The Institute of Medicine Principles and Advance Care Planning

Between the health care we have and the care we could have lies not just a gap, but a chasm.

Institute of Medicine, “Crossing the Quality Chasm”

The Institute of Medicine (IOM) is an independent, nonprofit organization in the United States that provides unbiased and authoritative advice to decision makers and the public (see Established in 1970, the IOM is the health arm of the National Academy of Sciences, which was chartered under President Abraham Lincoln in 1863.

The IOM claims to ask and answer the nation's most pressing questions about health and health care. The report from the committee on the Quality of Health Care in America made an urgent call for fundamental change to close the quality gap, recommending a redesign of the American health care
system, and providing overarching principles for specific direction for policymakers, health care leaders, clinicians, regulators, purchasers, and others.

“To Err Is Human”: Building a Safer Health System

“To Err Is Human” (Institute of Medicine, 1999) was a groundbreaking report that brought into sharp reality the harm that health care can cause patients. It stated:

Health care in the United States is not as safe as it should be and can be. At least 44,000 people, and perhaps as many as 98,000 people, die in hospitals each year as a result of medical errors that could have been prevented, according to estimates from two major studies. Even using the lower estimate, preventable medical errors in hospitals exceed attributable deaths to such feared threats as motor-vehicle wrecks, breast cancer, and AIDS.

It is important to include this report, as it highlights the scale of harm in health care when professionals thought they were delivering good care.

“The Quality Chasm”

“Crossing the Quality Chasm” is a subsequent IOM report (Institute of Medicine, 2001) that describes broader quality issues and defines six aims of quality care: care should be safe, effective, patient centered, timely, efficient, and equitable. This report also presents 10 rules for care delivery redesign.

Table 20.1 summarizes the IOM quality aims and rules for care delivery redesign from the Quality Chasm. These aims and rules are generic and apply to ACP and EOL care. Looking back at these proposed rules, it is timely to review them in the context of ACP and EOL care to highlight the importance of items 2 and 3 (care is effective and is customized according to the needs of the patient, with the patient as the source of control); 4 (knowledge is shared in a timely fashion and information flows freely); 8 (needs are anticipated); and 10 (cooperation among clinicians is a priority).

Improvement Science

Some readers will be familiar with the work of august institutions that promote and support the implementation of improvement science. Research and its methodology are distinct from improvement science. Research is often orientated around summative evaluation and is designed to answer very specific
TABLE 20.1

Crossing the Quality Chasm: A New Health System for the 21st Century March 1, 2001 Consensus Report IOM


1. Safe 1. Care is based on continuous healing relationships.

2. Effective 2. Care is customized according to patient needs and values.

3. Patient-centered 3. The patient is the source of control.

4. Timely 4. Knowledge is shared and information flows freely.

5. Efficient 5. Decision making is evidence-based.

6. Equitable 6. Safety is a system property.

7. Transparency is necessary.

8. Needs are anticipated.

9. Waste is continuously decreased.

10. Cooperation among clinicians is a priority.

IOM, Institute of Medicine.

questions, “Does the treatment work?” QI is orientated to learning how to apply the knowledge in effective systems and often uses formative evaluation. QI also incorporates cultural/social and behavioral factors. Again, these techniques can be used to improve ACP and EOL care. These people or community factors are even more relevant to get people and professionals to treat patients with respect and allow or facilitate communication and engagement in change programs that deliver better ACP and EOL care.

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