Institute of Medicine

Committee on Quality of Health Care in America

Second in a series of publications from the Institute of Medicine's Quality of Health Care in America project Today's health care providers have more research findings and more technology available to them than ever before. Yet recent reports have raised serious doubts about the quality of health care in America. Crossing the Quality Chasm makes an urgent call for fundamental change to close the quality gap. This book recommends a sweeping redesign of the American health care system and provides overarching principles for specific direction for policymakers, health care leaders, clinicians, regulators, purchasers, and others. In this comprehensive volume the committee offers: A set of performance expectations for the 21st century health care system. A set of 10 new rules to guide patient-clinician relationships. A suggested organizing framework to better align the incentives inherent in payment and accountability with improvements in quality. Key steps to promote evidence-based practice and strengthen clinical information systems. Analyzing health care organizations as complex systems, Crossing the Quality Chasm also documents the causes of the quality gap, identifies current practices that impede quality care, and explores how systems approaches can be used to implement change.

A New Health System for the 21st Century

Crossing the Quality Chasm

National Research Council

Division on Earth and Life Studies

Board on Health Sciences Policy

Board on Life Sciences

Human Embryonic Stem Cell Research Advisory Committee

In 2005, the National Academies released the book, Guidelines for Human Embryonic Stem Cell Research, which offered a common set of ethical standards for a field that, due to the absence of comprehensive federal funding, was lacking national standards for research. In order to keep the Guidelines up to date, given the rapid pace of scientific and policy developments in the field of stem cell research, the Human Embryonic Stem Cell Research Advisory Committee was established in 2006 with support from The Ellison Medical Foundation, The Greenwall Foundation, and the Howard Hughes Medical Institute. As it did in 2007 and 2008, the Committee identified issues that warranted revision, and this book addresses those issues in a third and final set of amendments. Specifically, this book sets out an updated version of the National Academies' Guidelines, one that takes into account the new, expanded role of the NIH in overseeing hES cell research. It also identifies those avenues of continuing National Academies' involvement deemed most valuable by the research community and other significant stakeholders.

Final Report of the National Academies' Human Embryonic Stem Cell Research Advisory Committee and 2010 Amendments to the National Academies' Guidelines for Human Embryonic Stem Cell Research

National Academy of Sciences

National Academy of Engineering

2005 "Rising Above the Gathering Storm" Committee

In the face of so many daunting near-term challenges, U.S. government and industry are letting the crucial strategic issues of U.S. competitiveness slip below the surface. Five years ago, the National Academies prepared Rising Above the Gathering Storm, a book that cautioned: "Without a renewed effort to bolster the foundations of our competitiveness, we can expect to lose our privileged position." Since that time we find ourselves in a country where much has changed--and a great deal has not changed. So where does America stand relative to its position of five years ago when the Gathering Storm book was prepared? The unanimous view of the authors is that our nation's outlook has worsened. The present volume, Rising Above the Gathering Storm, Revisited, explores the tipping point America now faces. Addressing America's competitiveness challenge will require many years if not decades; however, the requisite federal funding of much of that effort is about to terminate. Rising Above the Gathering Storm, Revisited provides a snapshot of the work of the government and the private sector in the past five years, analyzing how the original recommendations have or have not been acted upon, what consequences this may have on future competitiveness, and priorities going forward. In addition, readers will find a series of thought- and discussion-provoking factoids--many of them alarming--about the state of science and innovation in America. Rising Above the Gathering Storm, Revisited is a wake-up call. To reverse the foreboding outlook will require a sustained commitment by both individual citizens and government officials--at all levels. This book, together with the original Gathering Storm volume, provides the roadmap to meet that goal. While this book is essential for policy makers, anyone concerned with the future of innovation, competitiveness, and the standard of living in the United States will find this book an ideal tool for engaging their government representatives, peers, and community about this momentous issue.

Rapidly Approaching Category 5

Rising Above the Gathering Storm, Revisited

Experts estimate that as many as 98,000 people die in any given year from medical errors that occur in hospitals. That's more than die from motor vehicle accidents, breast cancer, or AIDS--three causes that receive far more public attention. Indeed, more people die annually from medication errors than from workplace injuries. Add the financial cost to the human tragedy, and medical error easily rises to the top ranks of urgent, widespread public problems. To Err Is Human breaks the silence that has surrounded medical errors and their consequence--but not by pointing fingers at caring health care professionals who make honest mistakes. After all, to err is human. Instead, this book sets forth a national agenda--with state and local implications--for reducing medical errors and improving patient safety through the design of a safer health system. This volume reveals the often startling statistics of medical error and the disparity between the incidence of error and public perception of it, given many patients' expectations that the medical profession always performs perfectly. A careful examination is made of how the surrounding forces of legislation, regulation, and market activity influence the quality of care provided by health care organizations and then looks at their handling of medical mistakes. Using a detailed case study, the book reviews the current understanding of why these mistakes happen. A key theme is that legitimate liability concerns discourage reporting of errors--which begs the question, "How can we learn from our mistakes?" Balancing regulatory versus market-based initiatives and public versus private efforts, the Institute of Medicine presents wide-ranging recommendations for improving patient safety, in the areas of leadership, improved data collection and analysis, and development of effective systems at the level of direct patient care. To Err Is Human asserts that the problem is not bad people in health care--it is that good people are working in bad systems that need to be made safer. Comprehensive and straightforward, this book offers a clear prescription for raising the level of patient safety in American health care. It also explains how patients themselves can influence the quality of care that they receive once they check into the hospital. This book will be vitally important to federal, state, and local health policy makers and regulators, health professional licensing officials, hospital administrators, medical educators and students, health caregivers, health journalists, patient advocates--as well as patients themselves. First in a series of publications from the Quality of Health Care in America, a project initiated by the Institute of Medicine

Building a Safer Health System

To Err Is Human

It is essential for patients and clinicians to have the resources needed to make informed, collaborative care decisions. Despite this need, only a small fraction of health-related expenditures in the United States have been devoted to comparative effectiveness research (CER). To improve the effectiveness and value of the care delivered, the nation needs to build its capacity for ongoing study and monitoring of the relative effectiveness of clinical interventions and care processes through expanded trials and studies, systematic reviews, innovative research strategies, and clinical registries, as well as improving its ability to apply what is learned from such study through the translation and provision of information and decision support. As part of its Learning Health System series of workshops, the Institute of Medicine's (IOM's) Roundtable on Value & Science-Driven Health Care hosted a workshop to discuss capacity priorities to build the evidence base necessary for care that is more effective and delivers higher value for patients. Learning What Works summarizes the proceedings of the seventh workshop in the Learning Health System series. This workshop focused on the infrastructure needs-including methods, coordination capacities, data resources and linkages, and workforce-for developing an expanded and efficient national capacity for CER. Learning What Works also assesses the current and needed capacity to expand and improve this work, and identifies priority next steps. Learning What Works is a valuable resource for health care professionals, as well as health care policy makers.

Infrastructure Required for Comparative Effectiveness Research: Workshop Summary

Learning What Works

Board on Global Health

Food and Nutrition Board

In 2007 and 2008, the world witnessed a dramatic increase in food prices. The global financial crisis that began in 2008 compounded the burden of high food prices, exacerbating the problems of hunger and malnutrition in developing countries. The tandem food price and economic crises struck amidst the massive, chronic problem of hunger and undernutrition in developing countries. National governments and international actors have taken a variety of steps to mitigate the negative effects of increased food prices on particular groups. The recent abrupt increase in food prices, in tandem with the current global economic crisis, threatens progress already made in these areas, and could inhibit future efforts. The Institute of Medicine held a workshop, summarized in this volume, to describe the dynamic technological, agricultural, and economic issues contributing to the food price increases of 2007 and 2008 and their impacts on health and nutrition in resource-poor regions. The compounding effects of the current global economic downturn on nutrition motivated additional discussions on these dual crises, their impacts on the nutritional status of vulnerable populations, and opportunities to mitigate their negative nutritional effects.

Workshop Summary

Mitigating the Nutritional Impacts of the Global Food Price Crisis

Forum on Microbial Threats

In March and early April 2009, a new, swine-origin 2009-H1N1 influenza A virus emerged in Mexico and the United States. During the first few weeks of surveillance, the virus spread by human-to-human transmission worldwide to over 30 countries. On June 11, 2009, the World Health Organization (WHO) raised the worldwide pandemic alert level to Phase 6 in response to the ongoing global spread of the novel influenza A (H1N1) virus. By October 30, 2009, the H1N1 influenza A had spread to 191 countries and resulted in 5,700 fatalities. A national emergency was declared in the United States and the swine flu joined SARS and the avian flu as pandemics of the 21st century. Vaccination is currently available, but in limited supply, and with a 60 percent effectiveness rate against the virus. The story of how this new influenza virus spread out of Mexico to other parts of North America and then on to Europe, the Far East, and now Australia and the Pacific Rim countries has its origins in the global interconnectedness of travel, trade, and tourism. Given the rapid spread of the virus, the international scientific, public health, security, and policy communities had to mobilize quickly to characterize this unique virus and address its potential effects. The World Health Organization and Centers for Disease Control have played critical roles in the surveillance, detection and responses to the H1N1 virus. The Domestic and International Impacts of the 2009-H1N1 Influenza A Pandemic: Global Challenges, Global Solutions aimed to examine the evolutionary origins of the H1N1 virus and evaluate its potential public health and socioeconomic consequences, while monitoring and mitigating the impact of a fast-moving pandemic. The rapporteurs for this workshop reported on the need for increased and geographically robust global influenza vaccine production capacities; enhanced and sustained interpandemic demand for seasonal influenza vaccines; clear "triggers" for pandemic alert levels; and accelerated research collaboration on new vaccine manufacturing techniques. This book will be an essential guide for healthcare professionals, policymakers, drug manufacturers and investigators.

Global Challenges, Global Solutions: Workshop Summary

The Domestic and International Impacts of the 2009-H1N1 Influenza A Pandemic

Board on the Health of Select Populations

Committee to Evaluate the Potential Exposure to Agent Orange/TCDD Residue and Level of Risk of Adverse Health Effects for Aircrew of Post-Vietnam C-123 Aircraft

From 1972 to 1982, approximately 1,500-2,100 US Air Force Reserve personnel trained and worked on C-123 aircraft that had formerly been used to spray herbicides in Vietnam as part of Operation Ranch Hand. After becoming aware that some of the aircraft on which they had worked had previously served this purpose, some of these AF Reservists applied to the US Department of Veterans Affairs (VA) for compensatory coverage under the Agent Orange Act of 1991. The Act provides health care and disability coverage for health conditions that have been deemed presumptively service-related for herbicide exposure during the Vietnam War. The VA denied the applications on the basis that these veterans were ineligible because as non-Vietnam-era veterans or as Vietnam-era veterans without "boots on the ground" service in Vietnam, they were not covered. However, with the knowledge that some air and wipe samples taken between 1979 and 2009 from some of the C-123s used in Operation Ranch Hand showed the presence of agent orange residues, representatives of the C-123 Veterans Association began a concerted effort to reverse VA's position and obtain coverage. At the request of the VA, Post-Vietnam Dioxin Exposure in Agent Orange-Contaminated C-123 Aircraft evaluates whether or not service in these C-123s could have plausibly resulted in exposures detrimental to the health of these Air Force Reservists. The Institute of Medicine assembled an expert committee to address this question qualitatively, but in a scientific and evidence-based fashion. This report evaluates the reliability of the available information for establishing exposure and addresses and places in context whether any documented residues represent potentially harmful exposure by characterizing the amounts available and the degree to which absorption might be expected. Post-Vietnam Dioxin Exposure rejects the idea that the dioxin residues detected on interior surfaces of the C-123s were immobile and effectively inaccessible to the Reservists as a source of exposure. Accordingly, this report states with confidence that the Air Force Reservists were exposed when working in the Operation Ranch Hand C-123s and so experienced some increase in their risk of a variety of adverse responses.

Post-Vietnam Dioxin Exposure in Agent Orange-Contaminated C-123 Aircraft

Committee on Military Nutrition Research

This book reviews the research pertaining to nutrient requirements for working in cold or in high-altitude environments and states recommendations regarding the application of this information to military operational rations. It addresses whether, aside from increased energy demands, cold or high-altitude environments elicit an increased demand or requirement for specific nutrients, and whether performance in cold or high-altitude environments can be enhanced by the provision of increased amounts of specific nutrients.

Applications for Military Personnel in Field Operations

Nutritional Needs in Cold and High-Altitude Environments

Board on Population Health and Public Health Practice

Committee on the Assessment of Studies of Health Outcomes Related to the Recommended Childhood Immunization Schedule

Vaccines are among the most safe and effective public health interventions to prevent serious disease and death. Because of the success of vaccines, most Americans today have no firsthand experience with such devastating illnesses as polio or diphtheria. Health care providers who vaccinate young children follow a schedule prepared by the U.S. Advisory Committee on Immunization Practices. Under the current schedule, children younger than six may receive as many as 24 immunizations by their second birthday. New vaccines undergo rigorous testing prior to receiving FDA approval; however, like all medicines and medical interventions, vaccines carry some risk. Driven largely by concerns about potential side effects, there has been a shift in some parents' attitudes toward the child immunization schedule. The Childhood Immunization Schedule and Safety identifies research approaches, methodologies, and study designs that could address questions about the safety of the current schedule. This report is the most comprehensive examination of the immunization schedule to date. The IOM authoring committee uncovered no evidence of major safety concerns associated with adherence to the childhood immunization schedule. Should signals arise that there may be need for investigation, however, the report offers a framework for conducting safety research using existing or new data collection systems.

Stakeholder Concerns, Scientific Evidence, and Future Studies

The Childhood Immunization Schedule and Safety

In 2005, the National Academies released the report Guidelines for Human Embryonic Stem Cell Research, which offered a common set of ethical standards for a field that, due to the absence of comprehensive federal funding, was lacking national standards for research. In order to keep the Guidelines up to date, given the rapid pace of scientific developments in the field of stem cell research, the Human Embryonic Stem Cell Research Advisory Committee was established in 2006 with support from The Ellison Medical Foundation, The Greenwall Foundation, and the Howard Hughes Medical Institute. This letter report is the committee's first set of amendments to the Guidelines and clarifies earlier recommendations and conclusions, including the criteria for determining which stem cell lines it is acceptable to use. Future deliberations of the committee will address items for which additional information gathering and more extensive debate and discussion will be necessary.

2007 Amendments to the National Academies' Guidelines for Human Embryonic Stem Cell Research

In 2005, the National Academies released the report Guidelines for Human Embryonic Stem Cell Research, which offered a common set of ethical standards for a field that, due to the absence of comprehensive federal funding, was lacking national standards for research. In order to keep the Guidelines up to date, given the rapid pace of scientific developments in the field of stem cell research, the Human Embryonic Stem Cell Research Advisory Committee was established in 2006 with support from The Ellison Medical Foundation, The Greenwall Foundation, and the Howard Hughes Medical Institute. As it did in 2007, the Committee identified issues that warranted revision, and this book addresses those issues in a second set of amendments. Most importantly, this book addresses new scientific developments in reprogramming of somatic cells to pluripotency by adding a new section and revising other relevant sections of the Guidelines.

2008 Amendments to the National Academies' Guidelines for Human Embryonic Stem Cell Research

Committee on Reviewing the HIVNET 012 Perinatal HIV Prevention Study

Mother-to-child transmission of HIV-1 afflicts hundreds of thousands of children every year, especially in parts of the world such as sub-Saharan Africa, where HIV infection is prevalent and resources are limited. This tragic reality has spurred researchers to search for an effective, safe, and inexpensive treatment that could reduce the risk of perinatal HIV transmission. The HIVNET 012 trial was designed to provide preliminary information on the comparative safety and efficacy of two relatively simple and inexpensive short courses of oral antiretroviral treatment likely to be feasible in resource-limited settings. The resulting report identified some problems with procedures and documentation, but concluded that these issues did not compromise the results of the study. However, these issues have led to public scrutiny and continued controversy. Review of the HIVNET 012 Perinatal HIV Prevention Study critically and objectively evaluates the study's design and conduct, and assesses the impact of the initial procedural issues on the validity of the overall findings and conclusions of the trial.

Review of the HIVNET 012 Perinatal HIV Prevention Study

Committee on Valuing Community-Based, Non-Clinical Prevention Policies and Wellness Strategies

During the past century the major causes of morbidity and mortality in the United States have shifted from those related to communicable diseases to those due to chronic diseases. Just as the major causes of morbidity and mortality have changed, so too has the understanding of health and what makes people healthy or ill. Research has documented the importance of the social determinants of health (for example, socioeconomic status and education) that affect health directly as well as through their impact on other health determinants such as risk factors. Targeting interventions toward the conditions associated with today's challenges to living a healthy life requires an increased emphasis on the factors that affect the current cause of morbidity and mortality, factors such as the social determinants of health. Many community-based prevention interventions target such conditions. Community-based prevention interventions offer three distinct strengths. First, because the intervention is implemented population-wide it is inclusive and not dependent on access to a health care system. Second, by directing strategies at an entire population an intervention can reach individuals at all levels of risk. And finally, some lifestyle and behavioral risk factors are shaped by conditions not under an individual's control. For example, encouraging an individual to eat healthy food when none is accessible undermines the potential for successful behavioral change. Community-based prevention interventions can be designed to affect environmental and social conditions that are out of the reach of clinical services. Four foundations - the California Endowment, the de Beaumont Foundation, the W.K. Kellogg Foundation, and the Robert Wood Johnson Foundation - asked the Institute of Medicine to convene an expert committee to develop a framework for assessing the value of community-based, non-clinical prevention policies and wellness strategies, especially those targeting the prevention of long-term, chronic diseases. The charge to the committee was to define community-based, non-clinical prevention policy and wellness strategies; define the value for community-based, non-clinical prevention policies and wellness strategies; and analyze current frameworks used to assess the value of community-based, non-clinical prevention policies and wellness strategies, including the methodologies and measures used and the short- and long-term impacts of such prevention policy and wellness strategies on health care spending and public health. An Integrated Framework for Assessing the Value of Community-Based Prevention summarizes the committee's findings.

An Integrated Framework for Assessing the Value of Community-Based Prevention

Forum on Blood Safety and Blood Availability

This volume explores the safety and availability of the nation's supply of blood and blood components. It discusses the risks of disease transmission, methods of guarding the blood supply, new ideas on safety and monitoring, risk tolerance, risk communication, and no-fault insurance.

Safety and Risk

Blood and Blood Products

Forum on Neuroscience and Nervous System Disorders

Autism spectrum disorders (ASD) constitute a major public health problem, affecting one in every 150 children and their families. Unfortunately, there is little understanding of the causes of ASD, and, despite their broad societal impact, many people believe that the overall research program for autism is incomplete, particularly as it relates to the role of environmental factors. The Institute of Medicine's Forum on Neuroscience and Nervous System Disorders, in response to a request from the U.S. Secretary of Health and Human Services, hosted a workshop called "Autism and the Environment: Challenges and Opportunities for Research." The focus was on improving the understanding of the ways in which environmental factors such as chemicals, infectious agents, or physiological or psychological stress can affect the development of the brain. Autism and the Environment documents the concerted effort which brought together the key public and private stakeholders to discuss potential ways to improve the understanding of the ways that environmental factors may affect ASD. The presentations and discussions from the workshop that are described in this book identify a number of promising directions for research on the possible role of different environmental agents in the etiology of autism.

Challenges and Opportunities for Research: Workshop Proceedings

Autism and the Environment

Edward D. Berkowitz

Since its founding in 1970, the Institute of Medicine has become an internationally recognized source of independent advice and expertise on a broad spectrum of topics and issues related to the advancement of the health sciences and education and public health. Institute activities, reports, and policy statements have gained a wide audience both in the United States and throughout the world. In this first formal history of the Institute, Professor Edward D. Berkowitz describes many of the important individuals and events associated with the Institute's creation, operation, development, and accomplishments since its founding, as well as the issues and challenges the Institute has confronted over the years that have helped shape it and to which it has contributed potential solutions and responses.

A History of the Institute of Medicine

To Improve Human Health

Committee to Study HIV Transmission Through Blood and Blood Products

During the early years of the AIDS epidemic, thousands of Americans became infected with HIV through the nation's blood supply. Because little reliable information existed at the time AIDS first began showing up in hemophiliacs and in others who had received transfusions, experts disagreed about whether blood and blood products could transmit the disease. During this period of great uncertainty, decision-making regarding the blood supply became increasingly difficult and fraught with risk. This volume provides a balanced inquiry into the blood safety controversy, which involves private sexual practices, personal tragedy for the victims of HIV/AIDS, and public confidence in America's blood services system. The book focuses on critical decisions as information about the danger to the blood supply emerged. The committee draws conclusions about what was doneâ€"and recommends what should be done to produce better outcomes in the face of future threats to blood safety. The committee frames its analysis around four critical area: Product treatmentâ€"Could effective methods for inactivating HIV in blood have been introduced sooner? Donor screening and referralâ€"including a review of screening to exlude high-risk individuals. Regulations and recall of contaminated bloodâ€"analyzing decisions by federal agencies and the private sector. Risk communicationâ€"examining whether infections could have been averted by better communication of the risks.

An Analysis of Crisis Decisionmaking

HIV and the Blood Supply

Health Sciences Section

Health Sciences Policy Program

Neuroscience and Behavioral Health Program

Committee on Lesbian Health Research Priorities

Women's health, as a field of study, is a developing discipline. Health theories in general have been based on studies of men. However, in recent years, more attention has shifted to women's health, realizing the disparities between men and women in relation to their health. During the last two decades, a similar shift has occurred for a group of womenâ€"lesbian womenâ€"to further identify and specify their health needs. Over the past decade, lesbians have organized to call for attention to the health issues of this community, resulting in several federally funded research initiatives. This book offers a comprehensive view of what is known about lesbian health needs and what questions need further investigation, including: How do we define who is lesbian? Are there unique health issues for lesbians? Are lesbians at higher or lower risk for such health problems as AIDS, sexually transmitted diseases, breast cancer, mental disorders, and substance abuse? How does homophobia affect lesbian health and the funding of research on lesbian health? How do lesbian health needs fit into the health care system and the larger society? What risk and protective factors shape the physical and mental health of lesbians? The book discusses how to determine which questions to ask about sexual orientation, the need to obtain information without violating privacy, the importance of considering racial and ethnic diversity in the study of lesbians, strategies for exchanging information among researchers and disseminating findings to the public, and mechanisms for supporting greater numbers of researchers. Lesbian Health takes a frank look at the political pressures, community attitudes, and professional concerns uniquely affecting the study of lesbian health issues. The book explores many other issues including the potential for transferring findings in this field to other population groups, including other rare populations and women in general.

Current Assessment and Directions for the Future

Lesbian Health

National Cancer Policy Board

Committee on Large-Scale Science and Cancer Research

The nature of biomedical research has been evolving in recent years. Technological advances that make it easier to study the vast complexity of biological systems have led to the initiation of projects with a larger scale and scope. In many cases, these large-scale analyses may be the most efficient and effective way to extract functional information from complex biological systems. Large-Scale Biomedical Science: Exploring Strategies for Research looks at the role of these new large-scale projects in the biomedical sciences. Though written by the National Academies' Cancer Policy Board, this book addresses implications of large-scale science extending far beyond cancer research. It also identifies obstacles to the implementation of these projects, and makes recommendations to improve the process. The ultimate goal of biomedical research is to advance knowledge and provide useful innovations to society. Determining the best and most efficient method for accomplishing that goal, however, is a continuing and evolving challenge. The recommendations presented in Large-Scale Biomedical Science are intended to facilitate a more open, inclusive, and accountable approach to large-scale biomedical research, which in turn will maximize progress in understanding and controlling human disease.

Institute of Medicine

Books

Your next favorite book is out there