9
Preparing the Workforce

Health care is not just another service industry. Its fundamental nature is characterized by people taking care of other people in times of need and stress. Patients are ill, families are worried, and the ultimate outcome may be uncertain. Stable, trusting relationships between a patient and the people providing care can be critical to healing or managing an illness. The people who deliver care are the health system’s most important resource.

All of the issues raised in the previous chapters of this report have important implications for the health care workforce, potentially requiring different work in new types of organizations that may use fewer people. Accountabilities and standards of care may change; relationships between patients and health professionals are certain to do so.

The health care workforce is large, having employed almost 6 million people in 1998 (Occupational Employment Statistics, 2000) with a wide variety of educational backgrounds, specialization, and skills. Professional hierarchies are well established and reinforced by training, laws, and regulations, as well as culture and history. In general, health professionals are also conservative, stressing the application of precedent and risk avoidance in clinical practice, particularly relative to changes that may affect the quality of care for patients. As a result, any change can be exceedingly slow and difficult to accomplish, especially if there is not a clear understanding of why the change may be needed or of its impact on current practices.

The importance of appropriately preparing the workforce for the changes in health care delivery that will be necessitated by the recommendations in this report cannot be underestimated. There are many serious challenges facing the



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Crossing the Quality Chasm: A New Health System for the 21st Century 9 Preparing the Workforce Health care is not just another service industry. Its fundamental nature is characterized by people taking care of other people in times of need and stress. Patients are ill, families are worried, and the ultimate outcome may be uncertain. Stable, trusting relationships between a patient and the people providing care can be critical to healing or managing an illness. The people who deliver care are the health system’s most important resource. All of the issues raised in the previous chapters of this report have important implications for the health care workforce, potentially requiring different work in new types of organizations that may use fewer people. Accountabilities and standards of care may change; relationships between patients and health professionals are certain to do so. The health care workforce is large, having employed almost 6 million people in 1998 (Occupational Employment Statistics, 2000) with a wide variety of educational backgrounds, specialization, and skills. Professional hierarchies are well established and reinforced by training, laws, and regulations, as well as culture and history. In general, health professionals are also conservative, stressing the application of precedent and risk avoidance in clinical practice, particularly relative to changes that may affect the quality of care for patients. As a result, any change can be exceedingly slow and difficult to accomplish, especially if there is not a clear understanding of why the change may be needed or of its impact on current practices. The importance of appropriately preparing the workforce for the changes in health care delivery that will be necessitated by the recommendations in this report cannot be underestimated. There are many serious challenges facing the

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Crossing the Quality Chasm: A New Health System for the 21st Century health care workforce, including difficulties in retention of personnel, the impending crisis in nursing supply, and the need for strong leadership within the health care system to guide and support what will be a very difficult transition. When clinicians are under stress themselves, it is difficult to take care of patients who are ill and stressed. Indeed, this was one of the key transitional issues identified during the committee’s deliberations. It is a broad topic that can only be introduced here, but the committee emphasizes the need for additional study to understand the effects of the changes recommended herein on how the workforce is prepared for practice, how it is deployed, and how it is held accountable. Recommendation 12: A multidisciplinary summit of leaders within the health professions should be held to discuss and develop strategies for (1) restructuring clinical education to be consistent with the principles of the 21st-century health system throughout the continuum of undergraduate, graduate, and continuing education for medical, nursing, and other professional training programs; and (2) assessing the implications of these changes for provider credentialing programs, funding, and sponsorship of education programs for health professionals. Recommendation 13: The Agency for Healthcare Research and Quality should fund research to evaluate how the current regulatory and legal systems (1) facilitate or inhibit the changes needed for the 21st-century health care delivery system, and (2) can be modified to support health care professionals and organizations that seek to accomplish the six aims set forth in Chapter 2. This chapter briefly examines three specific issues: clinical training and education, regulation of the health professions, and legal liability issues. Clinical training and education is seen as particularly important for changing the culture of health care practice to support achievement of the aims set forth in Chapter 2. Greater understanding is needed of why prior efforts at modifying clinical education have not had the desired impact and of the supportive strategies needed to overcome such barriers. CLINICAL EDUCATION AND TRAINING To achieve the six aims proposed in Chapter 2, additional skills may be required of health professionals—not just physicians, but all clinicians who care for patients. Prior chapters have identified a number of changes affecting health care delivery, including a shift from acute to chronic care, the need to manage a continually expanding evidence base and technological innovations, more clinical practice occurring in teams and complex delivery arrangements, and changing patient-clinician relationships. The need to balance cost, quality, and access in

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Crossing the Quality Chasm: A New Health System for the 21st Century health care will put pressures on clinical education programs, particularly given the outlay of public dollars for clinical education. The types of new or enhanced skills required by health professionals might include, for example, the ability to: Use a variety of approaches to deliver care, including the provision of care without face-to-face visits (e.g., using electronic communications to provide follow-up care and routine monitoring) (see Chapter 3). Synthesize the evidence base and communicate it to patients (see Chapter 6). Combine the evidence base, knowledge about population outcomes, and patient preferences to tailor care for an individual patient (Weed and Weed, 1999a) (see Chapter 6). Communicate with patients in a shared and fully open manner to support their decision making and self-management (to the extent they so desire), including the potential for unfettered access to the information contained in their medical records (see Chapter 3). Use decision support systems and other tools to aid clinical decision making in order to minimize problems of overuse and underuse and reduce waste (Weed and Weed, 1999a) (see Chapter 6). Identify errors and hazards in care; understand and implement basic safety design principles, such as standardization and simplification (Institute of Medicine, 2000) (see Chapter 5). Understand the course of illness and a patient’s experience outside of the hospital (where most training is conducted). Continually measure quality of care in terms of both process and outcomes; develop and implement best practices (Berwick et al., 1992) (see Chapter 5). Work collaboratively in teams with shared responsibility (Chassin, 1998) (see Chapter 5). Design processes of care and measure their effectiveness, even when the members of the team that cares for a patient are not in the same physical locale (Berwick et al., 1992). Understand how to find new knowledge as it continually expands, evaluate its significance and claims of effectiveness, and decide how to incorporate it into practice (Chassin, 1998) (see Chapter 6). Understand determinants of health, the link between medical care and healthy populations, and professional responsibilities. Teaching these skills will likely require changes in curriculum. Although some schools have added courses that are consistent with the desired skills, the needed content is likely to evolve over time. For example, many schools now have courses in patient communications, information systems, and biostatistics.

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Crossing the Quality Chasm: A New Health System for the 21st Century However, communicating with patients to improve adherence to a recommended treatment is different from communicating with patients who are key decision makers and full partners in their care. Using information technology to do a MEDLINE search is important, but not the same as using the technology as a central component in delivering care and using decision support as an aid to clinical decision making. Knowing biostatistics aids in understanding the published literature, but is not the same as using statistics to design processes of care to reduce variations in practice. Likewise, care provided by multidisciplinary teams involves more than knowing the responsibilities of people in a clinical department; it should involve knowing how to form and use teams to customize care across settings and over time, even when the members of the team are in entirely different physical locations. Although curriculum changes are essential in providing new skills to health professionals, they are not sufficient by themselves. It is also necessary to address how health professional education is approached, organized, and funded to better prepare students for real practice in an information rich environment. Two examples are teaching evidence-based practice and training in multidisciplinary teams. The traditional emphasis in clinical education, particularly medical education, is on teaching a core of knowledge, much of it focused on the basic mechanisms of disease and pathophysiological principles. Given the expansiveness and dynamic nature of the science base in health care, this approach should be expanded to teach how to manage knowledge and use effective tools that can support clinical decision making (Evidence-Based Medicine Working Group, 1992; Weed and Weed, 1999c). Effective teaching of evidence-based practice requires faculty role models, an emphasis on teaching the application of critical appraisal skills in actual patient care settings, and experience in conducting literature searches and applying methodological rules to the evaluation and understanding of evidence (Evidence-Based Medicine Working Group, 1992). In a survey of 269 internal medicine residency programs, it was found that only 99 offered a freestanding program in evidence-based medicine (Green, 2000). The curricula for these 99 programs varied greatly: 77 included critical appraisal of the literature; 52 provided information on how to search for evidence; 44 covered issues related to the articulation of a focused clinical question; 35 covered the application of evidence to individual decision making; and 23 included integration of the evidence into decision making in actual practice. Nearly all programs provided access to MEDLINE, while only about one-third provided access to the Cochrane Library (see Chapter 6). Similarly, as more care is provided by teams, more opportunities for multidisciplinary training should be offered (Institute of Medicine, 1996a). People should be trained in the kinds of teams in which they will provide care, starting with initial professional training and continuing through graduate training and ongoing professional development. Multidisciplinary training is difficult

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Crossing the Quality Chasm: A New Health System for the 21st Century to implement because of professional boundaries, the traditional hierarchical structure of health care, clinical specialization, faculty experience, and educational isolation. Changing the situation will require an examination of clinical curricula, funding for education, and faculty preparation. Although there was great interest and innovation in multidisciplinary training during the 1960s, little lasting change resulted (Pew Health Professions Commission, 1993). The ability to plan care and practice effectively using multidisciplinary teams takes on increasing importance as the proportion of the population with chronic conditions grows, requiring the provision of a mix of services over time and across settings. A changing relationship between clinicians and their patients also calls for new skills in communication and support for patient self-management, especially for patients with chronic conditions. Collaborative management requires collaboration between clinicians and patients in defining problems, setting goals, and planning care; training and support in self-management; and continuous follow-up (Von Korff et al., 1997). Patients with chronic conditions who are provided with knowledge and skills for self-management have been shown to experience improvements in health status and reduced hospitalizations (Lorig et al., 1999). Clinicians need to have skills to train patients in techniques of good self-management. Teaching a different set of skills also has implications for the capabilities of health care organizations that conduct training programs if these skills and behaviors are to be reinforced in training beyond basic coursework. For example, training can emphasize the importance of information technology in clinical care, but that message is not reinforced if students continue their training in health care organizations that are not equipped with such systems or where the faculty are not prepared to use the skills themselves. This is a particular challenge for training in ambulatory settings and physician offices. Although many would agree that more training needs to be offered in such settings, additional support may be required for this purpose. Although improved methods of training the next generation of clinicians are important, efforts must also be made to retool practicing clinicians. Traditional methods of continuing education for health professionals, such as formal conferences and dissemination of educational materials, have been shown to have little effect by themselves on changing clinician behaviors or health outcomes (Davis et al., 1995). Continuing education needs to emphasize a variety of interventions, particularly reminder systems, academic detailing, and patient-mediated methods, and use a mix of approaches, including Web-based technologies. Reorientation of credentialing processes to assess a clinician’s proficiency in evidence-based practice and the use of decision support tools may be necessary to provide strong incentives for clinicians to undertake this important learning process. The development of clinical leadership is another area that needs attention. Clinical leadership will be required to direct the changes discussed, but there will also be

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Crossing the Quality Chasm: A New Health System for the 21st Century a need for new leaders who are able to function effectively in and lead complex delivery systems. Finally, there are implications for the training and development of nonclinical administrative and management personnel, as well as governance. By making budgetary and resource decisions for health care organizations, these groups, with input from and in collaboration with the clinical community, influence priorities and the pace at which they are implemented. For example, the administration of a hospital can provide sufficient resources to support the implementation of medication order/entry systems that help clinicians provide safer care, or they can slow the pace at which such systems are implemented by not ensuring sufficient resources or training. Training and development for both management and governance should recognize the important role these groups play in collaborating with clinicians to make possible the types of changes needed for the health system of the 21st century. There have been many prior examinations of clinical education, particularly medical education. The structure and form of medical education were set through the Flexner report of 1910. That report called for a 4-year curriculum comprising 2 years of basic sciences and 2 years of clinical teaching, university affiliation (instead of proprietary schools), entrance requirements, encouragement of active learning and limited use of lectures and learning by memorization, and emphasis on the importance of problem solving and critical thinking (Ludmerer, 1999; Regan-Smith, 1998). More than 20 different reports followed Flexner’s, each calling for the reform of medical and clinical education. The striking feature of these reports is their similarity in the problems identified and proposed solutions. Christakis (1995) reviewed 19 reports and found eight objectives of reform among them: serve changing public interest, address physician workforce needs, cope with burgeoning knowledge, foster generalism and decrease fragmentation, apply new educational methods, address the changing nature of illness, address the changing nature of practice, and improve the quality and standards of education. Enarson and Burg (1992) reviewed 13 studies of medical education and summarized the recommended changes under the categories of (1) methods of instruction and curriculum content (including the need for a broad general education, definition of educational objectives, acquisition of lifelong learning skills, and expansion of training sites); (2) internal structure of medical school (including integration of medical education across the continuum of preparation, control of education programs in multidisciplinary and interdepartmental groups, and definition of budget for teaching); and (3) the relationship between medical schools and external organizations (including integration of accreditation processes, assessment of readiness for graduate training, and use of licensing exams). Many believe that changes in medical education are needed. In their survey of medical school deans, Cantor et al. (1991) found that 68 percent believed

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Crossing the Quality Chasm: A New Health System for the 21st Century fundamental change in medical education was needed. This was true for their own institutions as well as medical education overall. Petersdorf and Turner (1995) report that the education given to students is “dated and arcane” and not in tune with societal needs. In interpreting their survey of young physicians, Cantor et al. (1993) found that “while medical training has remained largely unchanged, the demands placed on practicing physicians have changed dramatically.” Some believe that the premises of the current apprenticeship model of medical education are so faulty in today’s complex health care environment that they need drastic overhaul (Chassin, 1998). Others have suggested that “research’s stranglehold on medical education reform needs to be broken by separating researchers from medical student teaching and from curriculum decision making” (Regan-Smith, 1998). Teaching should be an explicit and compensated part of one’s job. Still others have called for new relationships between medical schools and academic health centers that would permit the latter to focus on making the best decisions for patient care and allow medical schools to control education and its location (Thier, 1994). In such a circumstance, academic health centers might be affiliated with several medical schools and medical schools might be affiliated with multiple health centers to allow for greater flexibility by the partners. Medical curriculum has not been static over the years, but has undergone extensive changes (Anderson, 2000; Milbank Memorial Fund and Association of American Medical Colleges, 2000). However, many believe that in general, the current curriculum is overcrowded and relies too much on memorizing facts, and that the changes implemented have not altered the underlying experience of educators and student (Ludmerer, 1999; Regan-Smith, 1998). Despite the changes that have been made, the fundamental approach to clinical education has not changed since 1910. A number of reasons have been cited for so little response to so many calls for reform: Lack of funding to review curriculum and teaching methods and of resources to make changes in them (Griner and Danoff, 2000; Meyer et al., 1997) Emphasis on research and patient care, with little reward for teaching (Cantor et al., 1991; Griner and Danoff, 2000; Ludmerer, 1999; Petersdorf and Turner, 1995; Regan-Smith, 1998) Need for faculty development to ensure that faculty are available at training sites and able to teach students effectively (Griner and Danoff, 2000; Weed, 1981) Decentralized structure in medical schools, with powerful department chairs (Cantor et al., 1991; Marston, 1992; Petersdorf and Turner, 1995; Regan-Smith, 1998) No coordinated oversight across the continuum of education, and fragmented responsibilities for undergraduate and graduate education, licensing, certification, etc. (Enarson and Burg, 1992; Ludmerer, 1999)

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Crossing the Quality Chasm: A New Health System for the 21st Century Difficulty in assessing the impact of changes in teaching methods or curriculum (Ludmerer, 1999) Although much has been written on medical education, future work on the clinical preparation of the workforce should include examining issues related to the education of all health professionals individually and the way they interact with each other. Separation of clinical training programs and dispersed oversight of training programs, especially across the continuum of initial training, graduate training, and continuing development, inhibit the types and magnitude of change in clinical education. For example, various aspects of medical education are affected by the policies of the Liaison Committee on Medical Education, the Association of American Medical Colleges, the Accreditation Council for Graduate Medical Education, 27 residency review committees, the American Board of Medical Specialties and its 24 certifying boards, the Bureau of Health Professions at the Department of Health and Human Services, the American Medical Association, the American Osteopathic Association and its 18 certifying boards, the American Association of Colleges of Osteopathic Medicine, and various professional societies involved in continuing medical education. Similarly, nursing education is influenced by the policies of the American Association of Colleges of Nursing, the National League for Nursing, the American Nurses Credentialing Center, the National Council of State Boards of Nursing, the American Nurses Association, and various specialty nursing societies. Academic health centers and faculty also play a strong role in shaping the education experience of their students. Such diffusion of responsibilities for clinical education makes it difficult to create a vision for health professional education in the 21st century. REGULATION OF THE PROFESSIONS If innovative programs are to flourish, they will require regulatory environments that foster innovation in organizational arrangements, staffing and work relationships, and use of technology. The 21st-century health care system described in this report cannot be achieved without substantial change in the current environment of regulation and oversight. In general, regulation in this country can be characterized as a dense patchwork that is slow to adapt to change. It is dense because there is a forest of laws, regulations, agencies, and accreditation processes through which each care delivery system must navigate at the local, state, and federal levels. It is a patchwork system because the regulatory and accreditation frameworks at the state level are often inconsistent, contradictory, and duplicative, in part because the needs, priorities, and available resources of the states are not equal. And the regulating process is slow in that it is unable to keep pace with changes in health care. The health care delivery system is under great pressure to innovate and change to

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Crossing the Quality Chasm: A New Health System for the 21st Century incorporate new knowledge and technologies. Regulatory and accreditation requirements can, at times, be at odds with needed innovations (Pew Health Professions Commission, 1993). Statutes and regulations, while not the only factors that influence the practices of nonphysician clinicians, are powerful determinants of their authority and independence (Cooper et al., 1998). A key regulatory issue that affects the health care workforce and the way it is used is scope-of-practice acts, implemented at the state level. The general public does not have adequate information to judge provider qualifications or competence, so professional licensure laws are enacted to assure the public that practitioners have met the qualifications and minimum competencies required for practice (Pew Health Professions Commission, 1993; Safriet, 1994). Along with licensure, such state laws that define the scope of practice for specific types of caregivers serve as an important component of the overall system of health care quality oversight. One effect of licensure and scope-of-practice acts is to define how the health care workforce is deployed. In general, medical practice acts are defined broadly so that individual practitioners are licensed for medicine (not a specific specialty), and are thereby permitted to perform all activities that fall within medicine’s broad scope of practice. Although a dermatologist would not likely perform open-heart surgery, doing so is not restricted by licensure. However, patients often seek out information about a physician’s reputation and credentials, and professional societies also monitor the activities of their members. Other health professions have more narrowly defined scopes of practice, having to carve out their responsibilities from the medical practice act in each state (Safriet, 1994). Although scope-of-practice acts are motivated by the desire to establish minimum standards to ensure the safety of patients, they also have implications for the changes to the health care system recommended in this report. Since, any change can potentially affect scope-of-practice acts, it can be difficult to use alternative approaches to care, such as telemedicine, e-visits, nonphysician providers, and multidisciplinary teams, all of which can help in caring for patients across settings and over time (see Chapter 3). Current systems of licensure raise both jurisdictional and liability issues for some clinical applications of telemedicine, such as centralized consultation services to support primary care (Institute of Medicine, 1996b) or the provision of online, continuous, 24-hour monitoring and clinical management of patients in intensive care units for hospitals that have no or too few critical care intensivists on staff to provide this coverage (Janofsky, 1999; Rosenfeld et al., 2000). Integrated delivery systems that cross state lines and telemedicine have rendered geographic boundaries obsolete (Finocchio et al., 1998), making it more difficult for those charged by statute to protect the public. Scope-of-practice acts can include provisions that inhibit the use of nonphysician practitioners, such as advanced practice nurses and physician assistants, for primary care (Pew Health Professions Commission, 1993; Safriet, 1994).

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Crossing the Quality Chasm: A New Health System for the 21st Century In some states, advanced practice nurses can diagnose, treat, and prescribe; in others they work only under the direction of a physician (Cooper et al., 1998). Inconsistencies are exacerbated by variation in the scope of practice by setting of care. For example, advanced practice nurses may be permitted a broader scope of practice in rural areas or community health clinics than in other settings (Safriet, 1994). Such policies are enacted to address problems of underservice that exist in certain areas. Although patient needs do not necessarily differ in rural versus urban areas of a state, the available resources of talent, capital, and personnel often vary considerably. Scope-of-practice acts can also affect the ability to form cohesive care teams that draw on individuals from different disciplines to complement one another in patient care. The skills of some nonphysician providers may overlap with a subset of physician services, often creating tensions among clinicians (Cooper et al., 1998). For example, although there is a difference in their knowledge and training for practice, certified registered nurse anesthetists and anesthesiologists have a subset of skills that overlap (Cromwell, 1999). Separate governance structures and standards are maintained for different types of health professionals even though they may perform a subset of overlapping functions, practice together in the same state and at the same health care institutions, and serve the same population of patients (Finocchio et al., 1998). The complexity of rules across disciplines and settings makes it a challenge to form multidisciplinary teams and establish best practices, especially those that draw on caregivers based in different settings (e.g., hospital, physician’s office, and home). Scope-of-practice laws are not the only barrier to greater use of multidisciplinary teams (Sage and Aiken, 1997), but are an important one. Because licensure and scope-of-practice acts are implemented at the state level, there is a great deal of variation among the states in who is licensed and what standards for licensure and practice are applied. State licensure is not constitutionally based, but rather founded in tradition (Safriet, 1994). On the one hand, state licensure permits regulations to be tailored to meet local needs, resources, and patient expectations. On the other hand, the resulting state-by-state variation is not always logical given the growth of the Internet and the formation of large, multistate provider groups that cut across geographic boundaries. Even with new technologies and organizational arrangements, however, public protections must still be ensured. In response, some have proposed nationally uniform scopes of practice (O’Neil and the Pew Health Professions Commission, 1998) or, at least, more coordinated, publicly accountable policies (Grumbach and Coffman, 1998). The National Council of State Boards of Nursing has endorsed a mutual recognition model for interstate nursing practice that retains state licensure authority, but provides a mechanism for practice across state lines (similar to a driver’s license that is granted by one state and recognized in other states) (Finocchio et al., 1998). Still others have argued the relative merits of state-based versus national licensing systems (Federation of State Medical Boards, 1998).

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Crossing the Quality Chasm: A New Health System for the 21st Century The committee does not recommend one approach over another, but does call for greater coordination and communication among professional boards both within and across states as this issue is resolved over time. Although the preceding examples suggest that some regulations may be duplicative or outdated for today’s clinical practice, gaps exist in other areas as well. For example, current licensure and scope-of-practice laws offer no assurance of continuing competency. In a field with a continually expanding knowledge base, there is no mechanism for ensuring that practitioners remain up to date with current best practices. Responsibility for assessing competence is dispersed among multiple authorities. For example, a licensing board may question competence only if it receives a complaint, but does not routinely assess competency after initial licensure. A health care organization may assess competence when an individual applies for privileges or employment. Professional societies and organizations may require examination for certification, but are just beginning to assess competence in addition to knowledge for those health professionals who voluntarily seek certification. There are no consistent methods for ensuring the continued competence of health professionals within current state licensing functions or other processes. At least two approaches have been suggested to address this gap. First, some researchers have suggested that licensure be based on a professional’s demonstrated ability to perform certain functions or on a certain level of practice (Cooper et al., 1998; Weed and Weed, 1999b). In aviation, for example, pilots are granted a private, commercial, or air transport license by the Federal Aviation Administration. Generally, pilots first obtain a private, single-engine license and then progressively add multi-engine and instrument qualifications to obtain a commercial license. They can then accumulate flying hours and experience to qualify for an air transport license, subsequently obtaining particular types of ratings for specific aircraft (Bisgard, 2000). In addition, professional pilots are recertified at regular intervals throughout their flying career. Taking such an approach in health care would represent a profound paradigm shift, with a gradation of licensure being based on the services in which a health professional has demonstrated competence to serve patients. A second approach has been suggested, involving an additional level of oversight in which teams of practitioners, in addition to individuals, would be licensed or certified to perform certain tasks (Pew Health Professions Commission, 1993). For example, an individual receiving care for diabetes could go to a “certified” diabetes team that would ensure specific competencies and resources within the delivery team. The team could be collocated or comprise a dispersed network of individual providers practicing and communicating with each other as a team. The certification requirements could be used as a measure of quality by consumers and as a tool for quality improvement by teams seeking to obtain such certification.

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Crossing the Quality Chasm: A New Health System for the 21st Century It would be premature for the committee to offer a recommendation related to licensure, scope-of-practice, or other regulations. In raising these issues, however, we recognize their importance in supporting or hindering the types of changes recommended in this report. Thus we call for additional, in-depth study aimed at understanding the areas and forms of regulation that are most beneficial for patients and in which modification may be needed to achieve the 21st-century health care system envisioned in this report. Properly conceived and executed, regulation can both protect the public’s interest and support the ability of health care professionals and organizations to innovate and change to meet the needs of their patients. LEGAL LIABILITY ISSUES The recommendations in this report represent, in many instances, a very different way of delivering services to patients. Achieving the aims set forth in Chapter 2 will require significant innovations in the delivery of care, innovations that may also raise concerns associated with traditional forms of accountability, especially liability issues. Delivering care that is patient-centered, evidence-based, and systems-minded has implications for traditional methods of accountability, particularly with regard to patients’ participation in their care, efforts to define standards of care consistent with the evidence base rather than local traditions, and the responsibilities of individual practitioners who deliver care within larger systems that have the capacity for improvement. Innovations in care can contribute to increased threats of litigation because, by definition, innovation implies a change from previous practice, and medical advances are often imperfect when first applied in clinical practice. Mohr (2000) cites an early example of compound fractures. Through a change in treatment, patients may have avoided an amputation, but they did not always regain full functioning of the limb and pursued litigation against the physician. Significant innovation in health care will occur in many areas with the use of new processes of care and new technologies that will alter how and by whom services are delivered to patients. It is not yet clear how these new processes and technologies, such as e-mail, will affect the liability of health professionals in the future. Although less studied, changes in organizational approaches raise similar issues. For example, patients may receive care from members of a care team other than a physician or be counseled by e-mail rather than in a face-to-face visit. Such changes can be disorienting to patients if not well understood and in the short run, and create new hazards and new risks of litigation. Thus there is a need for good educational efforts and communication with patients about the changes taking place. It is also necessary, however, to examine the extent to which current liability approaches inhibit the kinds of changes needed to improve the quality and safety of care. For example, liability concerns can affect the

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Crossing the Quality Chasm: A New Health System for the 21st Century willingness of physicians and other clinicians to share information about areas in which quality improvement is needed if they believe the information may subsequently be used against them (Institute of Medicine, 2000). The committee’s previous report on patient safety calls for peer review protection of data that are used inside health care organizations or shared with others solely for purposes of improving safety and quality, as well as an improved climate for identifying areas needing improvement (Institute of Medicine, 2000). Legal issues are also likely to influence the development of evidence-based practice. The legal system influences health care through two types of decisions—medical malpractice and benefits coverage—both of which involve judgments about the quality of care (Rosoff, 2001). Should the legal system fail to incorporate evidence-based thinking into its decision-making processes (whether related to medical malpractice or other decisions), clinicians and health care organizations will be subject to confusing and conflicting incentives and demands. Legal decisions that involve determining whether care provided was consistent with the “standard practice in the relevant medical community” (Rosoff, 2001) often rely on expert testimony. It is unclear how courts will incorporate clinical evidence and clinical practice guidelines into legal decision making. To date, clinical practice guidelines have had little effect on litigation. In a legal search covering the period January 1980 to May 1994, Hyams et al. (1996) found only 37 cases involving clinical practice guidelines. But clinical practice guidelines probably have had some effect on prelitigation decisions, since surveys show that medical malpractice attorneys consider guidelines in making decisions about whether to take on malpractice cases and conducting settlement negotiations (Hyams et al., 1996). Alternative approaches to liability, such as enterprise liability or no-fault compensation, could produce a legal environment more conducive to uncovering and resolving quality problems. Enterprise liability shifts liability from individual practitioners to responsible organizations (Abraham and Weiler, 1994; Sage et al., 1994). For example, workplace injuries to employees are handled through a form of no-fault, enterprise liability. Although analysis of such approaches is beyond the scope of the present study, the committee believes they merit a focused, in-depth analysis. RESEARCH AGENDA FOR THE FUTURE HEALTH CARE WORKFORCE Modifying training, regulatory, and legal environments is not a quick strategy for changing practice. These environments are closely interrelated with the delivery setting. Training programs are not likely to change unless the delivery setting does so, but the setting cannot change if people are not trained to practice differently. Similarly, the delivery setting cannot change without modifications

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Crossing the Quality Chasm: A New Health System for the 21st Century in regulation and legislation, but adjustments in practice often prompt additional regulation to protect against unwanted consequences. A comprehensive approach is needed for the many aspects of health care workforce planning. Many prior efforts in such planning have focused on attempting to determine an appropriate supply of clinicians. Previous studies have examined the adequacy of supply for selected disciplines (e.g., physicians) or the mix of providers within a discipline (e.g., primary care and specialty mix of physicians), or have assumed a specific organizational model (e.g., supply of physicians needed given extensive enrollment in HMOs). Although a comprehensive workforce agenda should address issues of supply, it would be difficult to conduct any such studies meaningfully without first addressing how clinicians might be deployed given different approaches to training, regulation, and liability. It is not sufficient to ask how many health professionals are needed; one must also ask what types are needed (Pew Health Professions Commission, 1993). Ultimate assessments of supply depend on how responsibility for patients is divided among licensed clinicians, as well as on society’s expectations (Cromwell, 1999). Workforce planning should shift from determining the supply of clinicians in specific disciplines who continue to perform the same tasks using the same methods toward assessing the adequacy of supply given that care is provided through processes that rely on multidisciplinary approaches, modern technological support, and continuous care. The starting point for addressing workforce issues should not be the present environment of licensure, reimbursement, and organization of care, but a vision of how care ought to be delivered in the 21 st century. A comprehensive agenda on workforce planning should cover the following key issues: Training and Education Issues What is the vision for the education and training of health professionals for the 21st century? What is the relationship between the education of health care providers and quality of care? How is the vision relayed throughout the continuum of education? How can new health professionals learn most effectively the basic skills related to patient-centeredness, evidence-based practice, and systems thinking? How can such skills be reinforced in graduate training programs? How can they be meaningfully relayed to professionals already in practice? What are the implications of changes in clinical education for the health care organizations that serve as training sites? What is the potential effect on the role and mission of academic health centers? What are the implications of changes in clinical education for licensing and accreditation processes? For funding approaches to support clinical education?

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Crossing the Quality Chasm: A New Health System for the 21st Century Legal and Regulatory Issues How can regulatory and other oversight processes be coordinated to reinforce the principles of patient-centeredness, evidence-based practice, and systems thinking? What specific legal and regulatory constraints inhibit changes in processes of care? Where are different types of regulations needed? In what areas can existing regulations be streamlined or reduced? How can greater coordination among licensing boards within an individual state and across states be facilitated? How can the continuing competence of health professionals be assessed and ensured? Can liability reform support the principles of patient-centeredness, evidence-based practice, and systems thinking? Are alternative models, such as enterprise liability, desirable? What is the link between regulation of health professions and quality of care? What are the appropriate links among licensure, accountability, and liability? Workforce Supply Given a greater understanding of the previous issues (e.g., what training is provided, the need for greater flexibility in deploying human resources, and alternative approaches to accountability), what are the implications for the needed supply and mix of health professionals? REFERENCES Abraham, Kenneth S. and Paul C.Weiler. Enterprise Medical Liability and the Choice of the Responsible Enterprise. American Journal of Law and Medicine 20(1 & 2):29–36, 1994. Anderson, Brownell M., ed. A Snapshot of Medical Students’ Education at the Beginning of the 21st Century: Reports from 130 Schools. Academic Medicine 75(9, Suppl), 2000. Berwick, Donald M., A.Enthoven, and J.P.Bunker. Quality Management in the NHS: The Doctor’s Role—II. BMJ 304:304–8, 1992. Bisgard, J.Cris, Delta Airlines, Oct. 26, 2000. Personal communication: e-mail. Cantor, Joel C., Laurence C.Baker, and Robert G.Hughes. Preparedness for Practice: Young Physicians’ Views of Their Professional Education. JAMA 270(9):1035–40, 1993. Cantor, Joel C., Alan B.Cohen, Dianne C.Barker, et al. Medical Educators’ Views on Medical Education Reform. JAMA 265(8):1002–6, 1991. Chassin, Mark R. Is Health Care Ready for Six Sigma Quality? Milbank Quarterly 76(4):575–91, 1998. Christakis, Nicholas A. The Similarity and Frequency of Proposals to Reform U.S. Medical Education: Constant Concerns. JAMA 274(9):706–11, 1995. Cooper, Richard A., Tim Henderson, and Craig L.Dietrich. Roles of Nonphysician Clinicians as Autonomous Providers of Patient Care. JAMA 280(9):795–802, 1998. Cromwell, Jerry. Barriers to Achieving a Cost-Effective Workforce Mix: Lessons from Anesthesiology. Journal of Health Politics, Policy and Law 24(6):1331–61, 1999.

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