A CEO Checklist for High-Value Health Care: un documento di discussione dello IOM

L’Institute of Medicine ha organizzato una tavola rotonda su “Un’assistenza sanitaria guidata dal Valore & la Scienza, ad uso dei Direttori generali delle organizzazioni sanitarie. Partecipanti: Delos Cosgrove, Michael Fisher, Patricia Gabow, Gary Gottlieb,George Halvorson, Brent James, Gary Kaplan, Jonathan Perlin,Robert Petzel, Glenn Steele, John Toussaint.

Ne è uscito un documento di discussione: A CEO Checklist for High-Value Health Care.


Health care in the United States is at a critical point. Excessive costs are no longer tenable and mediocre outcomes are no longer tolerable. For 32 of the past 40 years, health care costs have grown faster than the rest of the U.S. economy.1 Federal health care costs—expected to reach $950 billion in 2012—will become the largest contributor to the national debt.2 States, too, are being crippled by health care costs. Medicaid now consumes almost a quarter of state budgets, crowding out investments in education and infrastructure.3 In the private sector, escalating costs have eroded the bottom line for employers who purchase health care for their employees and have eliminated any appreciable gains in income for American families during the past decade.4,5 Purchasers simply cannot afford the status quo.

Despite these expenditures, outcome shortfalls are pervasive. Population health measures such as life expectancy and preterm birth lag behind those of almost every other developed nation. Patients are still harmed by medical errors. Recent assessments indicate that 10 years after the IOM report To Err Is Human estimated that medical errors cause up to 98,000 deaths in hospitals each year,6 roughly 15 percent of hospital patients are still being harmed during their stays.7 Poor care coordination places further strain on patients and the system, with roughly 20 percent of discharged elderly patients returning to the hospital within 30 days.8 Faced with concerns about the cost and quality of health care, purchasers are developing concrete plans to leverage their buying power to reduce expenditures and demand high-value care—care that achieves better outcomes at lower costs.

These are the realities for health care executives today. As demand for high-value health care builds, care delivery leaders face the near-term imperative to transform the way their organizations operate. We know the potential for improvement exists. The amount of waste in the system—estimated to be at least 30 percent9—provides both the opportunity and the mandate for transformation. Replacing wasteful practices and procedures with those marked by effectiveness and efficiency can improve health outcomes and bottom lines at a time when pressures are growing on both counts.

Given the urgency at hand, each of us, with the assistance of farsighted staff and in cooperation with many of you in other institutional leadership positions, has been engaged in these kinds of efforts. To aid and accelerate the system-wide transformation necessary, we have assembled what we are calling “A CEO Checklist for High-Value Care” (the Checklist). The Checklist’s 10 items reflect the strategies that, in our experiences and those of others, have proven effective and essential to improving quality and reducing costs. They describe the foundational, infrastructure, care delivery, and feedback components of a system oriented around value, and represent basic opportunities—indeed obligations—for hospital and health care delivery system CEOs and Boards to improve the value of health care in their institutions.


The strategies in this Checklist are not, of course, of the “one-and-done” variety. Rather, the items we present here are elements that must become core components of an organization’s DNA. In some ways, they represent more a credo of commitment than a simple checklist, but each Checklist item is every bit as vital as the items on the checklists routinely used by pilots taking complicated aircraft into quickly changing conditions. Taken together, the Checklist provides a blueprint for improving quality and reducing cost amid a changing landscape.

We realize that while the elements on the Checklist are necessary to achieve high-value health care within an institution, they are not sufficient to reach full potential across the system. Forces outside the control of any single institution—economic incentives that reward volume over value, inequitable access to needed services, poor linkage of community and clinical services, and unnecessary regulatory requirements—can all serve as barriers to the transformation required. However pervasive, we cannot allow these issues to obscure the substantial gains that can be achieved from the steps well within our control as leaders of our institutions.

What follows is an item-by-item review of the basic issues, opportunities, and expectations for the 10 items on the Checklist, along with case material that briefly describes a sample of our experiences. To improve readability and access, we have been deliberately brief in the case descriptions, but more details may be found in the material in Appendix I, where follow-up contact information is also provided for additional conversations. Because this paper addresses the system-level issues that are central to achieving high-value health care, we do not discuss or spotlight some important work that has been developed around individual services that are often overused, unnecessary, or otherwise wasteful. In recognition of the utility of such analyses and inventories, we have included summaries of some of that work in Appendix II.

Ultimately, the transition to high-value care will be led and championed by executives who recognize high quality and lower cost as institutional aims, and will be sustained by a system-wide culture of continuous improvement. When successfully implemented, these systematic improvements that reduce waste and improve outcomes will maximize the value of health care delivered in the United States.


  1. Centers for Medicare and Medicaid Services. 2012. National Health Expenditure Data. Available at:http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/index.html (accessed May 22, 2012).
  2. Keehan, S. P., A. M. Sisko, C. J. Truffer, J. A. Poisal, G. A. Cuckler, A. J. Madison, J. M. Lizonitz, and S. D. Smith. 2011. National health spending projections through 2020: Economic recovery and reform drive faster spending growth. Health Affairs 30(8):1-12.
  3. The quarter of state budgets figure used includes both federal and state Medicaid contributions, as well as all federal contributions to the total budget. National Association of State Budget Officers. 2011. State Expenditure Report 2010 (Fiscal 2009-2011 Data). Available athttp://www.nasbo.org/sites/default/files/Summary%20-%20State%20Expenditure%20Report.pdf(accessed April 25, 2012); Kaiser Family Foundation. 2011. Moving ahead amid fiscal challenges: A look at Medicaid spending, coverage and policy trends results from a 50-state Medicaid budget survey for state fiscal years 2011 and 2012. Available at http://www.kff.org/medicaid/upload/8248.pdf(accessed January 23, 2012).
  4. Kaiser Family Foundation. 2011. Employer Health Benefits Survey. Available at
    http://ehbs.kff.org/pdf/2011/8225.pdf (accessed November 4, 2011).
  5. Auerbach, D., and A. L. Kellermann. 2011. A decade of health care cost growth has wiped out real income gains for an average US family. Health Affairs 30(9):1630-1636.
  6. Institute of Medicine. 1999. To err is human: Building a safer health system. Washington, DC: National Academy Press.
  7. Landrigan, C. P., G. J. Parry, C. B. Bones, A. D. Hackbarth, D. A. Goldmann, and P. J. Sharek. 2010. Temporal trends in rates of patient harm resulting from medical care. New England Journal of Medicine 363(22):2124-2134; U.S. Department of Health and Human Services. Office of Inspector General. 2010. Adverse events in hospitals: National incidence among Medicare beneficiaries. Washington, DC: Department of Health and Human Services.
  8. Jencks, S. F., M. V. Williams, and E. A. Coleman. 2009. Rehospitalizations among patients in the medicare fee for-service program. N Engl J Med 360(14):1418-1428.
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