1. This chapter discussed the iceberg as a metaphor for gaining a deeper understanding of a system. The chapter also discussed the need to ask not only the question, “What can we do differently?”

but also, “How can we best understand why we are getting the results we are getting?” The Institute of Medicine’s (IOM) report, Crossing the Quality Chasm: A New Health System for the 21st Century, recommends ten new rules for redesigning healthcare processes.

These rules may be thought of as replies to the question, “What can we do differently?” In the Underlying Structures Worksheet below, 135 the first column contains four of the IOM rules. The middle column contains the current state of the U.S. healthcare system relative to the rule (readers will recognize some of these statements from Figure 1.1). Complete the third column of the worksheet by answering the question, What underlying structures are contributing to the current state? Write your responses on the worksheet.
Underlying Structures Worksheet 136 S e c t i o n I I : T h e S y s t e m s A p p r o a c h Redesigned Current State What underlying Rule of the Healthcare structures contribute to (IOM 2001) System this system behavior in the United States?
Care based on continuous healing relationship The patient as the source of control Evidence-based decision making Safety as a system property Fragmentation across payers, providers, geographic locations Fifty-five percent of Americans surveyed are dissatisfied with the quality of healthcare in the United States, and 40 percent responded that in the past five years, quality of care has gotten worse (Kaiser Family Foundation 2004)
Adult Americans received 54.9 percent of recommended preventive care, acute care, and chronic care (McGlynn et al. 2003)
Between 44,000 and 98,000 deaths per year in the United States have been attributed to preventable medical errors, making medical errors the eighth leading cause of death (IOM 1999)