To improve health care we need to understand the motivations of those who work in it

Earlier this year the Institute of Medicine issued another report on health care quality, following its much heralded report on patient safety in 1999. Crossing the Quality Chasm is unequivocal in its assertion: the defects of American health care are so widespread that they detract from the “health, functioning, dignity, comfort, satisfaction, and resources of Americans.”1 The report fails, however, to create an equally compelling vision of how health care in the United States can be transformed. We are not given a sense of how hundreds of thousands of healthcare workers will be engaged in this enormous task.

The authors of this report characterise their earlier one, To Err is Human: Building a Safer Health System,2 as a “small part of an unfolding story of quality in American health care.” Yet that report, on medical errors, provoked universal, dramatic calls for action, while this latest report has received only a subdued response. Perhaps to the public and those who provide their care the quality problem is “old news.” Or perhaps the problem is too large and too close to grasp. The indictment of our current system acknowledges both the tremendous advances in medical science and the good intentions and dedicated work of the vast majority of care givers. Nevertheless, the report describes a system that is wasteful, often redundant, and lacking even the most basic information systems to support clinical care. Patients see long waiting times, …