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QMHC Book Review

QUALITY MANAGEMENT IN HEALTH CARE/SUMMER 2002

Crossing the Quality Chasm: A New Health

System for the 21st Century

Reviewed by Crossing the Quality Chasm: A New Health System

for the 21st Century, by the Committee on Quality of
Jean Gayton Carroll, PhD Health Care in America of the Institute of Medicine.
Editor Washington, DC: Institute of Medicine. National Acad-
Quality Management in Health Care emy Press, 2001. 335 pages, hardcover, $44.95.
Chicago, Illinois
In 1998 the Institute of Medicine formed its Com-
mittee on the Quality of Health Care. The committee’s
mission was to identify strategies for achieving a
substantial improvement in the quality of health care
delivered to Americans. The committee’s first report,
To Err is Human: Building a Safer Health System,
released in 1999, generated widespread interest and
spurred a great deal of follow-up research and discus-
sion on patient safety issues.
This, the second and final report of the committee,
addresses strategies for change not only in the health
care delivery system per se but also in the structures
and processes of the environment in which health
care organizations and their workforces function.
This expansive project was planned and carried out
under the leadership of a blue ribbon committee
chaired by William C. Richardson, President and
CEO of the Kellogg Foundation. Execution of the
project was the work of another stellar group, the
study staff, directed by Janet Corrigan and supported
by the auxiliary staff. The report was reviewed by a
panel of expert specialists.
Thanks to its good organization, starting with the
table of contents, what could have been a cumber-
some document turns out to be an easy read. A
helpful feature in the table of contents is the display,
within each chapter reference, of the page numbers
on which major topics are addressed. Organizing and
guiding the report’s content are 13 committee recom-
mendations, couched in fairly general terms. These
Quality Management in Health Care, 2002, 10(4), 60–61 recommendations are operationalized through more
© 2002 Aspen Publishers, Inc.

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concretely phrased “aims” and “rules” in the course
of the report.
In savvy journalistic style, the writers lay out six
aims for improvement in the system: that health care
be safe, effective, patient-oriented, timely, efficient,
and equitable. The need for the specific improve-
ments is illustrated with a case history. Then they
formulate 10 “rules”—the observance of which should
help to resolve the perceived problems. To get the
resolution process started, they propose that the
Agency for Healthcare Research and Quality identify
and focus on a list of common chronic health condi-
tions (the “priority conditions”) for which state-of-
the-art care and treatment processes will be devel-
oped and disseminated.
The committee recognizes that implementing sys-
tem redesign requires developing effective organiza-
tional structures and processes. The reengineering
principles of system design used in other industries
and how they could be applied to health care are well-
presented. The role of the leader in planning and
implementing change is thoughtfully addressed.
Especially well done is the chapter on “Applying
Evidence to Health Care Delivery.” The authors go into
detail on such aspects of evidence-based practice as
synthesizing clinical findings, using computer-based
clinical decision support systems, making information
available on the Internet, and defining quality mea-
sures. In another chapter, the related subject of the role
of information technology in the twenty-first century
delivery system is discussed. The authors argue for
the development of a comprehensive national health
information infrastructure, while acknowledging the
related need for a reliable apparatus to protect pri-
QMHC Book Review 61
vacy. However, their critical comment that, “Only a
fraction of clinicians offer e-mail as a communication
option to patients,” seems to ignore the weakness of
current privacy safeguards and the fact that access to
computers is by no means universal.
In a chapter that could serve well as one of the
readings for a graduate course in health system fi-
nance or organizational analysis, the committee ana-
lyzes payment policies, past and present, and their
impact on the quality of care. Mechanisms to improve
the way payment methods reward quality care are
presented and evaluated. In the final chapter, the
committee addresses the subject of preparing the
health care workforce for the future. The authors
make the point that health care workforce planning
must become comprehensive in scope, rather than
focused on such subjects as discipline-specific ratios
or existing organizational models. Their agenda on
workforce planning would address key issues in
training and education, legal and regulatory pro-
cesses, and workforce supply.
The report of the Technical Panel on the State of
Quality to the Quality of Health Care in America
Committee is included as Appendix A. Appendix B
is a chapter by Paul Plsek entitled, “Redesigning
Health Care with Insights from the Science of Com-
plex Adaptive Systems,” a fascinating discussion of
how applying the basic principles of complexity
thinking might aid in the redesigning effort. Each
chapter of the book has an ample bibliography. This
valuable and well-written report can be recommended
to anyone, whether clinician or nonclinician, who is
involved in the development of health care delivery
system strategy.