The Problem
Health care around the world is in need of revolutionary change. We are not performing at the level our patients deserve. There are huge gaps between knowledge and practice. Adverse events harm patients far too often. Too many people don’t get the care they need. And the system propagates waste: waste of time, resources, and good will. Health care is characterized by fragmentation — among disciplines, among organizations, and among geographic locales — while those it serves depend on coordinated effort.

American health care is a prime example of the consequences of fragmented care: high costs (40% higher than the next most expensive nation), injuries to patients (between 44,000 and 98,000 Americans dying in hospitals each year due to errors in their care), unscientific care (500 percent variation in rates of some surgical procedures from city to city), and poor service. Patients with chronic diseases — who account for 75 percent of all health care expenditures — are most vulnerable.*

*Sources:  Organisation for Economic Cooperation and Development (OECD.org), To Err Is Human (Institute of Medicine), The Dartmouth Atlas of Health Care, Centers for Disease Control and Prevention

Better Models of Care Exist
In 1999, the Institute of Medicine (IOM) issued a wake-up call to the American health care system. The call came in the form of a landmark report called To Err Is Human: Building a Safer Health System. In outlining the many ways in which the system was harming patients, the IOM created a new and alarming awareness that the status quo was no longer acceptable. Although the IOM report was directed at the American health care system, its challenge — and its vision of a better system — apply to health care systems in countries around the world.

In 2001, the IOM published Crossing the Quality Chasm: A New Health System for the 21st Century, which outlined fundamental changes that must be made in order to improve care. The report suggested that improvement efforts be organized around six primary aims:

Aim #1: Care should be SAFE: Patients should not be harmed by the care that is intended to help them. Current estimates from the Agency for Healthcare Research and Quality place medical errors as the eighth leading cause of death in this country. About 7,000 — people per year are estimated to die from medication errors alone — about 16 percent more deaths than the number attributable to work-related injuries.

Aim #2: Care should be EFFECTIVE: providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit. Estimates are that about half of all physicians rely on clinical experience rather than evidence to make decisions. But should they? Experts say that physicians in most practices do not see enough patients with the same conditions over long enough time to draw scientifically valid conclusions about their treatment.

Aim #3: Care should be PATIENT-CENTERED, respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions. One study of physician-patient interactions showed that physicians listen to patients' concerns for an average of 18 seconds before interrupting. Medical schools are beginning to place greater emphasis on the development of good patient-interaction skills.

Aim #4: Care should be TIMELY: reducing waits and sometimes harmful delays for both those who receive care and those who give care. Many hospital Emergency Departments (EDs) are symptomatic of a system that cannot reliably give timely care. One recent survey revealed the average wait at "crowded" EDs was one hour. One third of U.S. EDs report they must periodically divert ambulances to other facilities.

Aim #5: Care should be EFFICIENT: avoiding waste, including waste of equipment, supplies, ideas and energy. Some experts estimate that most physicians are productive only 50% of their time, in part because the system works against them. Working smarter, not harder, can reduce non-clinical work and increase "face time" with patients.

Aim #6: Care should be EQUITABLE: care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socio-economic status. There is a growing number of studies showing disparities in care and treatment for some population groups. The implications can be dramatic: for example, the life expectancy of a black child is seven years shorter than that of a white child in Baltimore, Maryland, USA.

Results
Examples of results from around the world demonstrate that breakthrough improvement in the health care is possible.

Patients Admitted for Heart Failure
Jonkoping, Sweden



The Jonkoping County Council, responsible for the health care of 330,000 residents living around Hoglandet, Sweden, launched a comprehensive initiative to improve the way care is coordinated and delivered to patients. Resulting improvements included reduced waiting time for specialty appointments, more effective patient education, and a better alignment between demand and capacity. Heart failure admissions dropped because patients were getting effective care when and where they needed it.

Rates of Failed Extubation
Johns Hopkins Medical Center
Baltimore, Maryland, USA



Failed extubation of ICU patients — meaning the patient was unable to breathe on his or her own and had to be reintubated — is associated with higher mortality, morbidity, and cost. Staff at John Hopkins identified factors associated with failed extubation, and developed and then implemented a guideline to reduce failures. The result was an 81% drop in failed extubations.

Increase in Visits to Family Medicine Clinic
Alaska Native Medical Center
Anchorage, Alaska, USA



Serving predominately Alaska Natives, the Alaska Native Medical Center in Anchorage is a Native-owned and managed health care center. In a culture that values wholeness, relationships, family, and community, the Center emphasizes family medicine. Open access scheduling and chronic care plans also support long-term relationships between providers and patients. Visits to the Urgent Care Center and Emergency Department have dropped as visits to the Family Medicine Clinic have increased.

Reducing Appointment Wait Times
National Primary Care Development Team (NPDT)
(Third Wave Practices)
Great Britain



In 2000 Great Britain's National Health Service launched its National Primary Care Collaborative, described as the world's largest health care improvement project. Now encompassing nearly 2,000 practices nationwide covering almost 11.5 million patients, the Collaborative has helped to reduce by an average of 60% the waiting time for an appointment with a general practitioner.