Bridging the Quality Chasm

David Lawrence

Kaiser Foundation Health Plan


This presentation focuses on the management of scientific and technological breakthroughs as they are made available to the health care delivery system—specifically on whether health care has kept pace with innovation by moving them into practice safely and responsibly. There is a substantial amount of overuse, misuse, and underuse of available science and technologies in the health care system—regardless of geography, type of payment, or when and where physicians were trained. To address this problem, the Institute of Medicine (IOM) undertook two studies, To Err Is Human, published in 2000, which focused on safety issues, and Crossing the Quality Chasm, published in 2001, which focused on quality issues. Both reports highlight the symptoms of a broken system. Both reports concluded that there is a mismatch between the rate and quantity of scientific and technological innovations and the ability of the health care system to use them safely and responsibly.

Wide variations in quality were documented as far back as 1975 in a small-area variation analysis by John Wennberg, M.D., and then in a variety of other studies across the country in the last 30 years (O’Connor et al., 1999; Wennberg, 1999). Recent safety studies, primarily but not exclusively studies by Lucien Leape and his colleagues at Harvard, identified a variety of medical errors that result in morbidity and mortality caused not because of physician malfeasance but because of system errors (Brennan et al., 1991; Leape et al., 2002; Thomas et al., 2000). The number of hospital deaths from these errors range from 30,000 to 80,000 per year. At this point, we have no understanding and little documentation of the number of errors in the ambulatory setting. Some early estimates in the United Kingdom and the United States have been published (Bubin, 1999; Fischer et al., 1997; Weingart et al., 2000). The total number of deaths attributable to errors in the health care system we think could be as high as 150,000 or even 200,000 per year.

Another measure was published by Barbara Starfield in an article in Journal of the American Medical Association in 2000. Dr. Starfield looked at the whole question of system-related deaths for all reasons, including errors. She concluded that 200,000 to 250,000 deaths per year were attributable to system-related causes, of which error is the most notable (Starfield, 2000). Starfield also made interesting comparisons between our system and others in terms of a variety of health outcomes. She concluded, as have many others, that although we spend an enormous amount on health care and lead the world in scientific innovation and technology, the results in terms of improved health do not match the level of investment.

There are also other symptoms of poor quality in the health care system. One of them has to do with responsiveness. In the Picker Institute studies of patient assessments of their health care experiences, about three-quarters of those surveyed indicated that their experiences with the health care system had led them to conclude that it was a “nightmare” to navigate (Picker Institute, 2000). They identified duplication, lack of communication, conflicting points of view about what should be done, and lack of understanding about what the science suggested. In short, the system is fragmented, fractured, and not patient-centric.

Finally, there is the cost of poor quality care, which has interesting implications for innovation. Between $.30 and $.40 of every dollar spent on health care is spent on the costs of poor quality. This extraordinary number represents slightly more than a half-trillion dollars a year. A vast amount of money is wasted on overuse, underuse, misuse, duplication, system failures, unnecessary repetition, poor communication, and inefficiency.

In this respect, the experience of General Electric Company and others in more tightly managed and highly organized manufacturing systems may be instructive. Companies often find substantial opportunities for improvement in the cost performance of the system by using quality-



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