satisfaction ratings, but also as a core way of learning about the system’s performance and how to improve it.

Although Americans continue to trust health care clinicians, including doctors and nurses (The Gallup Organization, 2000; The Henry J.Kaiser Family Foundation, 2000), the committee is concerned about Americans’ remarkably low level of confidence in the health care system overall. For example, in July 2000, only four in ten Americans surveyed for one poll reported having a lot or a great deal of confidence in “the medical system,” though it is not clear who or what kinds of settings were encompassed by their answers (Chambers, 2000). Of the 15 major industries included in the poll, the medical system ranked in the bottom half along with public schools, television and print news, and big business; poll participants reported having greater confidence in banks, the President, and the police. A Harris Poll conducted at the end of 1999 found that only 39 percent of respondents reported having a great deal of confidence in the “people in charge of running medicine” (Taylor, 1999). In 1998, The American Customer Satisfaction Index placed hospitals between the U.S. Postal Service and the Internal Revenue Service in customer satisfaction (Lieber, 1998).

One important route to restoring trust is through a commitment to transparency by all health care systems. Organizations and clinicians that act as though they have nothing to hide become more trustworthy. The health care system should seek to earn renewed trust not by hiding its defects, but by revealing them, along with making a relentless commitment to improve. The transition to openness is a difficult one for our often-beleaguered health care organizations, but it is a journey worth making. In the longer run, access to information can inspire trust among patients and caregivers that the system is working effectively to advance health. Such trust involves patient confidence both that those who are responsible for care have the information they need—regardless of where that information was generated—and that those organizations and caregivers will act in patients’ best interests and actively seek to advance their health.

Achieving a higher level of safety is an essential first step in improving the quality of care overall. Improving safety will in turn require systematic efforts from a broad array of stakeholders, including a commitment of clear and sustained leadership at the executive and board levels of organizations; a greatly changed culture of health care in which errors are tracked, analyzed, and interpreted for improvement rather than blame; extensive research on the factors leading to injury; and new systems of care designed to prevent error and minimize harm (Institute of Medicine, 2000b).


Effectiveness refers to care that is based on the use of systematically acquired evidence to determine whether an intervention, such as a preventive service, diagnostic test, or therapy, produces better outcomes than alternatives—

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