health information infrastructure, 176
Computer-aided decision support systems, 31
Computer-based clinical decision support systems (CDSS), 152–155
Congress, recommendations to, 7, 11, 17, 166
Constraints on exploiting information technology
access to medical knowledge-base, 31
computer-aided decision support systems, 31
enhanced patient and clinician communication, 31–32
reduction in errors, 31
Consumers
potential benefits of information technology for health of, 166–168
Context, in complex adaptive systems, 314
Continuous access, 68
Continuous flow, 125–126
redesigning care processes for, 124–126
Continuous healing relationships, care based on, 8, 61, 66–69
Control, patient as the source of, 8, 61, 70–72
Cooperation, among clinicians, 9, 62, 83
Coordinating care, across patient conditions, services, and settings over time, 12, 49– 50, 133–135
Coronary artery bypass graft (CABG) surgery, 241
CPG Infobase, 157
Criteria
for identifying priority conditions, 103
for including studies, 234
Crossing the chasm, 5–20
building organizational supports for change, 11–12
establishing a new environment for care, 13–20
establishing aims for the 21st-century health care system , 5–7
formulating new rules to redesign and improve care, 7–9
taking the first steps, 9–11
Current payment methods
barriers to quality improvement in, 191–199
incentives of, 184–191
Current Procedural Technology (CPT) coding, 199
Curricula, changes required, 209–210
Customization
based on patient needs and values, 8, 61, 69–70
mass, redesigning care processes for, 123– 124
D
Dana-Farber Cancer Institute, 45
Deaths, misuse leading to preventable, 304
Decision making, evidence-based, 8, 62, 76–77
Decision support systems, computer-aided, 31, 152–155
Delineating practice guidelines, 97–98
Delivery systems
highly fragmented, 112–114
poorly organized, 28–30
Dementia. See Alzheimer’s disease and other dementias
Department of Health and Human Services, 171–172
Bureau of Health Professionals, 214
Department of Veterans Affairs, 128, 171
Depression and anxiety disorders, 91, 97, 103
inappropriate acute care of, 297
Design for safety
designing procedures that can mitigate harm from errors, 123
designing procedures to make errors visible, 123
designing systems to prevent errors, 122–123
redesigning care processes for, 122–123
Developing effective teams, 12, 130–133
Diabetes Control and Complications Trial, 96
Diabetes mellitus, 91, 97, 103, 170
chronic care of, 265–268
Diabetes Quality Improvement Project, 158
Diagnosis, using computer-based clinical decision support systems for, 152–154
Diagnosis related groups (DRGs), 187, 192
Diagnostic cost groups (DCGs), 196
Disease management programs, 99–100
“Doc Talk” form, 72
Domestic violence, 134
“Double-loop” learning, 136
Drugs, using computer-based clinical decision support systems for prescribing of, 153
E
Education issues, 50
for the future health care workforce, 220
Educational institutions, recommendations to, 5, 34
Effectiveness, 46–48
21st-century health care system, 6
Efficiency, 52–53
improvements in, 164
21st-century health care system, 6
80/20 principle, system design using, 120–122
Embeddedness, in complex adaptive systems, 314
Emergent behavior, in complex adaptive systems, 313
Emotional support, 50
Encouragement, providing for positive change, 13
Environment for care
aligning payment policies with quality improvement, 17–19
applying evidence to health care delivery, 13–15
establishing new, 13–20
focus and align environment toward the six aims for improvement, 13
preparing the workforce, 19–20
provide assets and encouragement for positive change, 13
using information technology, 15–17
Equity, 53
21st-century health care system, 6
Errors
designing procedures to make visible, 123
designing systems to prevent, 122–123
reduction in, 31
“Essential technology,” 171
Evidence-Based Cardiovascular Medicine, 150
Evidence-based care, 28
Evidence-based decision making, 8, 62, 76–77, 145–163
background, 147–148
defining quality measures, 157–159
in health care delivery, 13–15, 145–163
making information available on the Internet, 155–157
synthesizing clinical evidence, 148–152
using computer-based clinical decision support systems, 152–155
Evidence-Based Medicine, 150
Evidence-Based Mental Health, 150
Evidence-Based Nursing, 150
Evidence-Based Practice Centers, 14, 145, 150– 151
“Evidence formulary,” 150
Evolutionary design, 314–315
Executive branch, recommendations to, 17, 166
Expressed needs, respect for patients’, 49
F
FACCT|ONE, 158
Family, involvement of, 50
Fear, relieving, 50
Fee-for-service payment, adapting, 199
Financial requirements, for automated clinical information, 174–175
Financial transactions, potential benefits of information technology for, 167–168
First steps
applications of priority conditions, 96–103
criteria for identifying priority conditions, 103
providing the resources needed to initiate change, 103–108
value of organizing around priority conditions, 92–96
Follow-up, patients’ needs for greater, 28
Food and Drug Administration, 26, 156
Foundation for Accountability, 158
Free flow of information, 8, 62, 72–75
Friends, involvement of, 50
Funding over several years, to ensure sustained and stable funding source, 104
G
Gastrointestinal disease, inappropriate acute care of, 302
General preventive care, 257
Genomics, 2
Good enough vision, 315–317
Group Health Cooperative of Puget Sound, 105
H
Harm from errors, designing procedures that can mitigate, 123
Harris Poll results, 46, 166–167
Healing relationships, care based on continuous, 8, 61, 66–69
Health care conditions, patients with rare or complex, 122
Health care constituencies, recommendations to, 5, 34
Health care delivery, applying evidence to, 13– 15
Health care environment, obtaining resources and responding to changes in, 138
Health Care Financing Administration, 196
Centers of Excellence, 100, 106
Foundation for Accountability, 158
Medicare Participating Heart Bypass Center demonstration, 188
Office of Research and Development, 106
Peer Review Organizations, 158
Health care needs, of medium predictability, 121–122
Health care organizations
as complex adaptive systems, 63–66
key challenges for the redesign of, 117–137
recommendations to, 6, 8–9, 34, 39–40
recommendations to leaders of, 17, 166
Health Care Quality Innovation Fund, 11
recommendations to, 91–92, 103–106, 166
Health care system, for the 21st-century, 6, 23– 60
Health care trustees and management, recommendations to, 5, 34
HEALTH database, 233
Health informatics associations and vendors, recommendations to, 17, 166
Health Insurance Portability and Accountability Act, 173
Health Plan Employer Data and Information Set (HEDIS), 157, 159, 240, 242
Health Planning and Administration, HEALTH database, 233
Health professional education, changes required, 210
Health professionals
new or enhanced skills required by, 209
Health professions, recommendations to, 5, 34
Health Resources Services Administration, Bureau of Primary Health Care, 91
Healthcare Informatics Standards Board, 172
HealthTopics, 157
Heart failure, 102
Hip fractures, acute care of, 259
Homeostasis, 137
Human factors issues, with automated clinical information, 175–176
Hyper Text Markup Language (HTML), 316
chronic care of, 269–270
Hysterectomy, inappropriate acute care involving, 297
I
Ideal care and actual care, gaps between in U.S., 236–238
Identifying community health needs, 138
Immediate needs, 2–4
Immunizations, 250–251
Improvement of care
formulating new rules to, 7–9
Inadequate quality of care
constraints on exploiting information technology, 30–33
growing complexity of science and technology, 25–26
increase in chronic conditions, 26–27
poorly organized delivery system, 28–30
underlying reasons for, 25–33
Inappropriate acute care
antibiotic use, 292–295
bronchitis/asthma, 296
cardiovascular disease, 298–301
carotid arteries, 302
cataracts, 302
depression, 297
gastrointestinal disease, 302
hysterectomy, 297
low back pain, 303
otitis media, 296
respiratory illness, 295
U.S. examples of, 292–303
Incentives of current payment methods, 184–191
blended methods, 188–189
budget approaches, 186–187
charted, 190
payment by unit of care, 187–188
per case payment, 187
Information, 50
about patients, their care, and outcomes, 95
automated clinical, 170–176
making available on the Internet, 155–157
patients’ need for, 28
strong focus on patient, 95
Information systems, supportive, 29
Information technology (IT), 164–180
automated clinical information, 170–176
constraints on exploiting, 30–33
making effective use of, 12, 127–128
need for a national health information infrastructure, 176–177
potential benefits of, 166–170
provide a common base for the development of, 101
using, 15–17
Infrastructure investments, 198–199
Inherent order, in complex adaptive systems, 313–314
Innovation, wide space for, 315–317
Institute for Healthcare Improvement, 91
Institute of Electrical and Electronics Engineers , 172
Institute of Medicine (IOM), 13, 17, 23–24, 100, 103, 136–137, 165, 171, 191, 199
definition of accidental injury, 45
definition of quality, 232
National Roundtable on Health Care Quality, 23
Quality of Health Care in America Project, 225
Technical Advisory Panel on the State of Quality, 24, 226, 231–232, 234
Insurance coverage. See Equity
Integrated Delivery System Research Network, 105
Integration of care, 49–50
Intensive care unit (ICU) patients, 77
Interdependence of changes, recognizing at all levels, 139–140
Intermountain Health Care, 105, 128, 171, 191, 201
Internet, 16, 30–32, 65, 154–155, 167, 176, 316
making information available on, 155–157
secure applications, 127
Investing, in the workforce, 139
Involvement, of family and friends, 50
J
Joint Commission on the Accreditation of Healthcare Organizations, 102, 157
Journal of Evidence-Based Health Care, 150
K
Kaiser-Permanente Health Plan, 105, 196
Key challenges for the redesign of health care organizations, 117–137
coordinating care across patient conditions, services, and settings over time, 12, 133–135
developing effective teams, 12, 130–133
incorporating performance and outcome measurements for improvement and accountability, 12, 135–137
making effective use of information technologies, 12, 127–128
managing clinical knowledge and skills, 12, 128–130
redesigning care processes, 11, 117–127
Knowledge-base, access to medical, 31
L
LDS Hospital, 77
Leaders of health care organizations
multidisciplinary summit of, 19, 208
recommendations to, 17
Leadership for managing change, 137–140
help obtain resources and respond to changes in health care environment, 138
identify and prioritize community health needs, 138
invest in the workforce, 139
optimize performance of teams that provide various services, 138–139
recognize the interdependence of changes at all levels, 139–140
support reward and recognition systems, 139
Legal liability issues
for the future health care workforce, 221
in workforce preparation, 218–219
Level of harm caused by poor quality, in the report on the state of quality, 227–228
Liaison Committee on Medical Education, 214
Licensure systems, 215–216
Low back pain, inappropriate acute care of, 303
M
Malcolm Baldrige National Quality Award, 119, 136–137
Managed care, affect on quality in U.S., 238
Management, using computer-based clinical decision support systems for, 152–154
Managing change, leadership for, 137–140
Managing clinical knowledge and skills, 12, 128–130
Mass customization, redesigning care processes for, 123–124
Mechanical systems thinking, reconciling with adaptive, 311–312
Medical Expenditure Panel Survey (MEPS), 10, 91, 103
Medical knowledge-base, access to, 31
Medical Subject Headings (MeSH), 233
Medicare and Medicaid, 150, 174, 187
Medicare Participating Heart Bypass Center demonstration, 188
Medicare Peer Review Organizations, 227
Medicine, distinct cultures of, 78
Medium predictability, health care needs of, 121–122
Mental/addictive disorder, chronic care of, 272– 274
Mental health
chronic care of, 270–272
misuse leading to, 306
Mergers, acquisitions, and affiliations, 3
Methodology
criteria for including studies, 234
in the review of the literature, 233–236
types of studies not included, 234–236
Midcourse corrections, public funding for mix of projects to permit, 105
Misuse, 304–307
adverse events, 304–305
correcting problems of, 193
mental health, 306
preventable deaths, 304
tuberculosis, 307
U.S. examples of, 304–307
Molecular medicine, 155
Monitoring, using computer-based clinical decision support systems for, 152–153
Multidisciplinary summit, of leaders of health care organizations, 19, 208
Multidisciplinary training, opportunities for, 210–211
Multiple institutions, comparisons of outcomes not included in quality report, 234–235
N
National Academies, The, 32, 166
National Cancer Institute, PDQ database, 72
National Center for Health Statistics, 91
National Coalition on Health Care (NCHC), 231, 233
National Committee for Quality Assurance, 103, 157–158
Health Plan Employer Data and Information Set, 157, 159, 240, 242
National Committee on Vital and Health Statistics, 173, 176
National Council of State Boards of Nursing, 214, 216
National Guideline Clearinghouse, 151, 157
National health information infrastructure, need for, 176–177
National Health Services Centre for Reviews and Dissemination, 150
National Institutes of Health, 2, 106, 156
National League for Nursing, 214
National Library of Medicine (NLM), 14, 55, 146, 172
Medical Subject Headings (MeSH), 233
National Quality Forum, 10, 13–14, 90–91, 146, 159
National Quality Report, 6–7
National Research Council, 32, 166
National Roundtable on Health Care Quality, 23
Needs
for further work, 228–229
Networking Health, 32
NOAH (New York Online Access to Health), 157
Nonclinical administrative management personnel, retraining, 212
Nonlinearity, in complex adaptive systems, 313
Novelty, in complex adaptive systems, 313
O
Obtaining resources, in the health care environment, 138
Office of Research and Development, 106
On Lok Senior Health Services, 81
“Open-access” scheduling, 125
Organizational development, stages of, 112–117
Organizational supports for change, 11–12, 111– 144
key challenges for the redesign of health care organizations, 117–137
leadership for managing change, 137–140
stages of organizational development, 112– 117
Organizing and coordinating care around patient needs
Centers of Excellence, 100, 106
disease management programs, 99–100
Organizing around priority conditions
ensures availability of specialized expertise to primary care practices, 95
includes strong focus on patient information and self-management, 95
redesigns practice to incorporate regular patient contact (regular follow-up), 94
relies on having good information about patients, their care, and outcomes, 95
uses protocol providing explicit statement of what needs to be done for patient, 94
ORYX system for hospitals, 157
Osteoarthritis, 170
Otitis media
acute care of, 259
inappropriate acute care of, 296
Outcome measurements, incorporating for improvement and accountability, 12, 135–137
Overuse problems
correcting, 193
findings about, 226–227
P
PacifiCare Health System, 200
Pain relief. See Physical comfort
Patient, as the source of control, 8, 61, 70–72
Patient-centeredness, 48–51
coordination and integration of care, 49–50
emotional support, relieving fear and anxiety, 50
information, communication, and education, 50
involvement of family and friends, 50
physical comfort, 50
respect for patients’ values, preferences, and expressed needs, 49
21st-century health care system, 6
Patient conditions, services, and settings, coordinating over time, 12, 133–135
Patient information and self-management, strong focus on, 95
Patient needs
customization based on, 8, 61, 69–70
organizing and coordinating care around, 98–100
Patients
recommendations to, 5, 8–9, 34
values of, 70
Patients’ expectations from their health care, 63
anticipation, 63
beyond patient visits, 63
control, 63
cooperation, 63
individualization, 63
information, 63
safety, 63
science, 63
transparency, 63
value, 63
Payment, reduce suboptimization in, 101–102
Payment by unit of care, incentives of current, 187–188
Payment methods
adapting blended, 200–201
barriers to quality improvement in current, 191–199
incentives of current, 184–191
Payment policies, 181–206
adapting existing payment methods to support quality improvement, 199–201
aligning with quality improvement, 17–19
barriers to quality improvement in current payment methods, 191–199
incentives of current payment methods, 184–191
need for a new approach, 201–204
PDQ database, 72
Peer Review Organizations (PROs), 227
Peptic ulcer disease, chronic care of, 269
Per case payment, incentives of current, 187
Performance measurements, incorporating for improvement and accountability, 12, 135–137
Performance of teams, optimizing, 138–139
Perverse payment mechanisms
blocking quality improvement in current payment methods, 191–195
correcting problems of misuse, 193
correcting problems of overuse, 193
correcting problems of underuse, 193
Pharmaceutical firms, 2
Physical comfort, 50
Physicians’ reports, not included in quality report, 235
Plan-do-study-act (PDSA) improvement methods, 315
Planned care, 28
Pneumococcal vaccine, findings about, 227
Pneumonia, 102
Policymakers, recommendations to, 5, 34
Poor quality, level of harm caused by, 227–228
Poorly organized delivery system
access to necessary clinical expertise, 29
evidence-based, planned care, 28
patients’ need for information and behavioral change, 28
patients’ needs for more time, resources, and follow-up, 28
supportive information systems, 29
Positive change, provide assets and encouragement for, 13
Potential benefits of information technology, 166–170
for administrative and financial transactions, 167–168
charted, 168
for clinical care, 167–168
for consumer health, 166–168
for professional education, 167, 169
Practice guidelines
delineate, 97–98
for synthesizing clinical evidence, 151–152
Practicing clinicians, retooling, 211–212
Predictable needs, patients with the most, 121
Preferences, respect for patients’, 49
Pregnancy and delivery, 102
acute care of, 260–264
Prescriptions, using computer-based clinical decision support systems for, 153
Preventable deaths, misuse leading to, 304
Preventive care
cancer screening, 251–253
cardiac risk factors, 254–257
general, 257
immunizations, 250–251
telemedicine technologies in, 170
underuse of, 250–257
using computer-based clinical decision support systems for, 152–153
Primary care practices, availability of specialized expertise to, 95
Prioritizing, community health needs, 138
Priority conditions
acute myocardial infarction, 102
Alzheimer’s disease and other dementias, 91, 103
applications of, 96–103
cardiac rehabilitation, 170
chronic heart failure, 97
criteria for identifying, 103
depression and anxiety disorders, 91, 97, 103
domestic violence, 134
heart failure, 102
ischemic heart disease, 91, 97, 103
organizing and coordinating care around patient needs, 98–100
osteoarthritis, 170
pneumonia, 102
pregnancy and related conditions, 102
provide a common base for the development of information technology, 101
reduce suboptimization in payment, 101– 102
simplify quality measurement, evaluation of performance, and feedback, 102–103
spinal cord injury, 97
surgical procedures and complications, 102
synthesize the evidence base and delineate practice guidelines, 97–98
Privacy concerns, with automated clinical information, 171–174
Private purchasers, recommendations to, 5, 8–9, 17–18, 39–40, 61–62, 166, 182, 184
Production planning, redesigning care processes for, 126–127
Professional education, potential benefits of information technology for, 167, 169
Professional groups, recommendations to, 6, 39–40
Profile of quality of care in U.S., from the review of the literature, 236–308
Program of All-Inclusive Care for the Elderly (PACE), 81
Protocol, providing explicit statement of what needs to be done for patient, 94
Provider groups, up-front investments required by, 197–199
Providing the resources needed to initiate change, 103–108
funding over several years to ensure sustained and stable funding source, 104
public funding for mix of projects to permit midcourse corrections, 105
public support providing partial funding for up-front costs health care organizations face implementing changes, 104–105
Public funding for mix of projects, to permit midcourse corrections, 105
Public health, potential benefits of information technology for, 167, 169
Public purchasers, recommendations to, 5, 8–9, 17–18, 39–40, 61–62, 166, 182, 184
Public support providing partial funding, for up-front costs health care organizations face implementing changes, 104–105
Purchasers, recommendations to, 5–6, 8–9, 17– 18, 34, 39–40, 61–62, 166, 182, 184
Q
Quality Center, 91
Quality Enhancement Research Initiative (QUERI), 97, 106
Quality gap, 23–25
Quality improvement
adapting existing payment methods to support, 199–201
aligning payment policies with, 17–19
impact on the bottom line, 198
Quality measures, defining, 157–159
Quality of care
conclusions about, 240–242
defining in the review of the literature, 232– 233
examples of inappropriate acute care, 292– 303
examples of misuse, 304–307
examples of underuse, 250–291
gaps between ideal care and actual care, 236–238
how managed care affects quality, 238
inadequate, 25–33
IOM definition of, 232
search strategy followed, 308
sources of information about, 240
as a system property, 4
trends in assessment of, 239–240
Quality of Health Care in America (QHCA) Project, 225
R
Rare health care conditions, patients with, 122
“Real-time tracking,” 137
Recommendations
to Agency for Healthcare Research and Quality, 10, 12, 19–20, 90–91, 182, 184, 208
to Department of Health and Human Services, 5, 34, 40
to educational institutions, 5, 34
to health care constituencies, 5, 34
to Health Care Financing Administration, 19, 182
to health care organizations, 6, 8–9, 34, 39– 40
to Health Care Quality Innovation Fund, 91–92, 103–106, 166
to health care trustees and management, 5, 34
to health informatics associations and vendors, 17, 166
to health professionals, 5, 34
to leaders of health care organizations, 17, 166
to private purchasers, 5, 8–9, 17–18, 39–40, 61–62, 166, 182, 184
to professional groups, 6, 39–40
to public purchasers, 5, 8–9, 17–18, 39–40, 61–62, 166, 182, 184
to purchasers, 5–6, 8–9, 17–18, 34, 39–40, 61–62, 166, 182, 184
to secretary of the Department of Health and Human Services, 7, 14, 40, 146, 173
Redesigning care, formulating new rules to, 7–9
Redesigning care processes, 11, 117–127
continuous flow, 124–126
design for safety, 122–123
mass customization, 123–124
production planning, 126–127
system design using the 80/20 principle, 120–122
Redesigning health care organizations
coordinating care across patient conditions, services, and settings over time, 12, 133–135
developing effective teams, 12, 130–133
incorporating performance and outcome measurements for improvement and accountability, 12, 135–137
key challenges for, 117–137
making effective use of information technologies, 12, 127–128
managing clinical knowledge and skills, 12, 128–130
Reengineering principles, 127
Referral networks, well-defined, 113–114
Regular patient contact (regular follow-up), redesigning practice to incorporate, 94
Regulation of the professions
ensuring continuing competency, 217
licensure systems, 215–216
scope-of-practice acts, 215–217
Regulators, recommendations to, 5, 34
Regulatory issues, for the future health care workforce, 221
Report on the state of quality in the U.S., 225– 308
discussion of findings, 226–227
level of harm caused by poor quality, 227– 228
need for further work, 228–229
review of the literature, 226, 231–308
Research, potential benefits of information technology for, 167, 169
Research agenda for the future health care workforce
legal and regulatory issues, 221
training and education issues, 220
workforce supply issues, 221
Resources
needed to initiate change, 103–108
obtaining in the health care environment, 138
patients’ needs for more, 28
Respiratory illness, inappropriate acute care of, 295
Responding to changes, in the health care environment, 138
Retooling practicing clinicians, 211–212
Retraining nonclinical administrative management personnel, 212
Review of the literature
defining quality, 232–233
methodology, 233–236
profile of quality of care in U.S., 236–308
in the report on the state of quality, 226, 231–308
Reward and recognition systems, supporting, 139
Robert Wood Johnson Foundation, 105
Rules for 21st-century health care system, 7–9, 61–88
anticipation of needs, 8, 62, 80–81
care based on continuous healing relationships, 8, 61, 66–69
contrasted with current approach, 67
cooperation among clinicians, 9, 62, 83
customization based on patient needs and values, 8, 61, 69–70
evidence-based decision making, 8, 62, 76– 77
health care organizations as complex adaptive systems, 63–66
need for transparency, 8, 62, 79–80
patient as the source of control, 8, 61, 70–72
safety as a system property, 8, 62, 78–79
shared knowledge and free flow of information, 8, 62, 72–75
waste continuously decreased, 9, 62, 81–83
S
Safety, 44–46
designing procedures that can mitigate harm from errors, 123
designing procedures to make errors visible, 123
designing systems to prevent errors, 122– 123
redesigning care processes for, 122–123
as a system property, 8, 62, 78–79
21st-century health care system, 5
Satisfaction ratings, not included in quality report, 235
Science, growing complexity of, 25–26
Science of complex adaptive systems (CAS), 312–314
adaptable elements, 313
co-evolution, 314
context and embeddedness, 314
emergent behavior, 313
inherent order, 313–314
non-predictable in detail, 313
nonlinearity, 313
novelty, 313
simple rules, 313
Scope-of-practice acts, 215–217
Search strategy, 308
Secretary of the Department of Health and Human Services, recommendations to, 7, 14, 40, 146, 173
Self-management, strong focus on patient, 95
Shared knowledge, 8, 62, 72–75
Shared-risk (budget) arrangements, adapting, 201
Simple rules, 315–317
in complex adaptive systems, 313
Simplifying quality measurement, evaluation of performance, and feedback, 102–103
“Single-loop” learning, 136
Specialized expertise, availability to primary care practices, 95
Spinal cord injury, 97
Stages of organizational development, 112–117
charted, 114–115
Stage 1—highly fragmented delivery system , 112–114
Stage 2—well-defined referral networks, 113–114
Stage 3—some movement toward patient-centered system, 113, 115–116
Stage 4—21st-century health care system envisioned, 115–117
Standards, need for, with automated clinical information, 171–174
State of Quality Panel, 226
Structural measures, not included in quality report, 235
Studies not included, 234–236
access to care studies, 235
comparisons of outcomes across multiple institutions, 234–235
physicians reports, 235
satisfaction ratings, 235
structural measures, 235
Suboptimization in payment, reducing, 101–102
Support, emotional, 50
Surgical procedures and complications, 102
Sustained and stable funding source, funding over several years to ensure, 104
Synthesizing clinical evidence, 97–98, 148–152
practice guidelines, 151–152
systematic reviews, 148–151
System design using the 80/20 principle
Level 1—most predictable needs, 121
Level 2—health care needs of medium predictability, 121–122
Level 3—patients with rare or complex health care conditions, 122
redesigning care processes for, 120–122
System properties, safety as, 8, 62, 78–79
Systematic reviews, for synthesizing clinical evidence, 148–151
Systems thinking, 309–311
T
Teams
developing effective, 12, 130–133
optimizing performance of, 138–139
Technical Advisory Panel on the State of Quality, 24, 226, 231–232, 234
Technology, growing complexity of, 25–26
Telemedicine technologies, 170
in preventive care, 170
Ten Commandments, 64
Time, patients’ needs for more, 28
Timeliness, 51–52
improvements in, 164
21st-century health care system, 6
To Err Is Human: Building a Safer Health System, 2, 24, 44, 119, 122
Traditional clinical education, reasons for little change in, 213–214
Training issues, for the future health care workforce, 220
Translating Research into Practice, 155
Transparency, need for, 8, 62, 79–80
Tuberculosis, misuse leading to, 307
21st-century health care system, 6, 23–60, 39– 60, 66–83
agenda for the future, 33–35
anticipation of needs, 8, 62, 80–81
care based on continuous healing relationships, 8, 61, 66–69
complexity thinking applied to design of, 314–317
contrasted with current approach, 67
cooperation among clinicians, 9, 62, 83
customization based on patient needs and values, 8, 61, 69–70
effective, 6
efficient, 6
equitable, 6
establishing aims for, 5–7
evidence-based decision making, 8, 62, 76–77
need for transparency, 8, 62, 79–80
patient as the source of control, 8, 61, 70–72
patient-centered, 6
quality gap, 23–25
safe, 5
safety as a system property, 8, 62, 78–79
shared knowledge and free flow of information, 8, 62, 72–75
six aims for improvement, 6, 40–54
timely, 6
underlying reasons for inadequate quality of care, 25–33
waste continuously decreased, 9, 62, 81–83
U
UCLA/RAND appropriateness method, 239
Underlying reasons for inadequate quality of care, 25–33
Underuse problems
of acute care, 258–264
of chronic care, 264–291
correcting problems of, 193
findings about, 227
of preventive care, 250–257
U.S. examples of, 250–291
Up-front costs health care organizations face, public support providing partial funding for, 104–105
Up-front investments required by provider groups
blocking quality improvement in current payment methods, 197–199
infrastructure investments, 198–199
measuring impact of quality improvement on the bottom line, 198
Urinary tract infections, acute care of, 259–260
U.S. General Accounting Office, 171
U.S. Preventive Services Task Force, 227
USA Today survey, 155
Using computer-based clinical decision support systems (CDSS)
for diagnosis and management, 152–154
for prescribing of drugs, 153
for prevention and monitoring, 152–153
V
Values
organizing around priority conditions, 92– 96
respect for patients’, 49
Veterans Health Administration (VHA), 97–98, 158.
See also Department of Veterans Affairs
Quality Enhancement Research Initiative, 97, 106
Virginia Mason Medical Center, 72
Vision, good enough, 315–317
W
Waste, continuously decreasing, 9, 62, 81–83
Wide space for innovation, 315–317
Workforce preparation, 19–20, 207–223
clinical education and training, 208–214
investing in, 139
legal liability issues, 218–219
regulation of the professions, 214–218
research agenda for the future health care workforce, 219–221
Workforce supply issues, for the future of health care, 221
health information found on, 31
technologies based on, 211
Y
Year 2000 Health Plan Employer Data and Information Set, 157, 159
