forts to improve quality; developed strategies for fostering greater accountability for quality; and identified important areas of research that should be pursued to facilitate improvements in quality. The committee has focused on the personal health care delivery system, specifically, the provision of preventive, acute, chronic, and end-of-life health care for individuals. Although the committee recognizes the critical role of the public health system in protecting and improving the health of our communities, this issue lies beyond the purview of the present study.

The committee has already spoken to one urgent quality problem—patient safety. In our first report, To Err Is Human: Building a Safer Health System, we concluded that tens of thousands of Americans die each year from errors in their care, and hundreds of thousands suffer or barely escape from nonfatal injuries that a truly high-quality care system would largely prevent (Institute of Medicine, 2000b).

As disturbing as the committee’s report on safety is, it reflects only a small part of the unfolding story of quality in American health care. Other defects are even more widespread and, taken together, detract still further from the health, functioning, dignity, comfort, satisfaction, and resources of Americans. This report addresses these additional quality problems. As the patient safety report was a call for action to make care safer, this report is a call for action to improve the American health care delivery system as a whole, in all its quality dimensions, for all Americans.


At no time in the history of medicine has the growth in knowledge and technologies been so profound. Since the first contemporary randomized controlled trial was conducted more than 50 years ago, the number of trials conducted has grown to nearly 10,000 annually (Chassin, 1998). Between 1993 and 1999, the budget of the National Institutes of Health increased from $10.9 to $15.6 billion, while investments by pharmaceutical firms in research and development increased from $12 to $24 billion (National Institutes of Health, 2000; Pharmaceutical Research and Manufacturers of America, 2000). Genomics and other new technologies on the horizon offer the promise of further increasing longevity, improving health and functioning, and alleviating pain and suffering. Advances in rehabilitation, cell restoration, and prosthetic devices hold potential for improving the heath and functioning of many with disabilities. Americans are justifiably proud of the great strides that have been made in the health and medical sciences.

As medical science and technology have advanced at a rapid pace, however, the health care delivery system has floundered in its ability to provide consistently high-quality care to all Americans. Research on the quality of care reveals

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