Across the Chasm: Six Aims for Changing the Health Care System

Information for this feature story was obtained from the IHI Calls to Action series, Implementing the Quality Chasm Report.
In 1999, the Institute of Medicine (IOM) in Washington, DC, USA, released To Err Is Human: Building a Safer Health System, an alarming report that brought tremendous public attention to the crisis of patient safety in the United States. In 2001, IOM followed up with Crossing the Quality Chasm: A New Health System for the 21st Century, a more detailed examination of the immense divide between what we know to be good health care and the health care that people actually receive.
The report calls the divide not just a gap but a chasm, and the difference between those two metaphors is quantitative as well as qualitative. Not only is the current health care system lagging behind the ideal in large and numerous ways, but the system is fundamentally and incurably unable to reach the ideal. In order to begin achieving real improvement in health care, the whole system has to change.
Let’s look at the other side of the chasm — at the ideal health care outlined by the report’s six "Aims for Improvement." To begin with, health care must be safe. This means much more than the ancient maxim "First, do no harm," which makes it the individual caregiver’s responsibility to somehow try extra hard to be more careful (a requirement modern human factors theory has shown to be unproductive). Instead, the aim means that safety must be a property of the system. No one should ever be harmed by health care again.
Second, health care must be effective. It should match science, with neither underuse nor overuse of the best available techniques — every elderly heart patient who would benefit from beta-blockers should get them, and no child with a simple ear infection should get advanced antibiotics. Third, health care should be patient-centered. The individual patient’s culture, social context, and specific needs deserve respect, and the patient should play an active role in making decisions about her own care. That concept is especially vital today, as more people require chronic rather than acute care. Fourth, care should be timely. Unintended waiting that doesn’t provide information or time to heal is a system defect. Prompt attention benefits both the patient and the caregiver.
Fifth, the health care system should be efficient, constantly seeking to reduce the waste — and hence the cost — of supplies, equipment, space, capital, ideas, time, and opportunities. And sixth, health care should be equitable. Race, ethnicity, gender, and income should not prevent anyone in the world from receiving high-quality care. We need advances in health care delivery to match the advances in medical science so the benefits of that science may reach everyone equally.
But we cannot hope to cross the chasm and achieve these aims until we make fundamental changes to the whole health care system. All levels require dramatic improvement, from the patient’s experience — probably the most important level of all — up to the vast environment of policy, payment, regulation, accreditation, litigation, and professional training that ultimately shapes the behavior, interests, and opportunities of health care. In between are the microsystems that bring the care to the patients, the small caregiving teams and their procedures and work environments, as well as all the hospitals, clinics, and other organizations that house those microsystems. "We’re trying to suggest actions for actors, whether you’re a congressman or the president or whether you’re a governor or a commissioner of public health, or whether you’re a hospital CEO or director of nursing in a clinic or chairman of medicine," says Donald M. Berwick, MD, MPP, former President and Chief Executive Officer of the Institute for Healthcare Improvement and one of the Chasm report’s architects. "No matter where you are, you can look at this list of aims and say that at the level of the system you house, the level you’re responsible for, you can organize improvements around those directions."
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