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

pneumonia, 227, 258

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



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Crossing the Quality Chasm: A New Health System for the 21st Century 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 pneumonia, 227, 258 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

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Crossing the Quality Chasm: A New Health System for the 21st Century 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 effectiveness, 6, 46–48 efficiency, 6, 52–53 equity, 6, 53 establishing, 5–7 patient-centeredness, 6, 48–51 safety, 5, 44–46 timeliness, 6, 51–52 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 Arthritis, 91, 103 Assets, providing for positive change, 13 Association of American Medical Colleges, 214 Asthma, 91, 103 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 Back problems, 91, 103 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

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Crossing the Quality Chasm: A New Health System for the 21st Century 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 Cancer, 91, 103 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 redesigning, 11, 117–127 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

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Crossing the Quality Chasm: A New Health System for the 21st Century 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 cooperation among, 9, 62, 83 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 recommendations to, 5, 34 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

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Crossing the Quality Chasm: A New Health System for the 21st Century 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 recommendations to, 5, 34, 40 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 Emphysema, 91, 103 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

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Crossing the Quality Chasm: A New Health System for the 21st Century 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 Gall bladder disease, 91, 103 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 recommendations to, 19, 182 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 recommendations to, 5, 34 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

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Crossing the Quality Chasm: A New Health System for the 21st Century High cholesterol, 91, 103 High Level 7, 172 Hip fractures, acute care of, 259 HIV/AIDS, 91, 97, 103, 134 Homeostasis, 137 Human factors issues, with automated clinical information, 175–176 Hyper Text Markup Language (HTML), 316 Hypertension, 91, 103 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 six aims for, 6, 40–54 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 free flow of, 8, 62, 72–75 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 Ischemic heart disease, 91, 97, 103

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Crossing the Quality Chasm: A New Health System for the 21st Century 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 MEDLINE, 156–157, 233 MEDLINEplus, 156–157, 233 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

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Crossing the Quality Chasm: A New Health System for the 21st Century 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 MEDLINE, 156–157, 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 anticipation of, 8, 62, 80–81 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

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Crossing the Quality Chasm: A New Health System for the 21st Century information, communication, and education, 50 involvement of family and friends, 50 movement toward, 113, 115–116 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 acute care of, 227, 258 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 for public health, 167, 169 for research, 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

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Crossing the Quality Chasm: A New Health System for the 21st Century 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 arthritis, 91, 103 asthma, 91, 103 back problems, 91, 103 cancer, 91, 103 cardiac rehabilitation, 170 chronic heart failure, 97 criteria for identifying, 103 depression and anxiety disorders, 91, 97, 103 diabetes, 91, 97, 103, 170 domestic violence, 134 emphysema, 91, 103 gall bladder disease, 91, 103 heart failure, 102 high cholesterol, 91, 103 HIV/AIDS, 91, 97, 103, 134 hypertension, 91, 103 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 stomach ulcers, 91, 103 stroke, 91, 97, 103 substance abuse, 97, 134 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

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Crossing the Quality Chasm: A New Health System for the 21st Century 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 RAND Corporation, 24, 226 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 clinicians, 5, 8–9, 34 to Congress, 7, 11, 17, 166 to consumers, 5, 34 to Department of Health and Human Services, 5, 34, 40 to educational institutions, 5, 34 to executive branch, 17, 166 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 health professions, 5, 34 to leaders of health care organizations, 17, 166 to patients, 5, 8–9, 34 to policymakers, 5, 34 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 regulators, 5, 34 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

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Crossing the Quality Chasm: A New Health System for the 21st Century 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

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Crossing the Quality Chasm: A New Health System for the 21st Century 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 Stomach ulcers, 91, 103 Stroke, 91, 97, 103 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 Substance abuse, 97, 134 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 vision of, 54–56, 115–117 waste continuously decreased, 9, 62, 81–83 U UCLA/RAND appropriateness method, 239 Underlying reasons for inadequate quality of care, 25–33

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Crossing the Quality Chasm: A New Health System for the 21st Century 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 Visa International, 65, 316 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 World Wide Web, 30, 154 health information found on, 31 technologies based on, 211 Y Year 2000 Health Plan Employer Data and Information Set, 157, 159