Have we crossed the chasm yet?

10 years af­ter IOM re­port, au­thors see progress, but ...

Modern Healthcare - - Front Page -

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.

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