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Many Challenges Await

Donna Shalala



By Donna E. Shalala, President, University of Miami and Former Secretary of Health and Human Services

Almost a decade ago I co-chaired a Presidential Commission on Consumer Protection in the Health Care Industry.

We concluded that the president should lead the nation in accepting a unifying Statement of Purpose for the health care system. We suggested: "The purpose of the health care system must be to continuously reduce the impact and burden of illness, injury, and disability, and to improve the health and functioning of the people of the United States."

I have not changed my mind about the need for federal and in particular presidential leadership.
We have our challenges:

  • While millions of Americans receive high-quality care every day— in many ways, the best care in the world— far too many Americans receive care that is of poor quality.
  • Quality problems include the overuse of services, the underuse of services, and the misuse of services.
  • For example, by just giving the right heart drug— beta-blockers— to patients after they suffer a heart attack, we could prevent thousands of deaths a year for just this one disease.
  • Total yearly hospital costs from mistakes in drug administration and prescription (preventable adverse drug events) alone amount to billions.
  • All told, the toll in human lives amounts to thousands of Americans dying each year as a result of avoidable errors in health care.
  • Other industries demand much better outcomes and fewer errors. As W.E. Deming once pointed out, "If we had to live with 99.9%, we would have: two unsafe plane landings per day at O'Hare, 16,000 pieces of lost mail every hour, [and] 32,000 bank checks deducted from the wrong bank account every hour." Yet in health care, the failure rate is substantially higher.
  • Poor-quality health care has tremendous social and economic consequences for our country— lost wages, reduced productivity, higher legal expenses, and lower confidence in the system.

We spend almost two trillion on health care and, as the Institute of Medicine has recently pointed out, less than 0.1 percent on assessing the comparative effectiveness of available interventions.

Though we are at the dawn of "personalized medicine," we have almost no capacity to absorb all the new information— studies, drugs, new procedures; our health care professionals are overwhelmed.

We quickly embrace information technology as a panacea— a fix for what ails our system. However, we know that electronic information systems are not an end in themselves, but a means to an end. The design of a successful information system must be driven by the needs of an organization for effective management, operations, and support services. In health care, managers need information that helps to assure high-quality and cost-effective health care. Clinicians need good information to make treatment decisions. Managers of support services need data to forecast personal needs and monitor their budgets. Smoothly running health care systems need all these different types of information to work together so that resources are allocated effectively and clinical services are organized around patient needs.

Evidence-based practice is the foundation for a quality health care system. Without research on health care quality, we cannot have evidence-based practice.

The federal government must significantly expand its financial commitment to the Agency for Healthcare Research and Quality for research on quality measures.

By supporting the development of these measures and tools, the government can keep them in the public domain, raise the floor, and level the playing field on which health plans, hospitals, and providers compete to improve quality.

By funding research and publishing its results, we encourage the sharing of best practices, fostering collaboration in a system of competition.

By translating research into the practice of our federal health care programs, we can serve as leaders in a marketplace that competes on quality rather than solely on cost.

Our aims for our patients ought to be straightforward:

  • Reduce the number of errors committed in the system.
  • Eliminate overuse of services while addressing the underuse of services in rural communities and elsewhere.
  • Increase patient participation in their care.

Government cannot do this alone.

The views presented in this commentary are those of the author and should not be attributed to The Commonwealth Fund or its directors, officers, or staff.


Publication Details



D. Shalala, Many Challenges Await, Modern Healthcare and The Commonwealth Fund, July 2007