AResearch Agenda For Bridging

Realizing the vision of the IOM’s landmark report, Crossing the Quality Chasm, will require new knowledge to support new policy and management. This paper lays out a research agenda that must be pursued if the health care system is to bridge the quality chasm. Based on a consensus process involving leading health care researchers and authorities, the paper highlights knowledge gaps and research directions in five areas identified by the Quality Chasm report as critical to its goals of building organizational supports for change; applying evidence to health care delivery; developing information technology; aligning payment policies with quality improvement; and preparing the workforce. A landmark report by the Institute of Medicine (IOM), Crossing the Quality Chasm, documented many of the failings of our current system and described a system that would provide health care of the highest attainable quality to all Americans. The report contains a compelling vision, but questions remain: How do we cross this chasm between where we are now and where we want to be? And what will it take to make this happen? New knowledge is an essential pillar in the bridge across the quality chasm. We need to know why gaps exist, what actions will be required to close those gaps, and how those actions can be carried out. However, because uninformed action carries the risk of inefficiency and perhaps even harm, research must accompany policy development and management innovations so that interventions can be planned well and their effects tracked. The Harvard Interfaculty Program for Health Systems Development (PHSI) was charged with preparing a research agenda for the Quality Chasm report. As our first step, we convened a group of prominent health services researchers and policymakers from a variety of backgrounds and institutions, to identify the major gaps in knowledge that stand in the way of achieving the report’s vision. We used a modified Delbecq small-group method to generate an initial ranked list of research questions and then used our own judgment, informed by a review of the literature and the Quality Chasm report itself, to generate the most important domains for research. We structured our inquiry using the five substantive chapters of the original report. Each of these chapters centers on a critical element of a health care system characterized by high quality: organizational supports, evidence-based care, clinical information technology, payment policies, and preparing the workforce. For each of these areas we tried to provide a general sense of the current knowledge base and to identify the most important research questions for future work. We aimed to identify the most pressing research needs, stimulate discussion, and lay the groundwork for future action. More detailed work will be required, because we did not always address how, or even whether, each of these questions can and should be researched. A further limitation is that our process did not include the views of health care consumers, which would be desirable in future work. Research agendas such as this one can seem like special pleading for a claim on Q u a l i t y C h a s m H E A LT H A F F A I R S ~ V o l u m e 2 2 , N u m b e r 2 1 7 9 limited societal resources. Although the research needs we identified have already been culled from a much longer list assembled by our expert panel, we recognize the need to select among even this limited agenda. Therefore, at the end of this paper we select our highest research priorities. Cross-Cutting Themes In Quality Improvement Research Need for more robust performance measures. Before we lay out specific findings, several larger, cross-cutting issues deserve emphasis. First is the importance of creating more robust performance measures to guide our actions and track our progress toward improving quality of care. The lack of such measures in many areas of interest—such as organizational performance, physician performance, systems-related measures, and the quality-related outcomes of workforce training—constitutes a major barrier not only to documenting and encouraging progress, but also to research on the merits of alternative social interventions. Research also is needed on optimal design and implementation of measurement strategies. For example, there is insufficient understanding of the value of different approaches to measurement (such as more measures versus fewer but more robust measures). Both the benefits and costs of performance measurement must be tracked to assure that benefits exceed costs over time. Role of the consumer/patient. A second cross-cutting theme is the urgent need for more concentrated, rigorous, and critical attention to the role of the consumer/patient in influencing the organization and behavior of the health care system. The Quality Chasm report’s embrace of patient-centered care is among its most important, powerful, and positive messages. However, we do not understand very well the behavior of consumers in health care. Consequently, uncertainties abound about the effects of actions undertaken in the name of the health care consumer. Understanding the effects of such efforts to “empower” and “activate” consumers should receive a high priority in future research. Complexity theory. A third theme concerns the need to explore the implications for health care research of complexity theory, a novel and potentially transforming perspective that profoundly influenced the IOM’s work. The Quality Chasm report does not explore fully the implications of this perspective for how future research should be conducted or policy formulated. Pursuing these potentially profound issues should be a high priority in future health-related research. Building Organizational Supports For Change Crossing the Quality Chasm acknowledges that one important key to improving quality lies in creating organizations that can optimize and improve the care process. To do this, research is needed to develop more robust performance measures to identify high-performing organizations, understand better what differentiates successful from unsuccessful organizations, elucidate the process of organizational change, and explore the role and characteristics of good leadership. 1 8 0 M a r c h / A p r i l 2 0 0 3 R e s e a r c h A g e n d a