the health care system in the direction of being safe, effective, patient-centered, timely, efficient, and equitable.

Several cautions are in order, however. First, as is in the nature of complex adaptive systems, the rules are interrelated and are, therefore, intended to be applied as a set rather than viewed as a menu of choices. Second, to take any one rule to its extreme is likely to lead to a caricature of the intended performance. This is also true of the descriptions of today’s approaches, which do not capture many of the good practices currently found in health care. The rules and descriptions are strong, but common sense must apply to their interpretation. Third, the rules provide guidance applicable to most clinical interactions, but they do not cover every possible clinical decision. Fourth, as with the six aims, rules will occasionally conflict with one another. The responsibility of the clinician is to try to resolve or mediate these conflicts most appropriately for a given patient at a particular time. In some cases, however, conflict among rules will remain. Notwithstanding, tension among rules is a property of a complex adaptive system that can represent an area of creativity and growth.

The rules do not need to be highly specific; as in any complex adaptive system, the workforce will translate the rules into wise local actions. But they do have to be powerful and logically related to the aims. Further, they should feel like changes from prevailing approaches.

Table 3–1 summarizes ten simple rules for the 21st-century health care system. In the following subsections, each rule is described and contrasted with the corresponding current approach. There is not in all cases a strong evidence base indicating that following a rule would result in better patient and population outcomes. Where such evidence is available, it is cited; where it is not, this is indicated, and the rationale for the committee’s espousal of the rule is provided.

In the 21st-century health care system, care should be organized and paid for so that all types of health care interactions that improve information transfer and strengthen the healing relationship are encouraged. What patients want and need from their care is relief from suffering and uncertainty—knowledge about what is wrong, what is likely to happen, and what can be done to change or manage that outcome. Sometimes, such relief can be provided only in a face-to-face visit. But many needs can and should be met through other forms of care, all centered on a relationship with the clinician. The current system often requires a visit as the only legitimate format for care, and more important, as the only form of professional work that is compensated and measured in the health care world as

Front Matter (R1-R22)

Executive Summary (1-22)

1 A New Health System for the 21st Century (23-38)

2 Improving the 21st-Century Health Care System (39-60)

3 Formulating New Rules to Redesign and Improve Care (61-88)

4 Taking the First Steps (89-110)

5 Building Organizational Supports for Change (111-144)

6 Applying Evidence to Health Care Delivery (145-163)

7 using Information Technology (164-180)

8 Aligning Payment Policies with Quality Improvement (181-206)

9 Preparing the Workforce (207-224)

Appendix A: Report of the Technical Panel on the State of Quality to the Quality of ealth Care in America Committee (225-308)

Appendix B: Redesigning Health Care with Insights from the Science of Complex Adaptive Systems (309-322)

Index (323-337)