The rest of the iceberg’: IOM looks at quality
New report builds on groundbreaking report
The Washington, DC-based Institute of Medicine’s (IOM) Committee on Quality of Healthcare in America released a sweeping 300-page report March 1 that claims fundamental changes are needed in the American health care system if "the quality gap" that currently exists is to be eliminated.
In his introductory remarks, committee chair William Richardson, president of the W.K. Kellogg Foundation, said the IOM’s previous report on medical errors, the controversial To Err Is Human, represented "only a small part of the unfolding story of quality in American health care — the tip of the iceberg. Other defects beyond safety are even more widespread." He claimed the current report discusses "the rest of the iceberg."
But while much of the report is aimed at national policy-makers, it also provides over-arching principles and detailed recommendations that hospital clinicians and managers can implement immediately. In addition to a comprehensive set of performance expectations that span the health care system, Crossing the Quality Chasm: A New Health System for the 21st Century maps out a set of 10 rules that hospitals can use to help guide patient-clinician relationships, as well as an organizing framework to better align incentives.
"We are talking about big changes here," asserts Donald Berwick, MD, MPP, president and CEO of the Institute for Healthcare Improvement. He says the question for quality assurance directors is how they can help bring about the type of new care systems outlined in the report. Berwick argues that the current care system cannot achieve the type of improvements that are needed. To remedy that, he says the committee is urging Congress to set aside $1 billion over the next three years for a health care quality innovation fund to foster the experimentation of new models of care outlined in the report.
The committee also is urging support for several regional demonstration projects funded by the Health Care Financing Administration, reports Berwick, clinical professor of pediatrics and health care policy at Harvard Medical School in Boston. In addition, he says the committee wants the Bush administration to embrace the principles outlined in the report as a national agenda for quality improvement.
At the local level, Berwick says the report offers a broad framework for hospital clinicians and managers. "There is a lot that can be accomplished at the local unit," he asserts. Most importantly, he says, hospitals can do far more to involve patients in their own care. Potential steps include giving patients fuller access to their medical records and instituting e-mail based care, he says.
The report also outlines the key steps to promoting evidence-based practice and strengthening clinical information systems. In addition, it documents the causes of "the quality gap," identifies current practices that impede quality care, and explores how systematic approaches can be used to implement change.
According to the report, its proposals translate into a new set of patient expectations for health care that are consistent with and reinforce the steps that must be taken to achieve significant improvement in health care quality. They also are consistent with the type of care most clinicians strive to provide. But the report says clinicians often lack the support of well-designed care systems and environments that nurture innovation and excellence.
Care should come in many forms
The report contends that patients should be afforded care whenever they need it but that it should come in many forms, including the Internet and by telephone, not just face-to-face visits. The report also details changes in the areas of individualization and control of health care services, as well as the science used to support it.
In order to bring this new type of system about, the report argues that it will be necessary to examine old assumptions and understand why they have led to the current "ineffective" health care system. Instead, the report maintains that it will be necessary to craft new operating assumptions that are embodied in the 10 new rules that it outlines. (See "The IOM's 10 rules for Crossing the Quality Chasm," in this issue.)
According to the report, the key to transforming health care organizations lies in understanding their complexity. It says that health care is complex because of the great number of interconnections within and among small care systems. For example, office practices and critical care units in hospitals are linked to other units such as laboratories and emergency departments and often are embedded in even larger "umbrella" organizations such as hospitals, health plans, and integrated delivery systems.
The report says that the task for clinicians and managers is not to treat all situations alike but rather to understand when specification and standardization are appropriate and when they are not. "The challenge of improving quality lies in understanding that in situations lacking high levels of certainty and clinical agreement, flexibility that results in variation based on patient needs is appropriate," states the report. Conversely, overspecification can result in too many unnecessary steps and hamper the ability to customize care.
The report argues that effective rules describe how the system should function but do not need to specify this functioning in detail. It highlights two systems functioning today that illustrate the "diverse, creative, and complex actions" that can arise from shared aims and general directions. The first example is the Internet, which was built to share research data electronically using agreed-upon transfer protocols and conventions.
While the Internet’s explosive growth and adaptation could not have been foreseen, controlled, or designed in detail, because the complexity was too great and individuals were bound by their old experience, a few simple rules were enough for a functional complex system to emerge on its own.
The report says that credit card systems that agree to graphic layout of a card and a common clearinghouse that allows any card to be used anywhere also illustrate this pattern. Member banks are free to compete on all other aspects of business, and this design has resulted in tremendous growth worldwide despite different currencies, customs, and banking systems.
"The committee believes these important lessons about simple rules for complex adaptive systems can be applied to health care systems as well," the report concludes. "In redesigning health care, the building blocks are the simple processes that make up the work of small systems of care and their interconnections."
(A copy of the report is available at www.iom.edu/qhca.)
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