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Suggested Citation:"Index." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Suggested Citation:"Index." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Suggested Citation:"Index." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Suggested Citation:"Index." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Suggested Citation:"Index." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Suggested Citation:"Index." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Suggested Citation:"Index." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Suggested Citation:"Index." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Suggested Citation:"Index." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Suggested Citation:"Index." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Suggested Citation:"Index." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Suggested Citation:"Index." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Suggested Citation:"Index." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Suggested Citation:"Index." Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. doi: 10.17226/10027.
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Index A shared-risk (budget) arrangements, 201 to support quality improvement, 199-201 Access Adaptive systems thinking, reconciling with to care studies, 235 mechanical, 311-312 to medical knowledge-base, 31 Adjusted clinical groups (ACGs), 195-196 Accidental injury, IOM definition of, 45 Administrative management personnel, Accreditation Council for Graduate Medical retraining nonclinical, 212 Education, 214 Administrative transactions, potential benefits ACP Journal Club, 145 of information technology for, 167-168 Action steps, 89-110 Adult respiratory distress symptom, 77 needed now, 2-4 Adverse events, misuse leading to, 304-305 Actual care and ideal care, gaps between in Adverse risk selection U.S., 236-238 adjusted clinical groups (ACGs), 195-196 Acute care. See also Inappropriate acute care; blocking quality improvement in current Priority conditions payment methods, 195-197 hip fractures, 259 clinical risk groups (CRGs), 196 otitis media, 259 diagnostic cost groups (DCGs), 196 pneumonia, 227, 258 Advisory Commission on Consumer Protection pregnancy and delivery, 260-264 and Quality in the Health Care Industry, underuse of, 258-264 6, 24, 39, 231 urinary tract infections, 259-260 Agency for Health Care Policy and Research. Acute myocardial infarction, 102 See Agency for Healthcare Research Adaptable elements, in complex adaptive and Quality (AHRQ) systems, 313 Agency for Healthcare Research and Quality Adapting existing payment methods (AHRQ), 10, 105 blended, 200-201 Center for Organization and Delivery capitation, 200 Studies, 105 fee-for-service, 199 323

324 INDEX Evidence-Based Practice Centers, 14, 145, American Nurses Credentialing Center, 214 150-151 American Osteopathic Association, 214 Integrated Delivery System Research American Society for Testing and Material, 172 Network, 105 American Standards Committee, 172 National Guideline Clearinghouse, 151, 157 American Thoracic Society, 192 recommendations to, 10, 12, 19-20, 90-91, Annual contracting arrangements, blocking 182, 184, 208 quality improvement in current payment Translating Research into Practice, 155 methods, 197 Agenda for crossing the chasm, 5-20 Antibiotic use, inappropriate acute care building organizational supports for change, involving, 292-295 11-12 Anticipation of needs, 8, 62, 80-81 establishing a new environment for care, current approach—react to needs, 81 13-20 new rule—anticipate needs, 81 establishing aims for the 21st-century health Anxiety. See also Depression and anxiety care system, 5-7 disorders formulating new rules to redesign and relieving, 50 improve care, 7-9 Applications of priority conditions, 96-103 taking the first steps, 9-11 organize and coordinate care around patient Agenda for the future, 33-35 needs, 98-100 Aging of the population, 26 provide a common base for the Aims for the 21st-century health care system, development of information technology, 5-6, 39-54 101 conflicts among, 53-54 reduce suboptimization in payment, 101-102 effectiveness, 6, 46-48 simplify quality measurement, evaluation of efficiency, 6, 52-53 performance, and feedback, 102-103 equity, 6, 53 synthesize the evidence base and delineate establishing, 5-7 practice guidelines, 97-98 patient-centeredness, 6, 48-51 Arthritis, 91, 103 safety, 5, 44-46 Assets, providing for positive change, 13 timeliness, 6, 51-52 Association of American Medical Colleges, Alzheimer’s disease and other dementias, 91, 103 214 American Academy of Physicians, 158 Asthma, 91, 103 American Association of Colleges of Nursing, chronic care of, 264-265 214 inappropriate acute care of, 296 American Association of Colleges of Automated clinical information, 170-176 Osteopathic Medicine, 214 financial requirements, 174-175 American Association of Health Plans, 151, human factors issues, 175-176 157 privacy concerns and need for standards, American Board of Medical Specialties, 214 171-174 American College of Physicians, 150, 158 American College of Physicians’ Journal Club, 150 B American Customer Satisfaction Index, 46 Back problems, 91, 103 American Diabetes Association, 158 Balanced Budget Act, 174 American Medical Association, 151, 157, 159, 214 Baldrige Award. See Malcolm Baldrige National Quality Award Code of Ethics, 45 Barriers to quality improvement in current American National Standards Institute, Healthcare Informatics Standards Board, payment methods, 191-199 adverse risk selection, 195-197 172 annual contracting arrangements, 197 American Nurses Association, 214 perverse payment mechanisms, 191-195

INDEX 325 up-front investments required by provider staff), 107-108 groups, 197-199 Pearl Clayton (mental health), 81 “Batch size of one,” 125 Cataracts, inappropriate acute care of, 302 Behavioral change, patients’ need for, 28 Center for Organization and Delivery Studies, Benefits of information technology, 166-170 105 Bill of Rights, 64 Centers for Disease Control and Prevention, 156 Biological approach, 314-315 Centers of Excellence, 100, 106 Biomedical research, increasing investments in, Change 25 building organizational supports for, 11-12 Blended payment methods in the health care environment, responding adapting, 200-201 to, 138 incentives of current, 188-189 leadership for managing, 137-140 British Medical Journal, 150 providing assets and encouragement for Bronchitis, inappropriate acute care of, 296 positive, 13 Budget approaches, incentives of current, 186- providing the resources needed to initiate, 187 103-108 Building organizational supports for change, Changes in Health Care Financing and 11-12 Organization Program, 105 Bureau of Health Professionals, 214 CHESS database, 55 Bureau of Primary Health Care, Quality Center, Chronic care 91 asthma, 264-265 Buyers Health Care Action Group, 200 cancer, 274-279 cardiovascular disease, 279-291 diabetes mellitus, 265-268 C hypertension, 269-270 mental/addictive disorder, 272-274 Cancer, 91, 103 mental health, 270-272 chronic care, 274-279 peptic ulcer disease, 269 screening, 251-253 underuse of, 264-291 Cancerfacts.com, 55 Chronic conditions, 3-4. See also Priority Capitation payment, adapting, 200 conditions Cardiac care problems, findings about, 227 health care for, 9 Cardiac rehabilitation, 170 increase in, 26-27 Cardiac risk factors, 254-257 Chronic heart failure, 97 Cardiovascular disease Clinical care, potential benefits of information chronic care of, 279-291 technology for, 167-168 inappropriate acute care of, 298-301 Clinical decision support system (CDSS), 151- Care processes 155 establishing new environment for, 13-20 Clinical education and training redesigning, 11, 117-127 changes in health professional education Carotid arteries, inappropriate acute care of, required, 210 302 curricular changes required, 209-210 Case histories new or enhanced skills required by health chronic care (using partnership to improve), professionals, 209 107 opportunities for multidisciplinary training, Henry L. (HIV positive), 69 210-211 hospital emergency department (improving reasons for little change in traditional timeliness of services), 107 clinical education, 213-214 Mary Chao (diabetes educator), 75 retooling practicing clinicians, 211-212 Maureen Waters (care as it could be), 54-56 retraining nonclinical administrative Ms. Martinez (failed care), 41-44, 49, 51 management personnel, 212 patient-centered primary care (reorganizing

326 INDEX Clinical evidence, synthesizing, 148-152 good enough vision, 315-317 Clinical Evidence, 150 simple rules, 315-317 Clinical expertise, access to necessary, 29 wide space for innovation, 315-317 Clinical information, automated, 170-176 Comprehensive national health information Clinical integration, 133 infrastructure, 176 Clinical knowledge and skills, managing, 12, Computer-aided decision support systems, 31 128-130 Computer-based clinical decision support Clinical risk groups (CRGs), 196 systems (CDSS), 152-155 Clinical Roadmap team, 135 Congress, recommendations to, 7, 11, 17, 166 Clinicians Constraints on exploiting information cooperation among, 9, 62, 83 technology recommendations to, 5, 8-9, 34 access to medical knowledge-base, 31 retooling practicing, 211-212 computer-aided decision support systems, Co-evolution, in complex adaptive systems, 314 31 Cochrane Collaboration, 13, 145, 149-150 enhanced patient and clinician Code of Ethics, 45 communication, 31-32 Collaborative Review Groups, 149 reduction in errors, 31 Comfort. See Physical comfort Consumers Committee on the Quality of Health Care in potential benefits of information technology America, 1, 23-24, 31, 225 for health of, 166-168 Technical Advisory Panel on the State of recommendations to, 5, 34 Quality, 24 Context, in complex adaptive systems, 314 Communication, 50 Continuous access, 68 enhanced patient and clinician, 31-32 Continuous flow, 125-126 Community health needs, identify and redesigning care processes for, 124-126 prioritize, 138 Continuous healing relationships, care based Competency, ensuring continuing, 217 on, 8, 61, 66-69 Complex adaptive systems (CAS), 309-317 Control, patient as the source of, 8, 61, 70-72 adaptable elements, 313 Cooperation, among clinicians, 9, 62, 83 co-evolution, 314 Coordinating care, across patient conditions, complexity thinking applied to design of the services, and settings over time, 12, 49- 21st-century health care system, 314-317 50, 133-135 context and embeddedness, 314 Coronary artery bypass graft (CABG) surgery, emergent behavior, 313 241 health care organizations as, 63-66 CPG Infobase, 157 inherent order, 313-314 Criteria non-predictable in detail, 313 for identifying priority conditions, 103 nonlinearity, 313 for including studies, 234 novelty, 313 Crossing the chasm, 5-20 reconciling mechanical and adaptive building organizational supports for change, systems thinking, 311-312 11-12 science of complex adaptive systems, 312- establishing a new environment for care, 314 13-20 simple rules, 313 establishing aims for the 21st-century health systems thinking, 309-311 care system, 5-7 Complex health care conditions, patients with, formulating new rules to redesign and 122 improve care, 7-9 Complexity thinking applied to design of the taking the first steps, 9-11 21st-century health care system, 314-317 Current payment methods biological approach and evolutionary barriers to quality improvement in, 191-199 design, 314-315 incentives of, 184-191

INDEX 327 Current Procedural Technology (CPT) coding, E 199 Curricula, changes required, 209-210 Education issues, 50 Customization for the future health care workforce, 220 based on patient needs and values, 8, 61, Educational institutions, recommendations to, 69-70 5, 34 mass, redesigning care processes for, 123- Effectiveness, 46-48 124 21st-century health care system, 6 Efficiency, 52-53 improvements in, 164 D 21st-century health care system, 6 80/20 principle, system design using, 120-122 Dana-Farber Cancer Institute, 45 Embeddedness, in complex adaptive systems, Deaths, misuse leading to preventable, 304 314 Decision making, evidence-based, 8, 62, 76-77 Emergent behavior, in complex adaptive Decision support systems, computer-aided, 31, systems, 313 152-155 Emotional support, 50 Delineating practice guidelines, 97-98 Emphysema, 91, 103 Delivery systems Encouragement, providing for positive change, highly fragmented, 112-114 13 poorly organized, 28-30 Environment for care Dementia. See Alzheimer’s disease and other aligning payment policies with quality dementias improvement, 17-19 Department of Health and Human Services, applying evidence to health care delivery, 171-172 13-15 Bureau of Health Professionals, 214 establishing new, 13-20 recommendations to, 5, 34, 40 focus and align environment toward the six Department of Veterans Affairs, 128, 171 aims for improvement, 13 Depression and anxiety disorders, 91, 97, 103 preparing the workforce, 19-20 inappropriate acute care of, 297 provide assets and encouragement for Design for safety positive change, 13 designing procedures that can mitigate harm using information technology, 15-17 from errors, 123 Equity, 53 designing procedures to make errors visible, 21st-century health care system, 6 123 Errors designing systems to prevent errors, 122-123 designing procedures to make visible, 123 redesigning care processes for, 122-123 designing systems to prevent, 122-123 Developing effective teams, 12, 130-133 reduction in, 31 Diabetes Control and Complications Trial, 96 “Essential technology,” 171 Diabetes mellitus, 91, 97, 103, 170 Evidence-Based Cardiovascular Medicine, 150 chronic care of, 265-268 Evidence-based care, 28 Diabetes Quality Improvement Project, 158 Evidence-based decision making, 8, 62, 76-77, Diagnosis, using computer-based clinical 145-163 decision support systems for, 152-154 background, 147-148 Diagnosis related groups (DRGs), 187, 192 defining quality measures, 157-159 Diagnostic cost groups (DCGs), 196 in health care delivery, 13-15, 145-163 Disease management programs, 99-100 making information available on the “Doc Talk” form, 72 Internet, 155-157 Domestic violence, 134 synthesizing clinical evidence, 148-152 “Double-loop” learning, 136 using computer-based clinical decision Drugs, using computer-based clinical decision support systems, 152-155 support systems for prescribing of, 153 Evidence-Based Medicine, 150

328 INDEX Evidence-Based Mental Health, 150 Healing relationships, care based on Evidence-Based Nursing, 150 continuous, 8, 61, 66-69 Evidence-Based Practice Centers, 14, 145, 150- Health care conditions, patients with rare or 151 complex, 122 “Evidence formulary,” 150 Health care constituencies, recommendations Evolutionary design, 314-315 to, 5, 34 Executive branch, recommendations to, 17, 166 Health care delivery, applying evidence to, 13- Expressed needs, respect for patients’, 49 15 Health care environment, obtaining resources and responding to changes in, 138 F Health Care Financing Administration, 196 Centers of Excellence, 100, 106 FACCT|ONE, 158 Foundation for Accountability, 158 Family, involvement of, 50 Medicare Participating Heart Bypass Center Fear, relieving, 50 demonstration, 188 Fee-for-service payment, adapting, 199 Office of Research and Development, 106 Financial requirements, for automated clinical Peer Review Organizations, 158 information, 174-175 recommendations to, 19, 182 Financial transactions, potential benefits of Health care needs, of medium predictability, information technology for, 167-168 121-122 First steps Health care organizations applications of priority conditions, 96-103 as complex adaptive systems, 63-66 criteria for identifying priority conditions, 103 key challenges for the redesign of, 117-137 providing the resources needed to initiate recommendations to, 6, 8-9, 34, 39-40 change, 103-108 recommendations to leaders of, 17, 166 value of organizing around priority Health Care Quality Innovation Fund, 11 conditions, 92-96 recommendations to, 91-92, 103-106, 166 Follow-up, patients’ needs for greater, 28 Health care system, for the 21st-century, 6, 23- Food and Drug Administration, 26, 156 60 Foundation for Accountability, 158 Health care trustees and management, Free flow of information, 8, 62, 72-75 recommendations to, 5, 34 Friends, involvement of, 50 HEALTH database, 233 Funding over several years, to ensure sustained Health informatics associations and vendors, and stable funding source, 104 recommendations to, 17, 166 Health Insurance Portability and Accountability Act, 173 G Health Plan Employer Data and Information Gall bladder disease, 91, 103 Set (HEDIS), 157, 159, 240, 242 Gastrointestinal disease, inappropriate acute Health Planning and Administration, HEALTH care of, 302 database, 233 General preventive care, 257 Health professional education, changes Genomics, 2 required, 210 Good enough vision, 315-317 Health professionals Group Health Cooperative of Puget Sound, 105 new or enhanced skills required by, 209 recommendations to, 5, 34 Health professions, recommendations to, 5, 34 H Health Resources Services Administration, Bureau of Primary Health Care, 91 Harm from errors, designing procedures that Healthcare Informatics Standards Board, 172 can mitigate, 123 HealthTopics, 157 Harris Poll results, 46, 166-167 Heart failure, 102

INDEX 329 High cholesterol, 91, 103 Information, 50 High Level 7, 172 about patients, their care, and outcomes, 95 Hip fractures, acute care of, 259 automated clinical, 170-176 HIV/AIDS, 91, 97, 103, 134 free flow of, 8, 62, 72-75 Homeostasis, 137 making available on the Internet, 155-157 Human factors issues, with automated clinical patients’ need for, 28 information, 175-176 strong focus on patient, 95 Hyper Text Markup Language (HTML), 316 Information systems, supportive, 29 Hypertension, 91, 103 Information technology (IT), 164-180 chronic care of, 269-270 automated clinical information, 170-176 Hysterectomy, inappropriate acute care constraints on exploiting, 30-33 involving, 297 making effective use of, 12, 127-128 need for a national health information infrastructure, 176-177 I potential benefits of, 166-170 provide a common base for the Ideal care and actual care, gaps between in development of, 101 U.S., 236-238 using, 15-17 Identifying community health needs, 138 Infrastructure investments, 198-199 Immediate needs, 2-4 Inherent order, in complex adaptive systems, Immunizations, 250-251 313-314 Improvement of care Innovation, wide space for, 315-317 formulating new rules to, 7-9 Institute for Healthcare Improvement, 91 six aims for, 6, 40-54 Institute of Electrical and Electronics Inadequate quality of care Engineers, 172 constraints on exploiting information Institute of Medicine (IOM), 13, 17, 23-24, technology, 30-33 100, 103, 136-137, 165, 171, 191, 199 growing complexity of science and definition of accidental injury, 45 technology, 25-26 definition of quality, 232 increase in chronic conditions, 26-27 National Roundtable on Health Care poorly organized delivery system, 28-30 Quality, 23 underlying reasons for, 25-33 Quality of Health Care in America Project, Inappropriate acute care 225 antibiotic use, 292-295 Technical Advisory Panel on the State of bronchitis/asthma, 296 Quality, 24, 226, 231-232, 234 cardiovascular disease, 298-301 Insurance coverage. See Equity carotid arteries, 302 Integrated Delivery System Research Network, cataracts, 302 105 depression, 297 Integration of care, 49-50 gastrointestinal disease, 302 Intensive care unit (ICU) patients, 77 hysterectomy, 297 Interdependence of changes, recognizing at all low back pain, 303 levels, 139-140 otitis media, 296 Intermountain Health Care, 105, 128, 171, 191, respiratory illness, 295 201 U.S. examples of, 292-303 Internet, 16, 30-32, 65, 154-155, 167, 176, 316 Incentives of current payment methods, 184-191 making information available on, 155-157 blended methods, 188-189 secure applications, 127 budget approaches, 186-187 Investing, in the workforce, 139 charted, 190 Involvement, of family and friends, 50 payment by unit of care, 187-188 Ischemic heart disease, 91, 97, 103 per case payment, 187

330 INDEX J M Joint Commission on the Accreditation of Malcolm Baldrige National Quality Award, Healthcare Organizations, 102, 157 119, 136-137 Journal of Evidence-Based Health Care, 150 Managed care, affect on quality in U.S., 238 Management, using computer-based clinical decision support systems for, 152-154 K Managing change, leadership for, 137-140 Managing clinical knowledge and skills, 12, Kaiser-Permanente Health Plan, 105, 196 128-130 Key challenges for the redesign of health care Mass customization, redesigning care processes organizations, 117-137 for, 123-124 coordinating care across patient conditions, Mechanical systems thinking, reconciling with services, and settings over time, 12, adaptive, 311-312 133-135 Medical Expenditure Panel Survey (MEPS), 10, developing effective teams, 12, 130-133 91, 103 incorporating performance and outcome Medical knowledge-base, access to, 31 measurements for improvement and Medical Subject Headings (MeSH), 233 accountability, 12, 135-137 Medicare and Medicaid, 150, 174, 187 making effective use of information Medicare Participating Heart Bypass Center technologies, 12, 127-128 demonstration, 188 managing clinical knowledge and skills, 12, Medicare Peer Review Organizations, 227 128-130 Medicine, distinct cultures of, 78 redesigning care processes, 11, 117-127 Medium predictability, health care needs of, Knowledge-base, access to medical, 31 121-122 MEDLINE, 156-157, 233 MEDLINEplus, 156-157, 233 L Mental/addictive disorder, chronic care of, 272- LDS Hospital, 77 274 Leaders of health care organizations Mental health multidisciplinary summit of, 19, 208 chronic care of, 270-272 recommendations to, 17 misuse leading to, 306 Leadership for managing change, 137-140 Mergers, acquisitions, and affiliations, 3 help obtain resources and respond to Methodology changes in health care environment, 138 criteria for including studies, 234 identify and prioritize community health in the review of the literature, 233-236 needs, 138 types of studies not included, 234-236 invest in the workforce, 139 Midcourse corrections, public funding for mix optimize performance of teams that provide of projects to permit, 105 various services, 138-139 Misuse, 304-307 recognize the interdependence of changes at adverse events, 304-305 all levels, 139-140 correcting problems of, 193 support reward and recognition systems, 139 mental health, 306 Legal liability issues preventable deaths, 304 for the future health care workforce, 221 tuberculosis, 307 in workforce preparation, 218-219 U.S. examples of, 304-307 Level of harm caused by poor quality, in the Molecular medicine, 155 report on the state of quality, 227-228 Monitoring, using computer-based clinical Liaison Committee on Medical Education, 214 decision support systems for, 152-153 Licensure systems, 215-216 Multidisciplinary summit, of leaders of health Low back pain, inappropriate acute care of, 303 care organizations, 19, 208

INDEX 331 Multidisciplinary training, opportunities for, O 210-211 Multiple institutions, comparisons of outcomes Obtaining resources, in the health care not included in quality report, 234-235 environment, 138 Office of Research and Development, 106 On Lok Senior Health Services, 81 N “Open-access” scheduling, 125 Organizational development, stages of, 112-117 National Academies, The, 32, 166 Organizational supports for change, 11-12, 111- National Cancer Institute, PDQ database, 72 144 National Center for Health Statistics, 91 key challenges for the redesign of health National Coalition on Health Care (NCHC), care organizations, 117-137 231, 233 leadership for managing change, 137-140 National Committee for Quality Assurance, stages of organizational development, 112- 103, 157-158 117 Health Plan Employer Data and Information Organizing and coordinating care around Set, 157, 159, 240, 242 patient needs National Committee on Vital and Health Centers of Excellence, 100, 106 Statistics, 173, 176 disease management programs, 99-100 National Council of State Boards of Nursing, Organizing around priority conditions 214, 216 ensures availability of specialized expertise National Guideline Clearinghouse, 151, 157 to primary care practices, 95 National health information infrastructure, need includes strong focus on patient information for, 176-177 and self-management, 95 National Health Services Centre for Reviews redesigns practice to incorporate regular and Dissemination, 150 patient contact (regular follow-up), 94 National Institutes of Health, 2, 106, 156 relies on having good information about National League for Nursing, 214 patients, their care, and outcomes, 95 National Library of Medicine (NLM), 14, 55, uses protocol providing explicit statement 146, 172 of what needs to be done for patient, 94 Medical Subject Headings (MeSH), 233 ORYX system for hospitals, 157 MEDLINE, 156-157, 233 Osteoarthritis, 170 National Quality Forum, 10, 13-14, 90-91, 146, Otitis media 159 acute care of, 259 National Quality Report, 6-7 inappropriate acute care of, 296 National Research Council, 32, 166 Outcome measurements, incorporating for National Roundtable on Health Care Quality, improvement and accountability, 12, 23 135-137 Needs Overuse problems anticipation of, 8, 62, 80-81 correcting, 193 for further work, 228-229 findings about, 226-227 Networking Health, 32 NOAH (New York Online Access to Health), 157 P Nonclinical administrative management personnel, retraining, 212 PacifiCare Health System, 200 Nonlinearity, in complex adaptive systems, Pain relief. See Physical comfort 313 Patient, as the source of control, 8, 61, 70-72 Novelty, in complex adaptive systems, 313 Patient-centeredness, 48-51 coordination and integration of care, 49-50 emotional support, relieving fear and anxiety, 50

332 INDEX information, communication, and education, Performance measurements, incorporating for 50 improvement and accountability, 12, involvement of family and friends, 50 135-137 movement toward, 113, 115-116 Performance of teams, optimizing, 138-139 physical comfort, 50 Perverse payment mechanisms respect for patients’ values, preferences, blocking quality improvement in current and expressed needs, 49 payment methods, 191-195 21st-century health care system, 6 correcting problems of misuse, 193 Patient conditions, services, and settings, correcting problems of overuse, 193 coordinating over time, 12, 133-135 correcting problems of underuse, 193 Patient information and self-management, Pharmaceutical firms, 2 strong focus on, 95 Physical comfort, 50 Patient needs Physicians’ reports, not included in quality customization based on, 8, 61, 69-70 report, 235 organizing and coordinating care around, Plan-do-study-act (PDSA) improvement 98-100 methods, 315 Patients Planned care, 28 recommendations to, 5, 8-9, 34 Pneumococcal vaccine, findings about, 227 values of, 70 Pneumonia, 102 Patients’ expectations from their health care, 63 acute care of, 227, 258 anticipation, 63 Policymakers, recommendations to, 5, 34 beyond patient visits, 63 Poor quality, level of harm caused by, 227-228 control, 63 Poorly organized delivery system cooperation, 63 access to necessary clinical expertise, 29 individualization, 63 evidence-based, planned care, 28 information, 63 patients’ need for information and safety, 63 behavioral change, 28 science, 63 patients’ needs for more time, resources, transparency, 63 and follow-up, 28 value, 63 supportive information systems, 29 Payment, reduce suboptimization in, 101-102 Positive change, provide assets and Payment by unit of care, incentives of current, encouragement for, 13 187-188 Potential benefits of information technology, Payment methods 166-170 adapting blended, 200-201 for administrative and financial barriers to quality improvement in current, transactions, 167-168 191-199 charted, 168 incentives of current, 184-191 for clinical care, 167-168 Payment policies, 181-206 for consumer health, 166-168 adapting existing payment methods to for professional education, 167, 169 support quality improvement, 199-201 for public health, 167, 169 aligning with quality improvement, 17-19 for research, 167, 169 barriers to quality improvement in current Practice guidelines payment methods, 191-199 delineate, 97-98 incentives of current payment methods, for synthesizing clinical evidence, 151-152 184-191 Practicing clinicians, retooling, 211-212 need for a new approach, 201-204 Predictable needs, patients with the most, 121 PDQ database, 72 Preferences, respect for patients’, 49 Peer Review Organizations (PROs), 227 Pregnancy and delivery, 102 Peptic ulcer disease, chronic care of, 269 acute care of, 260-264 Per case payment, incentives of current, 187

INDEX 333 Prescriptions, using computer-based clinical stomach ulcers, 91, 103 decision support systems for, 153 stroke, 91, 97, 103 Preventable deaths, misuse leading to, 304 substance abuse, 97, 134 Preventive care surgical procedures and complications, 102 cancer screening, 251-253 synthesize the evidence base and delineate cardiac risk factors, 254-257 practice guidelines, 97-98 general, 257 Privacy concerns, with automated clinical immunizations, 250-251 information, 171-174 telemedicine technologies in, 170 Private purchasers, recommendations to, 5, 8-9, underuse of, 250-257 17-18, 39-40, 61-62, 166, 182, 184 using computer-based clinical decision Production planning, redesigning care support systems for, 152-153 processes for, 126-127 Primary care practices, availability of Professional education, potential benefits of specialized expertise to, 95 information technology for, 167, 169 Prioritizing, community health needs, 138 Professional groups, recommendations to, 6, Priority conditions 39-40 acute myocardial infarction, 102 Profile of quality of care in U.S., from the Alzheimer’s disease and other dementias, review of the literature, 236-308 91, 103 Program of All-Inclusive Care for the Elderly applications of, 96-103 (PACE), 81 arthritis, 91, 103 Protocol, providing explicit statement of what asthma, 91, 103 needs to be done for patient, 94 back problems, 91, 103 Provider groups, up-front investments required cancer, 91, 103 by, 197-199 cardiac rehabilitation, 170 Providing the resources needed to initiate chronic heart failure, 97 change, 103-108 criteria for identifying, 103 funding over several years to ensure depression and anxiety disorders, 91, 97, sustained and stable funding source, 104 103 public funding for mix of projects to permit diabetes, 91, 97, 103, 170 midcourse corrections, 105 domestic violence, 134 public support providing partial funding for emphysema, 91, 103 up-front costs health care organizations gall bladder disease, 91, 103 face implementing changes, 104-105 heart failure, 102 Public funding for mix of projects, to permit high cholesterol, 91, 103 midcourse corrections, 105 HIV/AIDS, 91, 97, 103, 134 Public health, potential benefits of information hypertension, 91, 103 technology for, 167, 169 ischemic heart disease, 91, 97, 103 Public purchasers, recommendations to, 5, 8-9, organizing and coordinating care around 17-18, 39-40, 61-62, 166, 182, 184 patient needs, 98-100 Public support providing partial funding, for osteoarthritis, 170 up-front costs health care organizations pneumonia, 102 face implementing changes, 104-105 pregnancy and related conditions, 102 Purchasers, recommendations to, 5-6, 8-9, 17- provide a common base for the 18, 34, 39-40, 61-62, 166, 182, 184 development of information technology, 101 reduce suboptimization in payment, 101- Q 102 simplify quality measurement, evaluation of Quality Center, 91 Quality Enhancement Research Initiative performance, and feedback, 102-103 (QUERI), 97, 106 spinal cord injury, 97 Quality gap, 23-25

334 INDEX Quality improvement to health informatics associations and adapting existing payment methods to vendors, 17, 166 support, 199-201 to health professionals, 5, 34 aligning payment policies with, 17-19 to health professions, 5, 34 impact on the bottom line, 198 to leaders of health care organizations, 17, Quality measures, defining, 157-159 166 Quality of care to patients, 5, 8-9, 34 conclusions about, 240-242 to policymakers, 5, 34 defining in the review of the literature, 232- to private purchasers, 5, 8-9, 17-18, 39-40, 233 61-62, 166, 182, 184 examples of inappropriate acute care, 292- to professional groups, 6, 39-40 303 to public purchasers, 5, 8-9, 17-18, 39-40, examples of misuse, 304-307 61-62, 166, 182, 184 examples of underuse, 250-291 to purchasers, 5-6, 8-9, 17-18, 34, 39-40, gaps between ideal care and actual care, 61-62, 166, 182, 184 236-238 to regulators, 5, 34 how managed care affects quality, 238 to secretary of the Department of Health inadequate, 25-33 and Human Services, 7, 14, 40, 146, IOM definition of, 232 173 search strategy followed, 308 Redesigning care, formulating new rules to, 7-9 sources of information about, 240 Redesigning care processes, 11, 117-127 as a system property, 4 continuous flow, 124-126 trends in assessment of, 239-240 design for safety, 122-123 Quality of Health Care in America (QHCA) mass customization, 123-124 Project, 225 production planning, 126-127 system design using the 80/20 principle, 120-122 R Redesigning health care organizations coordinating care across patient conditions, RAND Corporation, 24, 226 services, and settings over time, 12, Rare health care conditions, patients with, 122 133-135 “Real-time tracking,” 137 developing effective teams, 12, 130-133 Recommendations incorporating performance and outcome to Agency for Healthcare Research and measurements for improvement and Quality, 10, 12, 19-20, 90-91, 182, 184, accountability, 12, 135-137 208 key challenges for, 117-137 to clinicians, 5, 8-9, 34 making effective use of information to Congress, 7, 11, 17, 166 technologies, 12, 127-128 to consumers, 5, 34 managing clinical knowledge and skills, 12, to Department of Health and Human 128-130 Services, 5, 34, 40 Reengineering principles, 127 to educational institutions, 5, 34 Referral networks, well-defined, 113-114 to executive branch, 17, 166 Regular patient contact (regular follow-up), to health care constituencies, 5, 34 redesigning practice to incorporate, 94 to Health Care Financing Administration, Regulation of the professions 19, 182 ensuring continuing competency, 217 to health care organizations, 6, 8-9, 34, 39- licensure systems, 215-216 40 scope-of-practice acts, 215-217 to Health Care Quality Innovation Fund, Regulators, recommendations to, 5, 34 91-92, 103-106, 166 Regulatory issues, for the future health care to health care trustees and management, 5, workforce, 221 34

INDEX 335 Report on the state of quality in the U.S., 225- shared knowledge and free flow of 308 information, 8, 62, 72-75 discussion of findings, 226-227 waste continuously decreased, 9, 62, 81-83 level of harm caused by poor quality, 227- 228 need for further work, 228-229 S review of the literature, 226, 231-308 Research, potential benefits of information Safety, 44-46 designing procedures that can mitigate harm technology for, 167, 169 from errors, 123 Research agenda for the future health care workforce designing procedures to make errors visible, 123 legal and regulatory issues, 221 designing systems to prevent errors, 122- training and education issues, 220 workforce supply issues, 221 123 redesigning care processes for, 122-123 Resources as a system property, 8, 62, 78-79 needed to initiate change, 103-108 obtaining in the health care environment, 21st-century health care system, 5 Satisfaction ratings, not included in quality 138 report, 235 patients’ needs for more, 28 Respiratory illness, inappropriate acute care of, Science, growing complexity of, 25-26 Science of complex adaptive systems (CAS), 295 312-314 Responding to changes, in the health care environment, 138 adaptable elements, 313 co-evolution, 314 Retooling practicing clinicians, 211-212 context and embeddedness, 314 Retraining nonclinical administrative management personnel, 212 emergent behavior, 313 inherent order, 313-314 Review of the literature defining quality, 232-233 non-predictable in detail, 313 nonlinearity, 313 methodology, 233-236 novelty, 313 profile of quality of care in U.S., 236-308 in the report on the state of quality, 226, simple rules, 313 Scope-of-practice acts, 215-217 231-308 Search strategy, 308 Reward and recognition systems, supporting, 139 Secretary of the Department of Health and Human Services, recommendations to, Robert Wood Johnson Foundation, 105 7, 14, 40, 146, 173 Rules for 21st-century health care system, 7-9, 61-88 Self-management, strong focus on patient, 95 Shared knowledge, 8, 62, 72-75 anticipation of needs, 8, 62, 80-81 Shared-risk (budget) arrangements, adapting, care based on continuous healing relationships, 8, 61, 66-69 201 Simple rules, 315-317 contrasted with current approach, 67 in complex adaptive systems, 313 cooperation among clinicians, 9, 62, 83 customization based on patient needs and Simplifying quality measurement, evaluation of performance, and feedback, 102-103 values, 8, 61, 69-70 “Single-loop” learning, 136 evidence-based decision making, 8, 62, 76- 77 Specialized expertise, availability to primary care practices, 95 health care organizations as complex Spinal cord injury, 97 adaptive systems, 63-66 need for transparency, 8, 62, 79-80 Stages of organizational development, 112-117 charted, 114-115 patient as the source of control, 8, 61, 70-72 Stage 1—highly fragmented delivery safety as a system property, 8, 62, 78-79 system, 112-114

336 INDEX Stage 2—well-defined referral networks, Ten Commandments, 64 113-114 Time, patients’ needs for more, 28 Stage 3—some movement toward patient- Timeliness, 51-52 centered system, 113, 115-116 improvements in, 164 Stage 4—21st-century health care system 21st-century health care system, 6 envisioned, 115-117 To Err Is Human: Building a Safer Health Standards, need for, with automated clinical System, 2, 24, 44, 119, 122 information, 171-174 Traditional clinical education, reasons for little State of Quality Panel, 226 change in, 213-214 Stomach ulcers, 91, 103 Training issues, for the future health care Stroke, 91, 97, 103 workforce, 220 Structural measures, not included in quality Translating Research into Practice, 155 report, 235 Transparency, need for, 8, 62, 79-80 Studies not included, 234-236 Tuberculosis, misuse leading to, 307 access to care studies, 235 21st-century health care system, 6, 23-60, 39- comparisons of outcomes across multiple 60, 66-83 institutions, 234-235 agenda for the future, 33-35 physicians reports, 235 anticipation of needs, 8, 62, 80-81 satisfaction ratings, 235 care based on continuous healing structural measures, 235 relationships, 8, 61, 66-69 Suboptimization in payment, reducing, 101-102 complexity thinking applied to design of, Substance abuse, 97, 134 314-317 Support, emotional, 50 contrasted with current approach, 67 Surgical procedures and complications, 102 cooperation among clinicians, 9, 62, 83 Sustained and stable funding source, funding customization based on patient needs and over several years to ensure, 104 values, 8, 61, 69-70 Synthesizing clinical evidence, 97-98, 148-152 effective, 6 practice guidelines, 151-152 efficient, 6 systematic reviews, 148-151 equitable, 6 System design using the 80/20 principle establishing aims for, 5-7 Level 1—most predictable needs, 121 evidence-based decision making, 8, 62, 76-77 Level 2—health care needs of medium need for transparency, 8, 62, 79-80 predictability, 121-122 patient as the source of control, 8, 61, 70-72 Level 3—patients with rare or complex patient-centered, 6 health care conditions, 122 quality gap, 23-25 redesigning care processes for, 120-122 safe, 5 System properties, safety as, 8, 62, 78-79 safety as a system property, 8, 62, 78-79 Systematic reviews, for synthesizing clinical shared knowledge and free flow of evidence, 148-151 information, 8, 62, 72-75 Systems thinking, 309-311 six aims for improvement, 6, 40-54 timely, 6 underlying reasons for inadequate quality of T care, 25-33 vision of, 54-56, 115-117 Teams waste continuously decreased, 9, 62, 81-83 developing effective, 12, 130-133 optimizing performance of, 138-139 Technical Advisory Panel on the State of U Quality, 24, 226, 231-232, 234 Technology, growing complexity of, 25-26 UCLA/RAND appropriateness method, 239 Telemedicine technologies, 170 Underlying reasons for inadequate quality of in preventive care, 170 care, 25-33

INDEX 337 Underuse problems Veterans Health Administration (VHA), 97-98, of acute care, 258-264 158. See also Department of Veterans of chronic care, 264-291 Affairs correcting problems of, 193 Quality Enhancement Research Initiative, findings about, 227 97, 106 of preventive care, 250-257 Virginia Mason Medical Center, 72 U.S. examples of, 250-291 Visa International, 65, 316 Up-front costs health care organizations face, Vision, good enough, 315-317 public support providing partial funding for, 104-105 Up-front investments required by provider W groups Waste, continuously decreasing, 9, 62, 81-83 blocking quality improvement in current payment methods, 197-199 Wide space for innovation, 315-317 Workforce preparation, 19-20, 207-223 infrastructure investments, 198-199 clinical education and training, 208-214 measuring impact of quality improvement on the bottom line, 198 investing in, 139 legal liability issues, 218-219 Urinary tract infections, acute care of, 259-260 regulation of the professions, 214-218 U.S. General Accounting Office, 171 U.S. Preventive Services Task Force, 227 research agenda for the future health care workforce, 219-221 USA Today survey, 155 Workforce supply issues, for the future of Using computer-based clinical decision support systems (CDSS) health care, 221 World Wide Web, 30, 154 for diagnosis and management, 152-154 health information found on, 31 for prescribing of drugs, 153 for prevention and monitoring, 152-153 technologies based on, 211 V Y Year 2000 Health Plan Employer Data and Values organizing around priority conditions, 92- Information Set, 157, 159 96 respect for patients’, 49

Crossing the Quality Chasm: A New Health System for the 21st Century Get This Book
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Second in a series of publications from the Institute of Medicine's Quality of Health Care in America project

Today's health care providers have more research findings and more technology available to them than ever before. Yet recent reports have raised serious doubts about the quality of health care in America.

Crossing the Quality Chasm makes an urgent call for fundamental change to close the quality gap. This book recommends a sweeping redesign of the American health care system and provides overarching principles for specific direction for policymakers, health care leaders, clinicians, regulators, purchasers, and others. In this comprehensive volume the committee offers:

  • A set of performance expectations for the 21st century health care system.
  • A set of 10 new rules to guide patient-clinician relationships.
  • A suggested organizing framework to better align the incentives inherent in payment and accountability with improvements in quality.
  • Key steps to promote evidence-based practice and strengthen clinical information systems.

Analyzing health care organizations as complex systems, Crossing the Quality Chasm also documents the causes of the quality gap, identifies current practices that impede quality care, and explores how systems approaches can be used to implement change.

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