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Fam Pract Manag. 2002;9(1):12

When the Institute of Medicine (IOM) published To Err is Human: Building a Safer Health System,1 the horrifying estimates of morbidity and mortality caused by medical errors made headlines for months. When the follow-up report, Crossing the Quality Chasm: A New Health System for the 21st Century,2 appeared last year, it made much less of a splash. After all, what’s sensational about the blueprint for a renovation project?

As often seems to be the case, though, the less sensational report is the more important one. Having problems pointed out is useful only in the context of an effort to address those problems. Donald M. Berwick, MD, the head of the Institute for Healthcare Improvement (IHI), made this point in his keynote address at the IHI National Forum on Quality that took place in Orlando last month. Berwick argues that Crossing the Quality Chasm should be the blueprint for several years of concerted effort to change the health care system.

The report, produced by the IOM Committee on Quality of Health Care in America, argues that the health care system isn’t just malfunctioning; it’s doing the wrong things: “The committee is confident that Americans can have a health care system of the quality they need, want and deserve. But we are also confident that this higher level of quality cannot be achieved by further stressing current systems of care. The current care systems cannot do the job. Trying harder will not work. Changing systems of care will.”

Think systems

The committee sees the health care system as a web of interactions between patients, communities, governments and organizations involved in or influencing health care delivery financing and consumption. But within this overall system, they see subsystems at all levels, from major health care plans to the practice “microsystem” to the doctor and patient in the exam room. The whole is an incredibly complex set of overlapping systems.

So, how do we go about changing a system of systems that is so large, so complex and so dysfunctional? Doesn’t the top-level system need to change in order for the systems enmeshed in it to make significant changes? This is the Gordian knot of health care system improvement. It seems that no loop can be extricated from the mess without first untangling another loop. The IOM recommends that patients “receive care whenever they need it and in many forms, not just face-to-face visits.” But how can you do that when payers insist on paying only for face-to-face visits? The IOM recommends that patients be given free access to information about their system’s “performance on safety, evidence-based practice and patient satisfaction.” But how can you be so free with information on safety in an environment as litigious as ours today? Even if you see what you want and need to do to improve the care you deliver, the larger system seems to oppose you at every turn. The effect is daunting and the outlook depressing.

You’re it

Berwick’s response is bracing: You are simply not allowed to say you won’t change unless the environment does. Despite the way things look, people are at work making improvements on all levels of the system, experimenting with pieces of what the new system may turn out to be – advanced access, improved chronic disease care, shared decision-making technologies and more. And at all levels of the system determined leaders are acting to protect these bubbles of experimentation from the often toxic environment of the larger system.

The fact is that the health care system as a whole isn’t under anyone’s control, and it is not going to change from the top down. If it changes, it will be from the inside out. It will change as the result of the gradual coalescence of bubbles of successful experimentation. The rules will change and the environment will change as the system changes. We can have a new and better health care system. But only if you change it and I change it. Nobody else can. Let’s get to work.

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Copyright © 2002 by the American Academy of Family Physicians.

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