REPORT OF A SUMMIT

THE IST ANNUAL CROSSING THE QUALITY CHASM SUMMIT

A Focus on Communities

Committee on the Crossing the Quality Chasm: Next Steps Toward a New Health Care System

Board on Health Care Services

Karen Adams, Ann C. Greiner, and Janet M. Corrigan, Editors

INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS
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The Ist Annual Crossing the Quality Chasm Summit: A Focus on Communities REPORT OF A SUMMIT THE IST ANNUAL CROSSING THE QUALITY CHASM SUMMIT A Focus on Communities Committee on the Crossing the Quality Chasm: Next Steps Toward a New Health Care System Board on Health Care Services Karen Adams, Ann C. Greiner, and Janet M. Corrigan, Editors INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES THE NATIONAL ACADEMIES PRESS Washington, D.C. www.nap.edu

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The Ist Annual Crossing the Quality Chasm Summit: A Focus on Communities THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This study was supported by Contract No. 046718 between the National Academy of Sciences and The Robert Wood Johnson Foundation. It was also supported by a subcontract from The Johns Hopkins Bloomberg School of Public Health with funds provided by Grant No. 037049 from the Robert Wood Johnson Foundation. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project. International Standard Book Number 0-309-09303-1 (Book) International Standard Book Number 0-309-54535-8 (PDF) Library of Congress Control Number: 002004112492 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2004 by the National Academy of Sciences. All rights reserved. Printed in the United States of America. The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin.

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The Ist Annual Crossing the Quality Chasm Summit: A Focus on Communities “Knowing is not enough; we must apply. Willing is not enough; we must do.” —Goethe INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES Adviser to the Nation to Improve Health

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The Ist Annual Crossing the Quality Chasm Summit: A Focus on Communities THE NATIONAL ACADEMIES Adviser to the Nation on Science, Engineering, and Medicine The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Bruce M. Alberts is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Wm. A. Wulf is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Bruce M. Alberts and Dr. Wm. A. Wulf are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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The Ist Annual Crossing the Quality Chasm Summit: A Focus on Communities COMMITTEE ON CROSSING THE QUALITY CHASM: NEXT STEPS TOWARD A NEW HEALTH CARE SYSTEM REED V. TUCKSON (Chair), Senior Vice President, Consumer Health and Medical Care Advancement, UnitedHealth Group, Minnetonka, MN RON J. ANDERSON, President and Chief Executive Officer, Parkland Memorial Health and Hospital System, Dallas, TX REGINA M. BENJAMIN, Founder and Chief Executive Officer, Bayou La Batre Rural Health Clinic, Inc., Bayou La Batre, AL LINDA BURNES BOLTON, Vice President and Chief Nursing Officer, Cedars-Sinai Medical Center and Burns and Allen Research Institute, Los Angeles, CA BRUCE E. BRADLEY, Director Health Plan Strategy and Public Policy, Health Care Initiatives, General Motors Corporation, Detroit, MI ALLEN S. DANIELS, Chief Executive Officer, Alliance Behavioral Care, University of Cincinnati Department of Psychiatry, Cincinnati, OH LILLEE S. GELINAS, Vice President and Chief Nursing Officer, VHA Inc., Irving, TX CHARLES J. HOMER, President and Chief Executive Officer, National Initiative for Children's Healthcare Quality, Boston, MA DAVID C. KIBBE, Director of the Center for Health Information Technology, American Academy of Family Physicians, Chapel Hill, NC MARY ANNE KODA-KIMBLE, Professor and Dean, School of Pharmacy, University of California San Francisco, San Francisco, CA PETER V. LEE, President and Chief Executive Officer, Pacific Business Group on Health, San Francisco, CA KATE R. LORIG, Professor of Medicine, Stanford University, Stanford, CA JOANNE LYNN, Director, The Washington Home Center for Palliative Care Studies, and Senior Scientist with The RAND Corporation, Washington, DC DAVID M. NATHAN, Director, Diabetes Center, Massachusetts General Hospital and Professor of Medicine, Harvard Medical School, Boston, MA CHERYL M. SCOTT, President and CEO, Group Health Cooperative, Seattle, WA JOHN A. SPERTUS, Director of Cardiovascular Education and Outcomes Research, Mid America Heart Institute and Professor of Medicine at the University of Missouri-Kansas City, Kansas City, MO I. STEVEN UDVARHELYI, Senior Vice President and Chief Medical Officer, Independence Blue Cross, Philadelphia, PA

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The Ist Annual Crossing the Quality Chasm Summit: A Focus on Communities Study Staff KAREN ADAMS, Co-Study Director ANN C. GREINER1, Co-Study Director DANITZA VALDIVIA, Senior Project Assistant Board on Health Care Services JANET M. CORRIGAN, Senior Director, Board on Health Care Services ANTHONY BURTON, Administrative Assistant Auxiliary Staff THOMAS M. MADDOX2, Gustav Leinhard Fellow in Health Sciences Policy PATSY O'MEARA3, Project Intern Editorial Consultants RONA BRIERE, Briere Associates, Inc. ALISA DECATUR, Briere Associates, Inc. 1   Served through January, 2004. 2   Served through May, 2003. 3   Served through December, 2003.

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The Ist Annual Crossing the Quality Chasm Summit: A Focus on Communities Reviewers This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the NRC's Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: GEORGE ISHAM, HealthPartners, Inc., Bloomington, MN ARTHUR AARON LEVIN, Center for Medical Consumers, New York, NY ANGELA BARRON MCBRIDE, Indiana University; Institute of Medicine Scholar-in-Residence JOSEPH E. SCHERGER, University of California, San Diego, CA LISA SIMPSON, All Children's Hospital; University of South Florida, St. Petersburg, FL Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by Elaine L. Larson, Columbia University, and Don E. Detmer, University of Cambridge and University of Virginia. Appointed by the National Research Council and Institute of Medicine, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.

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The Ist Annual Crossing the Quality Chasm Summit: A Focus on Communities Preface This report represents an important addition to a series of studies generated by the Institute of Medicine dedicated to improving the quality and safety of health care. It is firmly grounded in the principles articulated in Crossing the Quality Chasm: A New Health System for the 21st Century as a guide for the transformation of our current health care delivery system—namely the six aims of safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity. The 1st Annual Crossing the Quality Chasm Summit was convened specifically to address the redesign of the nation’s currently broken health care delivery system. As recommended in the Quality Chasm report, the summit was focused on improving care processes for a targeted set of priority areas, in this case five common, high-burden chronic conditions: asthma, depression, diabetes, heart failure, and pain control in advanced cancer. The summit benefited from the contributions and expertise of more than 200 local and national health care leaders who convened to collaborate on the development of strategies for improving the quality of care for individuals with these five chronic illnesses. As described in this report, significant progress is being made toward implementing the above six aims in communities across the country. It is our hope that readers will be encouraged by the support of the national champions who participated in the summit and expressed their support for efforts to facilitate the broad achievement of key strategic priorities. The reader of this report will also appreciate how much more is required from every stakeholder in the American health care system if the goals of optimal quality and safety are to be achieved. I am deeply appreciative of the support of our sponsor, The Robert Wood Johnson Foundation; my colleagues on the Institute of Medicine committee who helped organize and lead the summit; and all who so generously contributed their experience, judgment, and expertise to this effort. Reed V. Tuckson, M.D. Chair August 2004

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The Ist Annual Crossing the Quality Chasm Summit: A Focus on Communities Foreword In January 2004, the Institute of Medicine (IOM) was pleased to convene the 1st Annual Crossing the Quality Chasm Summit. This was a high-energy endeavor designed to move us closer to realizing the vision for the nation’s health care system described in the 2001 IOM report Crossing the Quality Chasm: A New Health System for the 21st Century. That report called for fundamental redesign of the current system. To begin this transformation, the report recommended focusing on a set of priority conditions, taking into account frequency, burden, and resource use. A subsequent IOM report, Priority Areas for National Action: Transforming Health Care Quality identified 20 such areas, 5 of which—asthma, depression, diabetes, heart failure, and pain control in advanced cancer—were initially targeted for the summit’s work. At the summit, representatives of innovative communities from across the country joined forces with national leaders and organizations to identify strategies for achieving high-quality care for patients burdened with these five chronic illnesses. The synergy between local and national leaders at the summit was strong, and the strategies put forth are actionable now. The essential goal is to close the gap between what we know to be best practice and how care is routinely delivered today. Although much work remains to achieve the kind of fundamental change called for in the Quality Chasm report, it is apparent that we are well on our way. I applaud the communities and national champions who participated in the summit for their creative approaches and their dedication to improving the quality and safety of health care for all Americans. Harvey V. Fineberg, M.D., Ph.D. President, Institute of Medicine August 2004

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The Ist Annual Crossing the Quality Chasm Summit: A Focus on Communities Acknowledgments The Committee on the Crossing the Quality Chasm Summit wishes to acknowledge the many people whose contributions made this report possible. We appreciate how willingly and generously these individuals contributed their time and expertise to assist the committee. The committee benefited from the knowledge and input of members of the liaison panel: Brian Austin, MacColl Institute for Health Care Innovation at Group Health Cooperative; Donald M Berwick, Institute for Healthcare Improvement; Maureen Bisognano, Institute for Healthcare Improvement; Carolyn M. Clancy, Agency for Healthcare Research and Quality; Lisa M. Koonin, Centers for Disease Control and Prevention; Dan Stryer, Agency for Healthcare Research and Quality; Ed Wagner, MacColl Institute for Health Care Innovation at Group Health Cooperative; and Stephanie Zaza, Centers for Disease Control and Prevention. Presenters and panelists helped inform and enlighten summit participants: Donald M. Berwick, Institute for Healthcare Improvement; William L. Bruning, Mid-America Coalition on Health Care Community Initiative on Depression; Albert D. Charbonneau, Rochester Health Commission; Helen Darling, President, National Business Group on Health; Jack C. Ebeler, Alliance of Community Health Plans; Harvey V. Fineberg, Institute of Medicine; Henry Gaines, United Automobile Workers/General Motors Community Health Initiatives; George J. Isham, HealthPartners, Inc.; Sylvia Drew Ivie, The Help Everyone Clinic, Inc.; John Lumpkin, The Robert Wood Johnson Foundation; Jay M. Portnoy, Children's Mercy Hospital; and Martha Whitecotton, Carolinas Medical Center. Facilitators for the cross-cutting strategy sessions were invaluable to a successful and productive summit: Gerard F. Anderson, The Johns Hopkins University; David Brailer, Health Technology Center; Christine K. Cassel, American Board of Internal Medicine; Russell E. Glasgow, Kaiser Permanente Colorado; Judith Hibbard, University of Oregon; Arnold Milstein, Pacific Business Group on Health; Shoshanna Sofaer, Baruch College; and David M. Stevens, Agency for Healthcare Research and Quality. Summit scribes provided timely and vital recording of work produced during the strategy sessions: Shari M. Erickson, Institute of Medicine; Beverly Lunsford, The Washington Home; Elizabeth McCann, medical student at Columbia College of Physicians and Surgeons; Sydney Morss Dy, the Johns Hopkins Bloomberg School of Public Health; Hsien Seow, The Washington Home; Lynne Page Snyder, Institute of Medicine; and Anne Wilkinson, the RAND Corporation. Special thanks also go to Joanne Lynn of The Washington Home Center for Palliative Care Studies for providing the student volunteers to help with recording.

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The Ist Annual Crossing the Quality Chasm Summit: A Focus on Communities Webcasts and transcripts of the summit were graciously facilitated by the Kaiser Family Foundation. They are freely accessible at <http://www.kaisernetwork.org/healthcast/iom/06jan04>. Support for this project was generously provided by The Robert Wood Johnson Foundation. We are also grateful to the Johns Hopkins Bloomberg School of Public Health for its support of the summit’s cross-cutting strategy sessions.

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The Ist Annual Crossing the Quality Chasm Summit: A Focus on Communities Contents     EXECUTIVE SUMMARY   1      Abstract   1      Priority Areas for Focusing and Implementing the Quality Chasm Vision   2      1st Annual Crossing the Quality Chasm Summit   2      Setting the Context for the Summit   6      Cross-Cutting Sessions   6      Condition-Specific Action Plans   10      Next Steps   11 1   INTRODUCTION   13      Background   13      The Quality Chasm Summit   15      Scope and Organization of the Report   24 2   MEASUREMENT   27      Definition and Overarching Themes   27      Key Strategies   28      Closing Statement   35 3   INFORMATION AND COMMUNICATIONS TECHNOLOGY   37      Definition and Overarching Themes   37      Key Strategies   38      Closing Statement   44 4   CARE COODINATION   47      Definition and Overarching Themes   47      Key Strategies   48      Closing Statement   55 5   PATIENT SELF-MANAGEMENT SUPPORT   57      Definition and Overarching Themes   57      Key Strategies   58      Closing Statement   65 6   FINANCE   67      Definition and Overarching Themes   67      Key Strategies   69      Closing Statement   75

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The Ist Annual Crossing the Quality Chasm Summit: A Focus on Communities 7   COALITION BUILDING   77      Definition and Overarching Themes   77      Key Strategies   78      Closing Statement   83 8   CONDITION-SPECIFIC ACTION PLANS   85      Asthma   86      Depression   88      Diabetes   90      Heart Failure   91      Pain Control in Advanced Cancer   93 9   NEXT STEPS   97      Synopsis of Reactor Panel and Audience Feedback   97      Commitments of National Champions   99      Closing Statement   108 APPENDIX A—   BIOGRAPHICAL SKETCHES OF COMMITTEE MEMBERS   111 APPENDIX B—   QUALITY CHASM SELECTED BIBLIOGRAPHY   117 APPENDIX C—   DESCRIPTIONS OF SUMMIT COMMUNITIES   119 APPENDIX D—   COMMUNITY SELECTION CRITERIA   125 APPENDIX E—   SUMMIT ATTENDEES   129 APPENDIX F—   CONFERENCE PREWORK AND SAMPLE MATRICES   139 APPENDIX G—   SUMMIT PLANNING   149 APPENDIX H—   SUMMIT AGENDA   151 APPENDIX I—   FACILITATING THE SUMMIT WORKING GROUPS   155 APPENDIX J—   CONDITION-SPECIFIC WORKING GROUP QUESTIONS   157