Chapter 2

Crossing the Quality Chasm:
Adaptation for Mental Health and Addictive Disorders

Allen Daniels, Ed.D.
Professor of Clinical Psychiatry
University of Cincinnati

Mary Jane England, M.D.
President
Regis College

Ann K. Page, R.N., M.P.H.
Senior Program Officer
Institute of Medicine

Janet Corrigan, Ph.D., M.B.A.
Director, Board on Health Care Services
Institute of Medicine

In November 2003, the Institute of Medicine (IOM) of the National Academies of Science initiated a new study at the request of the Department of Health and Human Services’ Substance Abuse and Mental Health Services Administration (SAMHSA) and the Robert Wood Johnson Foundation. These organizations asked the IOM to identify ways to improve the quality of mental health services and services for the treatment of substance use disorders in the United States. They further asked that the IOM use a previously published IOM titled Crossing the Quality Chasm: A New Health System for the 21st Century (2001) as the framework for this study.

Crossing the Quality Chasm

Crossing the Quality Chasm was the final report of the Committee on the Quality of Health Care in America. This unique committee was created by the IOM in 1998 as a response to the accumulating number of studies documenting that the way in which health care is delivered has not kept pace with the advances in medical technology and with the growing evidence about how to effectively treat diseases. Many people fail to receive the care that is known to be most effective in treating their health conditions, or they receive costly care that carries risk but has little or no benefit. And sometimes, individuals simply receive the wrong treatments.

The committee’s first report, To Err Is Human, (IOM, 2000) was a wake-up call to health care providers, organizations, and all components of the health care system. It documented that not only was health care often of poor quality, it was actually unsafe. The evidence in this report indicates that between 44,000 and 98,000 people in the United States die every year from problems in the way the delivery of health care is designed. This number is more than those who die from breast cancer, AIDS, or motor vehicle accidents. These deaths are not necessarily a result of “bad” doctors, nurses, or other health care workers, but of fundamental problems in how health services are organized and delivered. The report received widespread attention at the highest level of the government, in the media, and among health care organizations and consumer advocates.

The report’s message and its recommendations for building safer systems of care delivery within health care organizations and across the entire U.S. health care system spurred action by the government and many private sector organizations. At the same time, the Committee on the Quality of Health Care in America knew that keeping patients safe from harm is not the only goal for health care. Consumers also need to receive care that is effective in treating their illness, responsive to their values and treatment preferences, timely, efficient, and equitable. These concerns were the focus of the second and final Committee report: Crossing the Quality Chasm: A New Health System for the 21st Century (IOM, 2001).

This report advanced the notion that failures in the health system are not due to the intent or efforts of those involved in the care process but to fundamental failures in the way these systems are established. It called attention to the need to redesign health care practices at every level of the U.S. health care system. Changes needed in the design of health systems include:

• how individual health care providers interact with their patients


• how the multiple providers who deliver care to an individual patient communicate and coordinate with each other


• how health care organizations design their delivery of care


• how those parties external to the actual delivery of care, but that exert tremendous influence on how care is delivered (i.e., the regulatory agencies, payers, and external oversight organizations), need to align their practices to foster the delivery of quality health care.

The Quality Chasm report put forth the following six aims or common values for the U.S. health care system that it urged all parties to embrace and use to guide their quality improvement efforts:

1. Safe care—avoids injuries to patients from the care intended to help them.


2. Effective care—provides services based on scientific knowledge to all who could benefit and refrains from providing services to those not likely to benefit.


3. Patient-centered care—is respectful of and responsive to individual patient preferences, needs, and values and ensures that patient values guide all clinical decisions.


4. Timely care—reduces waiting time and sometimes harmful delays for both those who receive and those who give care.


5. Efficient care—avoids waste, in particular waste of equipment, supplies, ideas, and energy.


6. Equitable care—does not vary in quality because of personal characteristics, such as gender, ethnicity, geographic location, and socioeconomic status.

The Chasm report called for health care system redesign efforts to be guided by 10 rules that called for:

1. Care based on continuous healing relationships. Patients should receive care whenever they need it and in many forms, not just as face-to-face visits. This rule implies that the health care system should be responsive (24 hours a day, every day) and that access to care should be provided over the Internet, by telephone, and by other means, in addition to face-to-face visits.


2. Customization based on patient needs and values. The system of care should be designed to meet the common types of needs but to have the capacity to respond to individual patient choices and preferences, including those shaped by ethnic and cultural beliefs and practices.


3. The patient as the source of control. Patients should be given the necessary information and the opportunity to exercise the degree of control they choose over health care decisions that affect them. The health system should be able to accommodate differences in patient preferences and to encourage shared decisionmaking.


4. Shared knowledge and the free flow of information. Patients should have unfettered access to their own medical information and to clinical knowledge. Clinicians and patients should communicate effectively and share information.


5. Evidence-based decisionmaking. Patients should receive care based on the best available scientific knowledge. Care should not vary illogically from clinician to clinician or from place to place.


6. Safety as a system property. Patients should be safe from injury caused by the care systems. Reducing risk and ensuring safety require greater attention to systems that help prevent and mitigate errors.


7. The need for transparency. The health care system should make information available to patients and their families, allowing them to make informed decisions when selecting a health plan, hospital, or clinical practice, or choosing among alternative treatments. This should include information describing the system’s performance on safety, evidence-based practice, and patient satisfaction.


8. Anticipation of needs. The health systems should anticipate patient needs, rather than simply reacting to events.


9. Continuous decrease in waste. The health system should not waste resources or patient time.


10. Cooperation among clinicians. Clinicians and institutions should collaborate actively and communicate to ensure an appropriate exchange of information and coordination of care.

The Chasm report also described specific actions that health care organizations and other parties will need to take to achieve the six aims, such as the following:

• Apply work design principles, which are well known and used in other industries, to health care.


• Provide decision support to health care workers to help them appropriately incorporate the burgeoning knowledge base into their clinical practices.


• Use the power of information technology to support all levels of decisionmaking and communication across the multiple providers serving a given patient.


• Realign payment policies to support the adoption of strategies to achieve better quality health care.

The Adaptation for Behavioral Health

Following the publication of the Quality Chasm report, the American College of Mental Health Administration (ACMHA) focused its annual summit (2002) on “Crossing the Quality Chasm: Translating the Institute of Medicine Report for Behavioral Health.” This summit brought together more than 90 leaders in the behavioral health field who examined the report and considered its relevance. The overwhelming consensus of the participants of the ACMHA 2002 Summit was that the IOM Quality Chasm framework is immediately relevant and applicable to the concerns of behavioral health systems of care and policy. In addition, the participants affirmed the need to translate the material to the specific field of behavioral health care issues and to address its integration into the larger general health care systems. Furthermore, the participants acknowledged and endorsed the IOM paradigm as a strategic planning blueprint for the redesign of the behavioral health care system. Detailed summaries of the findings of this summit are available at www.acmha.org.

The Quality Chasm report has been well received by public and private health care organizations, government bodies, and quality improvement organizations. As testimony to its success—and to its potential value for improving the quality of care of mental health and substance use treatment services—a committed group of public and private sponsors with long-standing commitments to improved delivery of mental health and substance use treatment services have come together to provide support for the study. This group includes The Substance Abuse and Mental Health Services Administration (SAMHSA), the Robert Wood Johnson Foundation, the Department of Veterans Affairs, the National Institute on Drug Abuse, the National Institute on Alcohol Abuse and Alcoholism, the Annie E. Casey Foundation, and the Cigna Foundation.

The IOM project has convened the Committee on Crossing the Quality Chasm: Adaptation to Mental Health and Addictive Disorders. The charge for this committee is to (1) consider the Chasm report’s aims, rules, and organizational and environmental supports and identify those that need special attention and implementation strategies for application in mental health and addictions disorders care and (2) develop a blueprint for the redesign of behavioral health care delivery.

The committee conducting this study consists of consumers and consumer advocates, health care providers, health services researchers, and policy experts with knowledge in mental health and addiction illness and treatment; primary care; child mental health; systems engineering; Medicaid; geropsychiatry; veterans’ health care; mental health law and ethics; mental health, addiction, and general health delivery systems; economics of general and mental health care; and information technology. The committee is chaired by Mary Jane England, M.D., and a full committee membership roster is available at www.iom.edu.

The charge to the committee is to use the context of the Quality Chasm report to create a strategic blueprint for the field that encompasses the following areas: mental illness and substance use disorders; public and private payer and delivery systems; care for children and adults; veterans; and all four levels of Quality Chasm intervention points (clinician, microsystems or teams, health care organizations, and external agencies). To complete its project, the committee will meet six times between April 2004 and April 2005 and produce a final report in fall 2005.

The committee’s work, which is governed by the methods established by the Institute of Medicine, includes direct testimony, commissioned reports, and evidence-based findings. The final report will summarize the findings of the committee and include a review of the current issues that face the field, the implications of the original Quality Chasm report, their application for the behavioral health field, and recommendations that will help guide the strategic blueprint. It is also anticipated that the final report will include systems of accountability for measuring the successful application of the recommendations.

Conclusions

The Committee on Crossing the Quality Chasm: Adaptation to Mental Health and Addictive Disorders has been actively working on this project. A wide spectrum of stakeholders has supplied constructive testimony. Stakeholders include recipients of care; providers; and representatives of behavioral health systems, funders, and purchasers of care. The work of the committee has been an open and constructive dialog, with the goal of producing a report that will be helpful to the field and will fulfill the committee’s charge. The full report will be available late in 2005 and will be accessible through the IOM Web site.

References

Institute of Medicine. (2000). To err is human: Building a safer health system. L. T. Kohen, J. M. Corrigan, & M. S. Donaldson (Eds.). Washington, DC: National Academy Press.

Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press.