Have we crossed the chasm yet?
10 years after IOM report, authors see progress, but ...
It’s been 10 years since the Committee on Quality of Health Care in America released its second and final report, Crossing the Quality Chasm: A New Health System for the 21st Century. Many of the report’s key terms—“evidence-based,” “patient-centered,” “transparent”—now form the language commonly used to talk about healthcare quality in everything from government-led improvement initiatives to hospital marketing materials.
But it wasn’t always that way, according to committee members.
While many of those who helped to write the report acknowledge that progress has faltered in some areas, they say the biggest achievement of Crossing the Quality Chasm— and of its companion report, the landmark To Err is Human: Building a Safer Health System, released two years earlier—is that the two efforts combined changed the mindset of an industry.
“It provided a jolt to the field,” says Dr. Mark Chassin, who was a member of the committee and is currently president of the Joint Commission, a not-for-profit healthcare accreditation organization. “It elevated the recognition that these problems of overuse, underuse and misuse were quite widespread, and no organization, no matter how wellknown, was immune from them. Ten years later, there are few if any leaders who would say, ‘Not in my organization. These are someone else’s problems.’ Just a decade ago, it was a drastically different environment.”
William Richardson, president emeritus of Johns Hopkins University, chaired the committee and agrees that the report prompted a seismic shift in attitudes.
“Obviously, if you look at progress, we still have a long way to go,” Richardson says. “But the level of reservation has gone way down and the awareness and acceptance of the report’s recommendations has gone way up.”
Appointed by the Institute of Medicine in 1998, committee members were charged with outlining strategies for improving healthcare delivery, exploring new payment models, reducing variation and lowering the likelihood of errors.
“Healthcare has safety and quality problems because it relies on outmoded systems of work,” they stated in the report. “Poor designs set the workforce up to fail, regardless of how hard they try. If we want safer, higher quality care, we will need to have redesigned systems of care, including the use of information technology to support clinical and administrative processes.”
A road map for change
The committee’s 19-member roster included prominent healthcare policy experts, including Dr. Donald Berwick, founder and then-president of the Institute for Healthcare Improvement, who now serves as CMS administrator; Lucian Leape, adjunct professor at the Harvard School of Public Health and chairman of the Lucian Leape Institute; and Mary Wakefield, current administrator of HHS’ Health Resources and Services Administration.
Members laid out an agenda that featured six aims for healthcare—that it should be safe, effective, patient-centered, timely, efficient and equitable—as well as detailed lists of rules and recommendations to be used to redesign care. For instance, the committee recommended aligning payment policies to spur quality improvement, a practice that has been attempted in small-scale pilots and privatepayer initiatives and is now being rolled out on a larger scale by the CMS.
Those strategies, according to Janet Corrigan, president and CEO of the National Quality Forum, are what differentiated the Crossing the Quality Chasm report from the committee’s earlier report on safety.
“ To Err is Human was a wake-up call and it had a huge communications impact,” says Corrigan, who served as director of IOM’s healthcare quality project staff, which oversaw production of the two reports. “But Crossing the Quality Chasm was more of a road map for fundamental change of the system. Indeed, for us to address the problems in the original report, we needed to go down that road.”
Corrigan echoes Chassin’s view that the quality report helped to change the mindset of those in the healthcare system and put performance improvement high on the priority list. That shift, she says, has paved the way for improvements, including the development of quality measures and increasing adoption of health information technology, bolstered by the healthcare IT provisions of the federal stimulus law.
Dr. Mohamad Fakih, an infectious-disease specialist at St. John Providence Health System, Warren, Mich., reviews a chart with Janice Rey, manager of infection control.