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Erring is human: will we cross the quality chasm?
  1. D E Detmer
  1. Gillings Professor of Health Management, University of Cambridge, Cambridge CB2 1AJ, UK d.detmer{at}

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    A local rural land agent with some newly acquired knowledge was eagerly entreating a farmer to quadruple his crop yields by adopting new methods. After an exhortation of some length, the farmer raised his hand to silence the fellow and drawled, “Sorry, not interested. I already know how to be a much better farmer than I am today”. The research of the late Nobel Laureate Herbert Simon, who studied decision making processes in economic organisations, revealed that humans have a “bounded rationality” that “satisfices” rather than constantly seeks to “optimise”. As a matter of human nature and disposition, human organisations do not constantly seek to be better and do better. Instead, it is quite easy to find clear evidence of underperformance in organisations relating to every field of human endeavour. Like other organisations, health care institutions don't improve dramatically simply by pointing out lapses in their performance.

    For the past 30 years the Institute of Medicine (IOM) in Washington has published many health policy reports that reflect the thoughtful expert advice of its multidisciplinary committees—reports that outline steps capable of generating better health care.1 Since 1996 the IOM has sought explicitly to influence the quality of US health care over the next decade. A committee formed in 1998 to recommend the action needed to generate lasting and continual threshold improvement in the US health system has now produced two reports, To err is human: building a safer health system and Crossing the quality chasm: a new health system for the 21st century.23 Both reports are receiving a great deal of media, professional, and government attention. But these are still early days and, while the impact of these reports on the quality and safety of health care has yet to be realised, Professor Kenneth Shine, the IOM President, has noted that the first report has taken on a life of its own.

    The first report focuses on the substantial body of research that reveals major shortcomings in both the safety and quality of health care. For example, 44 000–98 000 Americans are estimated to die unnecessarily each year in hospital and half of these deaths are considered potentially avoidable.2 Similar quality problems do not typify all US industries—for example, during the calendar year 2000 there was not a single fatality from commercial airline use. Health care clearly has a great deal to learn. Furthermore, unless we change our ways soon and develop systems of care which are safe and capable of delivering good quality care, the demographic impact of an aging population with rising chronic care needs will add further stress to a system which cannot now always guarantee safety, let alone continuous improvement. Even new tools such as information technology and an enormously expanded knowledge base of health care will have far less effectiveness unless the system as a whole is changed, made safer, and is capable of consistently delivering good quality care.

    The second report, published last month, calls for a national effort to create a system that is fully committed to being safe, effective, patient centred, timely, efficient, and equitable. A health care system worthy of the name must commit “to continually reduce the burden of illness, injury, and disability, and to improve the health and functioning of the people …” To deliver such dramatic changes will require leadership, broad commitment, and the intelligent deployment of resources.

    Clearly, a baseline requirement for dramatic improvements in health care is a robust national health information infrastructure. The UK's Information for health strategy has its parallel in the vision for a national health information infrastructure described by the National Committee on Vital and Health Statistics.45 Neither is getting the funding it deserves and substantial financing at the national level will be required. Furthermore, while technology is a crucial part of the solution, the whole process of reform must centre on the patient and the facilitation of the healing relationships between patients and healthcare workers. The system must allow patients to make informed choices and, as far as is feasible, to control their care.

    Setting dramatically high aspirations for safety and quality in individual care and system performance is certain to generate a great deal of interest and action. Or will it? And what impact, if any, will these reports from the USA have in Europe? Most experts familiar with the health systems of economically developed economies see many parallels and similarities despite national idiosyncrasies. While the findings and recommendations of these reports appear to be generalisable, the real interest is to see how much action will result and, if reforms are implemented, to ask whether the process of implementation is generalisable.

    In the USA early public and professional response to the safety report was generally quite supportive. However, there are clinicians who believe that the report was unfair and misguided and that patients' confidence in doctors and hospitals will be seriously undermined by these reports from the IOM. So far, there has been nothing to suggest negative public reaction despite evidence that half of the population has been following the reports in the media. Equally, there is little evidence that hospitals are any safer for patients. Having said that, there has been a generally salutary response to the report throughout the USA and some action at the level of the federal government has occurred as well. Millions of new dollars are being directed to produce regular national reports on the quality of care and to increase the support for research on quality and incident reporting.

    Some wag noted that there is nothing like a “near death” experience to focus one's attention sufficiently to change one's errant ways. Whether the constant drip feed of news articles describing a graphic example of poor quality care qualifies either the US system or the NHS in the UK as “near death” or not, I leave to others to decide. However, the IOM reports do offer a fairly detailed prescription for responsible leadership from the health professions. Certainly, nations do need an industrial strength health care system worthy of the name. Admittedly, media interest, political scrutiny, layers of complex and conflicting regulations, and dense professional cultures make health systems notoriously difficult to change, even when they wish to do so. But the evidence that supports the need for change is there.

    Whether that farmer changed his farming practice was ultimately up to him, but that didn't mean that the consequences of his decision wouldn't affect his crops, his output. Apparently, he was sufficiently satisfied to continue “satisficing”. We, in health care, have our own food chain to worry about and its output is the health of both our patients and the population. We now know that the farmer—that is, the individual care worker—is only as good as the system around him. Totally independent practitioners working their own little plots just won't get the result that statistics show is delivered by good systems. The difficulty for healthcare professionals who learn to be good individual practitioners is that today's health care is dependent on the good individual practitioner working well in an interprofessional team within a good, well thought out health care system. If individual doctors, nurses, managers, and governments understand this, realise that we need urgently to reform, and offer transformational leadership, historic improvements in our care systems can result within a decade. It is true that the details for accomplishing these dramatic results are not all worked out. But surely our patients will do better if, in the future, we “satisfice” within a system enhanced with computer based decision support and embedded safety protocols. Surely this is our hour to do this essential work. Let's get on with it. Remember, our role as health professionals is to help while doing no harm. Unnecessary deaths are simply not acceptable.


    Professor Detmer was a member of the committee of both reports.