Date: March 1, 2001
Contacts: Saira Moini, Media Relations Officer
Kathi McMullin, Media Relations Assistant
(202) 334-2138; e-mail <>

U.S. Health Care Delivery System Needs Major Overhaul
To Improve Quality and Safety

WASHINGTON -- The nation's health care industry has foundered in its ability to provide safe, high-quality care consistently to all Americans, says a new report from the Institute of Medicine of the National Academies. Reorganization and reform are urgently needed to fix what is now a disjointed and inefficient system.

To spur an overhaul, Congress should create an "innovation fund" of $1 billion for use during the next three to five years to help subsidize promising projects and communicate the need for rapid and significant change throughout the health system, the report adds. Just as a solid commitment of public funds and other resources supported the ultimately successful mapping of the human genome, a similar commitment is needed to redesign the health care delivery system so all Americans can benefit.

"Americans should be able to count on receiving care that uses the best scientific knowledge to meet their needs, but there is strong evidence that this frequently is not the case," said William C. Richardson, chair of the committee that wrote the report and president of the W.K. Kellogg Foundation, Battle Creek, Mich. "The system is failing because it is poorly designed. For even the most common conditions, such as breast cancer and diabetes, there are very few programs that use multidisciplinary teams to provide comprehensive services to patients. For too many patients, the health care system is a maze, and many do not receive the services from which they would likely benefit."

Clinicians, health care organizations, and purchasers -- companies or groups that compensate health care providers for delivering services to patients -- should focus on improving care for common, chronic conditions such as heart disease, diabetes, and asthma that are now the leading causes of illness in the United States and consume a substantial portion of health care resources. These ailments typically require care involving a variety of clinicians and health care settings, over extended periods of time. But physician groups, hospitals, and health care organizations work so independently from one another that they frequently provide care without the benefit of complete information about patients' conditions, medical histories, or treatment received in other settings, the committee pointed out.

The committee's previous report, To Err Is Human: Building a Safer Health System, found that more people die from medical mistakes each year than from highway accidents, breast cancer, or AIDS. But findings in that report amounted to only the tip of the iceberg in the larger story about quality care. America's health system is a tangled, highly fragmented web that often wastes resources by providing unnecessary services and duplicating efforts, leaving unaccountable gaps in care and failing to build on the strengths of all health professionals, the new report states. It calls for immediate action to improve care -- in all aspects and for everyone -- over the next decade, and offers a comprehensive strategy to do so. The committee examined the health care delivery system as a whole; it did not address the issue of the uninsured, who are the subject of a separate Institute of Medicine project.

Use of Information Technology Is Key

The report envisions a revamped system that not only is centered on the needs, preferences, and values of patients, but also encourages teamwork among health care workers and makes much greater use of information technology. Health care organizations are only beginning to apply technological advances. For example, patient information typically is dispersed in a collection of paper records, which often are poorly organized, illegible, and not easy to retrieve, making it nearly impossible to manage various chronic illnesses that require frequent monitoring and ongoing patient support. Many patients also could have their needs met more quickly and at a lower cost if they had the option of communicating with health care professionals through e-mail. The use of automated medication order entry systems can reduce errors in prescribing and dosing drugs, and computerized reminders can help both patients and clinicians identify needed services. However, the report recognizes that many policy, payment, and legal issues would have to be resolved before much headway could be made.

A nationwide effort is needed to build a technology-based information infrastructure that would lead to the elimination of most handwritten clinical data within the next 10 years, the committee said. Congress, the executive branch, leaders of health care organizations, and public and private purchasers should work together toward this goal. Without a national pledge to create and fund such a technological framework, progress to enhance quality of care will be painfully slow.

A Broad View of Quality

To initiate across-the-board reform, the federal Agency for Healthcare Research and Quality should identify 15 or more common health conditions, most of them chronic, the report says. Then, health care professionals, hospitals, health plans, and purchasers should develop strategies and action plans to improve care for each of these priority conditions over a five-year period.

To stay aware of the big picture, the U.S. Department of Health and Human Services (HHS) should monitor and track quality improvements in six key areas: safety, effectiveness, responsiveness to patients, timeliness, efficiency, and equity. And the secretary of HHS should report annually to Congress and the president on progress made in those areas, the report says.

In addition, public and private purchasers should develop payment policies that reward quality. Current methods provide little financial reward for improvements in the quality of health care delivery, and may even inadvertently pose barriers to innovation. With input from relevant private and public interests, the federal government should identify, test, and evaluate various payment options that more closely align compensation methods with quality-improvement goals.

The committee also offers 10 new rules intended to make the health system more responsive to patients' needs and preferences and to encourage their participation in decision-making. These rules also are intended to promote the development of systems that are consciously and carefully designed to be safe, anticipate patient needs, promote cooperation among clinicians, use resources wisely, and make available information on quality and safety performance (see attached list).

The study was sponsored by the Institute of Medicine, National Research Council, Robert Wood Johnson Foundation, California Health Care Foundation, the Commonwealth Fund, and U.S. Department of Health and Human Services. The Institute of Medicine is a private, nonprofit institution that provides health policy advice under a congressional charter granted to the National Academy of Sciences. A committee roster follows.

Copies of Crossing the Quality Chasm: A New Health System for the 21st Century are available from the National Academies Press on the Internet at or by calling 202-334-3313 or 1-800-624-6242. Reporters may obtain a copy from the Office of News and Public Information at the letterhead address (contacts listed above).

Board on Health Care Services

Committee on Quality of Health Care in America

William C. Richardson, Ph.D.* (chair)
President and Chief Executive Officer
W.K. Kellogg Foundation
Battle Creek, Mich.

Donald M. Berwick, M.D., M.P.P.*
President and Chief Executive Officer
Institute for Healthcare Improvement, and
Clinical Professor of Pediatrics and Health Care Policy
Harvard Medical School

J. Cris Bisgard, M.D., M.P.H.
Director of Health Services
Delta Air Lines Inc.

Lonnie R. Bristow, M.D.*
Former President
American Medical Association, and
Vice Chair
Physician Leadership on National Drug Policy
Walnut Creek, Calif.

Charles R. Buck Jr., Sc.D.
Program Leader
Health Care Quality and Strategy Initiatives
General Electric Co.
Fairfield, Conn.

Christine K. Cassel, M.D.*
Professor of Geriatrics and Internal Medicine and Chairman
Henry L. Schwarz Department of Geriatrics and Adult Development
Mount Sinai School of Medicine
New York City

Mark R. Chassin, M.D., M.P.H., M.P.P.*
Professor and Chairman
Department of Health Policy
Mount Sinai School of Medicine
New York City

Molly Joel Coye, M.D., M.P.H.*
Senior Fellow
Institute for the Future, and
Health Technology Center
San Francisco

Don E. Detmer, M.D.*
Dennis Gillings Professor of Health Management
Judge Institute of Management Studies
University of Cambridge
Cambridge, England

Jerome H. Grossman, M.D.*
Chairman and Chief Executive Officer
Lion Gate Management Corp.

Brent C. James, M.D., M.Stat.
Vice President for Medical Research and Executive Director
Institute for Health Care Delivery Research
Intermountain Health Care Inc.
Salt Lake City

David McK. Lawrence, M.D., M.P.H.*
Chairman and Chief Executive Officer
Kaiser Foundation Health Plan Inc.
Oakland, Calif.

Lucian L. Leape, M.D.
Adjunct Professor of Health Policy
Department of Health Policy and Management
Harvard School of Public Health

Arthur Levin, M.P.H.
Center for Medical Consumers
New York City

Rhonda J. Robinson-Beale, M.D.
Executive Medical Director of Medical and Care Management Clinical Programs
Blue Cross Blue Shield of Michigan

Joseph E. Scherger, M.D., M.P.H.*
Associate Dean for Primary Care, and
Professor and Chair
Department of Family Medicine
College of Medicine
University of California

Arthur Southam, M.D.
President and Chief Executive Officer
Health Net
Woodland Hills, Calif.

Mary Wakefield, R.N., Ph.D.
Professor and Director
Center for Health Policy Research and Ethics
George Mason University
Fairfax, Va.

Gail L. Warden, M.H.A.*
President and Chief Executive Officer
Henry Ford Health System


Janet M. Corrigan, Ph.D.
Study Director

*Member, Institute of Medicine


Private and public purchasers, health care organizations, clinicians, and patients should work together to redesign health care processes in accordance with the following rules:

1. Care based on continuous healing relationships. Patients should receive care whenever they need it and in many forms, not just face-to-face visits. This rule implies that the health care system should be responsive at all times (24 hours a day, every day) and that access to care should be provided over the Internet, by telephone, and by other means in addition to face-to-face visits.

2. Customization based on patient needs and values. The system of care should be designed to meet the most common types of needs, but have the capability to respond to individual patient choices and preferences.

3. The patient as the source of control. Patients should be given the necessary information and the opportunity to exercise the degree of control they choose over health care decisions that affect them. The health system should be able to accommodate differences in patient preferences and encourage shared decision-making.

4. Shared knowledge and the free flow of information. Patients should have unfettered access to their own medical information and to clinical knowledge. Clinicians and patients should communicate effectively and share information.

5. Evidence-based decision-making. Patients should receive care based on the best available scientific knowledge. Care should not vary illogically from clinician to clinician or from place to place.

6. Safety as a system property. Patients should be safe from injury caused by the care system. Reducing risk and ensuring safety require greater attention to systems that help prevent and mitigate errors.

7. The need for transparency. The health care system should make information available to patients and their families that allows them to make informed decisions when selecting a health plan, hospital, or clinical practice, or when choosing among alternative treatments. This should include information describing the system's performance on safety, evidence-based practice, and patient satisfaction.

8. Anticipation of needs. The health system should anticipate patient needs, rather than simply reacting to events.

9. Continuous decrease in waste. The health system should not waste resources or patient time.

10. Cooperation among clinicians. Clinicians and institutions should actively collaborate and communicate to ensure an appropriate exchange of information and coordination of care.