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Committee on the Crossing the Quality Chasm:
Next Steps Toward a New Health Care System
Board on Health Care Services
Karen Adams, Ann C. Greiner, and Janet M. Corrigan, Editors

THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001
NOTICE: The project that is the subject of this report was approved by the Governing Board of the Na-
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mittee responsible for the report were chosen for their special competences and with regard for appropri-
ate balance.
This study was supported by Contract No. 046718 between the National Academy of Sciences and The
Robert Wood Johnson Foundation. It was also supported by a subcontract from The Johns Hopkins
Bloomberg School of Public Health with funds provided by Grant No. 037049 from the Robert Wood
Johnson Foundation. Any opinions, findings, conclusions, or recommendations expressed in this publi-
cation are those of the author(s) and do not necessarily reflect the view of the organizations or agencies
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Copyright 2004 by the National Academy of Sciences. All rights reserved.
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Research Council.
www.national-academies.org
COMMITTEE ON CROSSING THE QUALITY CHASM:
NEXT STEPS TOWARD A NEW HEALTH CARE SYSTEM
REED V. TUCKSON (Chair), Senior Vice President, Consumer Health and Medical Care
Advancement, UnitedHealth Group, Minnetonka, MN
RON J. ANDERSON, President and Chief Executive Officer, Parkland Memorial Health and
Hospital System, Dallas, TX
REGINA M. BENJAMIN, Founder and Chief Executive Officer, Bayou La Batre Rural Health
Clinic, Inc., Bayou La Batre, AL
LINDA BURNES BOLTON, Vice President and Chief Nursing Officer, Cedars-Sinai Medical Center
and Burns and Allen Research Institute, Los Angeles, CA
BRUCE E. BRADLEY, Director Health Plan Strategy and Public Policy, Health Care Initiatives,
General Motors Corporation, Detroit, MI
ALLEN S. DANIELS, Chief Executive Officer, Alliance Behavioral Care, University of Cincinnati
Department of Psychiatry, Cincinnati, OH
LILLEE S. GELINAS, Vice President and Chief Nursing Officer, VHA Inc., Irving, TX
CHARLES J. HOMER, President and Chief Executive Officer, National Initiative for Children's
Healthcare Quality, Boston, MA
DAVID C. KIBBE, Director of the Center for Health Information Technology, American Academy of
Family Physicians, Chapel Hill, NC
MARY ANNE KODA-KIMBLE, Professor and Dean, School of Pharmacy, University of California
San Francisco, San Francisco, CA
PETER V. LEE, President and Chief Executive Officer, Pacific Business Group on Health,
San Francisco, CA
KATE R. LORIG, Professor of Medicine, Stanford University, Stanford, CA
JOANNE LYNN, Director, The Washington Home Center for Palliative Care Studies, and Senior
Scientist with The RAND Corporation, Washington, DC
DAVID M. NATHAN, Director, Diabetes Center, Massachusetts General Hospital and Professor of
Medicine, Harvard Medical School, Boston, MA
CHERYL M. SCOTT, President and CEO, Group Health Cooperative, Seattle, WA
JOHN A. SPERTUS, Director of Cardiovascular Education and Outcomes Research, Mid America
Heart Institute and Professor of Medicine at the University of Missouri-Kansas City,
Kansas City, MO
I. STEVEN UDVARHELYI, Senior Vice President and Chief Medical Officer, Independence Blue
Cross, Philadelphia, PA
v
Study Staff
KAREN ADAMS, Co-Study Director

ANN C. GREINER1, Co-Study Director
DANITZA VALDIVIA, Senior Project Assistant
Board on Health Care Services
JANET M. CORRIGAN, Senior Director, Board on Health Care Services

ANTHONY BURTON, Administrative Assistant
Auxiliary Staff
THOMAS M. MADDOX2, Gustav Leinhard Fellow in Health Sciences Policy

PATSY O'MEARA3, Project Intern
Editorial Consultants
RONA BRIERE, Briere Associates, Inc.

ALISA DECATUR, Briere Associates, Inc.
1
Served through January, 2004.
2
Served through May, 2003.
3
Served through December, 2003.
vi
Reviewers
This report has been reviewed in draft form by individuals chosen for their diverse perspectives and
technical expertise, in accordance with procedures approved by the NRC's Report Review Committee.
The purpose of this independent review is to provide candid and critical comments that will assist the
institution in making its published report as sound as possible and to ensure that the report meets institu-
tional standards for objectivity, evidence, and responsiveness to the study charge. The review comments
and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to
thank the following individuals for their review of this report:
GEORGE ISHAM, HealthPartners, Inc., Bloomington, MN

ARTHUR AARON LEVIN, Center for Medical Consumers, New York, NY
ANGELA BARRON MCBRIDE, Indiana University; Institute of Medicine Scholar-in-Residence
JOSEPH E. SCHERGER, University of California, San Diego, CA
LISA SIMPSON, All Children's Hospital; University of South Florida, St. Petersburg, FL
Although the reviewers listed above have provided many constructive comments and suggestions,
they were not asked to endorse the conclusions or recommendations nor did they see the final draft of
the report before its release. The review of this report was overseen by Elaine L. Larson, Columbia
University, and Don E. Detmer, University of Cambridge and University of Virginia. Appointed by the
National Research Council and Institute of Medicine, they were responsible for making certain that an
independent examination of this report was carried out in accordance with institutional procedures and
that all review comments were carefully considered. Responsibility for the final content of this report
rests entirely with the authoring committee and the institution.
vii
Preface
This report represents an important addition to a series of studies generated by the Institute of
Medicine dedicated to improving the quality and safety of health care. It is firmly grounded in the
principles articulated in Crossing the Quality Chasm: A New Health System for the 21st Century as a
guide for the transformation of our current health care delivery system—namely the six aims of safety,
effectiveness, patient-centeredness, timeliness, efficiency, and equity.
The 1st Annual Crossing the Quality Chasm Summit was convened specifically to address the
redesign of the nation’s currently broken health care delivery system. As recommended in the Quality
Chasm report, the summit was focused on improving care processes for a targeted set of priority areas,
in this case five common, high-burden chronic conditions: asthma, depression, diabetes, heart failure,
and pain control in advanced cancer.
The summit benefited from the contributions and expertise of more than 200 local and national
health care leaders who convened to collaborate on the development of strategies for improving the
quality of care for individuals with these five chronic illnesses. As described in this report, significant
progress is being made toward implementing the above six aims in communities across the country. It is
our hope that readers will be encouraged by the support of the national champions who participated in
the summit and expressed their support for efforts to facilitate the broad achievement of key strategic
priorities.
The reader of this report will also appreciate how much more is required from every stakeholder in
the American health care system if the goals of optimal quality and safety are to be achieved.
I am deeply appreciative of the support of our sponsor, The Robert Wood Johnson Foundation; my
colleagues on the Institute of Medicine committee who helped organize and lead the summit; and all
who so generously contributed their experience, judgment, and expertise to this effort.
Reed V. Tuckson, M.D.

Chair
August 2004
ix
Foreword
In January 2004, the Institute of Medicine (IOM) was pleased to convene the 1st Annual Crossing
the Quality Chasm Summit. This was a high-energy endeavor designed to move us closer to realizing
the vision for the nation’s health care system described in the 2001 IOM report Crossing the Quality
Chasm: A New Health System for the 21st Century. That report called for fundamental redesign of the
current system. To begin this transformation, the report recommended focusing on a set of priority
conditions, taking into account frequency, burden, and resource use. A subsequent IOM report, Priority
Areas for National Action: Transforming Health Care Quality identified 20 such areas, 5 of which—
asthma, depression, diabetes, heart failure, and pain control in advanced cancer—were initially targeted
for the summit’s work.
At the summit, representatives of innovative communities from across the country joined forces with
national leaders and organizations to identify strategies for achieving high-quality care for patients
burdened with these five chronic illnesses. The synergy between local and national leaders at the
summit was strong, and the strategies put forth are actionable now. The essential goal is to close the gap
between what we know to be best practice and how care is routinely delivered today.
Although much work remains to achieve the kind of fundamental change called for in the Quality
Chasm report, it is apparent that we are well on our way. I applaud the communities and national
champions who participated in the summit for their creative approaches and their dedication to
improving the quality and safety of health care for all Americans.
Harvey V. Fineberg, M.D., Ph.D.

President, Institute of Medicine
August 2004
xi
Acknowledgments
The Committee on the Crossing the Quality Chasm Summit wishes to acknowledge the many people
whose contributions made this report possible. We appreciate how willingly and generously these
individuals contributed their time and expertise to assist the committee.
The committee benefited from the knowledge and input of members of the liaison panel: Brian
Austin, MacColl Institute for Health Care Innovation at Group Health Cooperative; Donald M Berwick,
Institute for Healthcare Improvement; Maureen Bisognano, Institute for Healthcare Improvement; Carolyn
M. Clancy, Agency for Healthcare Research and Quality; Lisa M. Koonin, Centers for Disease Control and
Prevention; Dan Stryer, Agency for Healthcare Research and Quality; Ed Wagner, MacColl Institute for
Health Care Innovation at Group Health Cooperative; and Stephanie Zaza, Centers for Disease Control and
Prevention.
Presenters and panelists helped inform and enlighten summit participants: Donald M. Berwick,
Institute for Healthcare Improvement; William L. Bruning, Mid-America Coalition on Health Care
Community Initiative on Depression; Albert D. Charbonneau, Rochester Health Commission; Helen
Darling, President, National Business Group on Health; Jack C. Ebeler, Alliance of Community Health
Plans; Harvey V. Fineberg, Institute of Medicine; Henry Gaines, United Automobile Workers/General
Motors Community Health Initiatives; George J. Isham, HealthPartners, Inc.; Sylvia Drew Ivie, The Help
Everyone Clinic, Inc.; John Lumpkin, The Robert Wood Johnson Foundation; Jay M. Portnoy, Children's
Mercy Hospital; and Martha Whitecotton, Carolinas Medical Center.
Facilitators for the cross-cutting strategy sessions were invaluable to a successful and productive
summit: Gerard F. Anderson, The Johns Hopkins University; David Brailer, Health Technology Center;
Christine K. Cassel, American Board of Internal Medicine; Russell E. Glasgow, Kaiser Permanente
Colorado; Judith Hibbard, University of Oregon; Arnold Milstein, Pacific Business Group on Health;
Shoshanna Sofaer, Baruch College; and David M. Stevens, Agency for Healthcare Research and Quality.
Summit scribes provided timely and vital recording of work produced during the strategy
sessions: Shari M. Erickson, Institute of Medicine; Beverly Lunsford, The Washington Home; Elizabeth
McCann, medical student at Columbia College of Physicians and Surgeons; Sydney Morss Dy, the Johns
Hopkins Bloomberg School of Public Health; Hsien Seow, The Washington Home; Lynne Page Snyder,
Institute of Medicine; and Anne Wilkinson, the RAND Corporation. Special thanks also go to Joanne
Lynn of The Washington Home Center for Palliative Care Studies for providing the student volunteers to
help with recording.
xiii
Webcasts and transcripts of the summit were graciously facilitated by the Kaiser Family
Foundation. They are freely accessible at <http://www.kaisernetwork.org/healthcast/iom/06jan04>.
Support for this project was generously provided by The Robert Wood Johnson Foundation. We
are also grateful to the Johns Hopkins Bloomberg School of Public Health for its support of the summit’s
cross-cutting strategy sessions.
Contents
EXECUTIVE SUMMARY .......................................................................................................... 1
Abstract ..................................................................................................................................... 1
Priority Areas for Focusing and Implementing the Quality Chasm Vision......................................... 2
1st Annual Crossing the Quality Chasm Summit ............................................................................. 2
Setting the Context for the Summit ............................................................................................... 6
Cross-Cutting Sessions ................................................................................................................ 6
Condition-Specific Action Plans ..................................................................................................10
Next Steps .................................................................................................................................11
1 INTRODUCTION .................................................................................................................13
Background ...............................................................................................................................13
The Quality Chasm Summit ........................................................................................................15
Scope and Organization of the Report ..........................................................................................24
2 MEASUREMENT .................................................................................................................27
Definition and Overarching Themes.............................................................................................27
Key Strategies............................................................................................................................28
Closing Statement ......................................................................................................................35
3 INFORMATION AND COMMUNICATIONS TECHNOLOGY ....................................37

Key Strategies............................................................................................................................38
4 CARE COODINATION .......................................................................................................47

Key Strategies............................................................................................................................48
5 PATIENT SELF-MANAGEMENT SUPPORT .................................................................57

Key Strategies ...........................................................................................................................58
6 FINANCE...............................................................................................................................67
Key Strategies............................................................................................................................69
xv
xvi CONTENTS
7 COALITION BUILDING ....................................................................................................77

Key Strategies............................................................................................................................78
8 CONDITION-SPECIFIC ACTION PLANS .......................................................................85

Asthma .....................................................................................................................................86
Depression ................................................................................................................................88
Diabetes ....................................................................................................................................90
Heart Failure..............................................................................................................................91
Pain Control in Advanced Cancer ................................................................................................93
9 NEXT STEPS.........................................................................................................................97
Synopsis of Reactor Panel and Audience Feedback .......................................................................97
Commitments of National Champions ..........................................................................................99
Closing Statement ....................................................................................................................108
APPENDIX A—BIOGRAPHICAL SKETCHES OF COMMITTEE MEMBERS .............111

APPENDIX B—QUALITY CHASM SELECTED BIBLIOGRAPHY ...................................117
APPENDIX C—DESCRIPTIONS OF SUMMIT COMMUNITIES.....................................119
APPENDIX D—COMMUNITY SELECTION CRITERIA .................................................125
APPENDIX E—SUMMIT ATTENDEES ...............................................................................129
APPENDIX F—CONFERENCE PREWORK AND SAMPLE MATRICES.......................139
APPENDIX G—SUMMIT PLANNING .................................................................................149
APPENDIX H—SUMMIT AGENDA .....................................................................................151
APPENDIX I—FACILITATING THE SUMMIT WORKING GROUPS ...........................155
APPENDIX J—CONDITION-SPECIFIC WORKING GROUP QUESTIONS ..................157
Executive Summary
ABSTRACT
On January 6 and 7, 2004, the Institute of Medicine (IOM) hosted the 1st Annual Crossing the
Quality Chasm Summit, convening a group of national and community health care leaders to pool
their knowledge and resources with regard to strategies for improving patient care for five common
chronic illnesses. This summit was a direct outgrowth and continuation of the recommendations
put forth in the 2001 IOM report Crossing the Quality Chasm: A New Health System for the 21st
Century. The summit’s purpose was to offer specific guidance at both the community and national
levels for overcoming the challenges to the provision of high-quality care articulated in the Quality
Chasm report and for moving closer to achievement of the patient-centered health care system
envisioned therein.
1
1ST ANNUAL CROSSING THE QUALITY CHASM SUMMIT
The Institute of Medicine’s (IOM) 2001 report Hoffman et al., 1996; Partnership for
Crossing the Quality Chasm: A New Health Prevention, 2002). In response, an IOM
System for the 21st Century rose out of a series committee was convened to select at least 15
of studies conducted by the IOM and others priority conditions for which reform strategies
documenting serious and widespread quality should be implemented. After carefully
problems in the nation’s health care system analyzing such criteria as impact on the
(Chassin and Galvin, 1998; IOM, 2000; population, potential for improvement, and
President's Advisory Commission on Consumer inclusiveness for a broad range of individuals,
Protection and Quality in the Health Care health care settings, and providers, the
Industry, 1998; Schuster et al., 1998). committee identified 20 priority clinical areas
Disturbing examples of overuse of procedures for national action. These 20 areas represent the
that cannot help, underuse of procedures known full spectrum of health care, including
to be beneficial, and misuse or errors of preventive care, acute and chronic disease
execution of care are pervasive (Bates et al., management, and palliative care (IOM, 2003).
1995; Berwick, 2004; Leatherman and
McCarthy, 2002; Wang et al., 2000; Wennberg
et al., 2004). And despite more than a decade of
alarming statistics, the quality of care the
1ST ANNUAL CROSSING THE
average American receives is still unacceptable. QUALITY CHASM SUMMIT
This observation is supported by a recent study The 1st Annual Crossing the Quality Chasm
published in the New England Journal of Summit was charged with catalyzing the
Medicine revealing that on average, Americans transformation of the health care delivery
have just over a 50 percent chance of receiving system as delineated in the Quality Chasm
recommended care for a host of acute and report. A diverse committee representing a
chronic conditions, as well as preventive wide range of perspectives from many health
services (McGlynn et al., 2003). care sectors was assembled to organize and lead
this activity. While the committee is
Given the magnitude and urgency of this responsible for the overall quality and accuracy
problem, the Quality Chasm report called not of this report as a record of what transpired at
for incremental tentative steps, but a major the summit, the views contained herein are not
overhaul of the current health care delivery necessarily those of the committee.
system. Though reforming a system as vast and
complex as American health care is a daunting In an effort to manage this enormous
task, the Quality Chasm report distilled the undertaking, the committee decided to narrow
principles of change into six guiding aims: its focus to 5 of the original 20 priority areas—
health care should be safe, effective, patient- asthma, depression, diabetes, heart failure, and
centered, timely, efficient, and equitable (IOM, pain control in advanced cancer—with the goal
2001:5). that lessons learned from this initial summit
would then be disseminated and further applied
to the remaining 15 priority areas and beyond.
PRIORITY AREAS FOR FOCUSING
The committee then identified 6 critical cross-
AND IMPLEMENTING THE QUALITY cutting topics applicable to all of these priority
CHASM VISION areas: measurement, information and
As a starting point for translating the above six communications technology, care coordination,
aims into clinical reality, the Quality Chasm patient self-management support, finance, and
report recommended focusing on a set of community coalition building.
common chronic conditions that account for the
majority of the nation’s health care burden and
resource consumption (Druss et al., 2002, 2001;
2
EXECUTIVE SUMMARY
It was decided that the summit should have a Research and Quality. The committee also
community focus, as successful community identified summit attendees who would best
innovations can provide a lens for viewing how serve to inform and advance the Quality Chasm
to redesign care delivery systems, and involving vision. More than 200 individuals participated
community stakeholders would help mobilize in this event, including nationally recognized
the next round of quality improvement efforts. experts in the five clinical conditions and six
Communities can also serve as “laboratories of cross-cutting areas; representatives of 15 local
innovation” to assess what does and does not communities (see Box ES-1), chosen from a
work before a policy is adopted nationally. pool of 90 across the country; and leaders from
Additionally, working at the community level national organizations referred to as “national
can strengthen the interface between the champions” (see Box ES-2), which through
personal and the population-based health their influence could expedite progress at the
systems. local level.2 The design of the summit is unique
in the IOM’s experience in that it brought
Having laid this groundwork, the committee together innovative local and regional providers
identified three objectives for the summit: (“doers”) and national leaders, as well as
representatives of national public, voluntary,
• To stimulate and further local and national and private organizations (“environments”).
quality improvement efforts, consistent with
the IOM’s Crossing the Quality Chasm
report, focusing on five priority areas— “Each of the communities that are
asthma, depression, diabetes, heart failure, participating is a building block. Each is
and pain control in advanced cancer. an experimental center. Each is a place of
• To describe measurable aims and innovation. And if we take advantage of
appropriate strategies for improving care in our mutual learning in the course of this
the five targeted priority areas, including day to renew our own sense of possibility
endorsing performance measures necessary and direction then the objectives of our
to assess progress over 3 to 5 years.1 meeting will have been accomplished.”
• To stimulate supportive interrelationships
and synergies between locally based efforts —Harvey Fineberg, President, IOM
and resources at the national level, and to
make highly visible the resulting
commitments.
To achieve these objectives, the committee

solicited the input and advice of several liaison
groups, including the Centers for Disease
Control and Prevention; the Institute for
Healthcare Improvement; the MacColl Institute
for Healthcare Innovation at Group Health
Cooperative; and the Agency for Healthcare
1
Although performance measurement standards for each condition were called for by the participants—as noted at a
number of points in this report—the summit itself did not endorse any specific performance measures for the targeted
conditions.
2
There are many champions of health care quality improvement around the nation. Some play on a national stage in the
scope of their work, while some are regional and others are located in communities. Those listed are a number of key
players who work at the national level; some of them, as well as others not listed, make an impact at the international level
as well. It is hoped that others will join this list, and we emphasize that any omissions are unintentional.
3
Box ES-1. Summit Communities
• Asthma communities
− Children’s Mercy Hospital/Kansas City Asthma Coalition
− Controlling Asthma in the Richmond Metropolitan Area (CARMA)
− The Pediatric/Adult Asthma Coalition of New Jersey
− Philadelphia Department of Health
• Depression communities
− Intermountain Health Care–Depression in Primary Care Initiative
− Mid-America Coalition on Health Care Community Initiative on Depression
• Diabetes communities
− The Asheville Project
− County of Santa Cruz, California
− Madigan Army Medical Center
− The Washington State Diabetes Collaborative
• Heart failure communities

− Grand Rapids Medical Education and Research Center
− Greater Flint Health Coalition
− The Oregon Heart Failure Project
• Pain control in advanced cancer communities

− Kaiser-Bellflower
− Rochester Health Commission
4
EXECUTIVE SUMMARY
Box ES-2. National Champions
• Agency for Healthcare Research and Quality

• Alliance of Community Health Plans
• American Association of Retired Persons
• American Board of Internal Medicine
• American Cancer Society
• American Diabetes Association
• American Heart Association
• American Hospital Association
• American Pain Foundation
• America’s Health Insurance Plans
• Blue Cross and Blue Shield Association
• Bridges to Excellence
• Centers for Disease Control and Prevention
• Centers for Medicare and Medicaid Services
• General Electric Company
• Grantmakers in Health
• Institute for Healthcare Improvement
• Institute of Medicine
• Joint Commission on Accreditation of Healthcare Organizations
• Leapfrog Group
• MacColl Institute for Healthcare Innovation at Group Health Cooperative
• National Association of Community Health Centers
• National Business Coalition on Health
• National Business Group on Health
• National Cancer Institute
• National Center for Healthcare Leadership
• National Committee for Quality Assurance
• National Quality Forum
• Pacific Business Group on Health
• Substance Abuse and Mental Health Services Administration
• The Robert Wood Johnson Foundation
• UnitedHealth Group
• URAC
• VHA, Inc.
5
SETTING THE CONTEXT FOR THE their disease, but taking a more holistic
SUMMIT approach to their care. The summit was
deliberately structured to reflect this philosophy,
In launching the summit, Reed Tuckson, chair emphasizing solutions that transcend any one
of the IOM committee that organized this event, chronic illness, in the belief that applying
set the stage by positioning the patient as “true lessons from the core set of five priority
north”—serving as a compass to steer and guide conditions to other conditions would be
health care reform efforts (Berwick, 2002). In expedited if the cross-cutting areas were the
this vein, the summit was organized to reinforce central focus.
the Quality Chasm report’s core tenet of patient-
centered health care. Patient-centered care has
different meanings for each patient. For some
patients it may mean care only for themselves; “The ultimate judge of the quality of our
for others it includes both patients and their work is the patient, end of story.”
families; while for others it comprises non–
professionally trained caregivers who serve as a
safety net. When the “patient” is referred to in —Don Berwick, summit keynote speaker
this report, the term implicitly represents this
full range of circumstances.
At the summit, participants first heard from

Martha Whitecotton, a registered nurse, who
poignantly described the shortfalls of the current CROSS-CUTTING SESSIONS
health care delivery system by relaying her The confirmed diagnosis of a broken,
family’s experiences in trying to obtain high- fragmented health care delivery system led
quality care for a child with major depression. directly to the identification of the six cross-
She highlighted gaps and deficiencies in care cutting areas enumerated above. These areas
relevant not only to depression, but to all largely reflect those discussed in the Quality
chronic conditions. Examples included lack of Chasm series of reports, with one exception—
a well-coordinated care plan, poor community coalition building, added to reflect
communication among multiple clinicians the interests and needs of summit participants
involved in a patient’s care, and failure to from communities. The purpose of the sessions
inform patients and their families about best in these six areas was to identify strategies and
practices. Redressing these deficiencies became opportunities for overcoming barriers to high-
the focus of the work at the summit. quality care, learning from communities that
have made promising advances, as well as from
Continuing on this theme during his keynote distinguished individuals and organizations
speech, Don Berwick, President of the Institute recognized as leaders in these fields. Following
for Healthcare Improvement, reiterated the is a synthesis of the key strategies to be
emphasis on honoring the patient—respecting explored as identified by the summit
patients’ preferences, needs, ethnicity, and participants (summarized in Boxes ES-3
diversity, and viewing them as the ultimate through ES-8).
source of control. He translated the Quality
Chasm aims from the patient’s perspective: “to
have health care with no needless deaths, no
needless pain or suffering, no unwanted waiting,
no helplessness, and no waste” (Berwick, 2004).
Embracing this approach requires not
segregating patients into silos as defined by
6
EXECUTIVE SUMMARY
To create relevant measurement sets,

Box ES-3. Measurement: Key participants advanced the idea of a matrix, with
Strategies the six Quality Chasm aims on one axis and the
priority areas on the other, whose cells would be
populated with appropriate measures. They also
• Integrating measurement into
supported public reporting of quality outcomes,
the delivery of care to benefit
including patient-centered measures of
patient care
experience. Dissemination of this information
• Improving information and must be done in a way that is meaningful and
communications technology useful to different audiences.
infrastructure to reduce the
burden of data collection
Box ES-4. Information and
• Focusing on longitudinal change
Communications Technology:
in performance and patient-
Key Strategies
centered outcomes in addition to
point-in-time measures
• Using standardized systems
• Improving public reporting by
effectively disseminating results • Leveraging federal leadership to
to diverse audiences accelerate the adoption of
electronic health records
• Creating a public utility that
Measurement holds data at the local level
Summit participants called for national
organizations, accrediting agencies, and Information and Communications
appropriate subspecialty providers to agree on a Technology
defined, well-validated set of performance
measures for the 5 chronic conditions featured The importance of patients’ access to and
at the summit, subsequently to be expanded to control of their health records was reiterated
the other 15 priority areas. At present, during many of the sessions at the summit.
clinicians collect different data for multiple Ideally, patient health information would be
parties, making the process not only stored in a transportable electronic format,
overwhelming, but often infeasible in a climate easily retrieved from any computer regardless of
of limited resources. A parsimonious set of software or system requirements. A companion
measures would: goal would be for all providers’ offices to have
electronic health records. Both of these visions
• Reduce redundancy and ease the load of highlight the urgent need for national data
data collection. standards, as transmitting health information
across organizational and regional boundaries is
• Permit benchmarking and meaningful severely stymied today by the inability of
comparisons within organizations, across different computer systems to “talk” to each
communities, and nationally. other in a common language—referred to as
• Allow for longitudinal patient-focused lack of interoperability. Accelerating the uptake
measures that appraise changes in health of information and communications technology
status and function over time. would involve a dual strategy of new financial
incentives for clinicians from the private sector
• Capture community-based measures derived to invest in the necessary infrastructure, such as
from actionable community-wide aims. the Bridges to Excellence program (Bridges to
Excellence, 2004), and federal leadership in
7
promulgating national data standards (IOM, and holding each team member accountable for
2002a). Additionally, participants characterized ensuring that a patient’s care is properly
health data as a public good and suggested managed. Participants emphasized that
creating a public utility that would store these practicing clinicians, managers, educational
data, making them accessible at the community leaders, and current students will need
level. preparation and guidance on care coordination
principles, such as working in interdisciplinary
teams, in both the didactic and clinical
Box ES-5. Care Coordination: components of their initial and ongoing
Key Strategies professional training.
• Aligning financial incentives

• Providing educational supports, Box ES-6. Patient Self-Management
including multidisciplinary health Support: Key Strategies
professions education, teaching
of care coordination principles in • Identifying and disseminating
academic settings, and evidence-based self-
development of care teams management practices
• Instituting patient-centered • Recognizing the centrality of
health records, supported by self-management to good patient
information and communications care and incorporating it into
technology health care culture
• Ensuring accountability and • Developing programs and tools
defining roles for care applicable to diverse populations
• Providing incentives for the
appropriate use of self-
Care Coordination
management supports
To address the problem of care coordination not integrated into the delivery of
being routinely reimbursed under most payment health care
schemes today, participants emphasized the
• Making better use of all
need for a shared vision around an operational
members of the health care
construct—consistent with the evidence base—
team
defining what good care coordination would be.
Once operationalized, care coordination could
then be measured, with the goal of quickly
disseminating successful reimbursement
Patient Self-Management Support
models. Despite the strong evidence base for many self-
management practices, it is often difficult for
Effective management of chronic conditions practitioners to assess best practices or to
requires the delivery of many services, hand- distinguish between those that are grounded in
offs to other specialists, and aggressive follow- evidence and those that are not (Bodenheimer et
up. To address these challenges, participants al., 2002; Lorig et al., 1999, 2001). Participants
suggested a two-pronged approach: suggested consolidating this information and
(1) empowering patients and families to play a disseminating it to providers, patients, and their
central role in the diffusion and exchange of families through a centralized clearinghouse.
their health information, and (2) formulating Additionally, they favored aggressive expansion
clearly defined roles for health care practitioners of the existing evidence base—both learning
8
EXECUTIVE SUMMARY
from rapid-cycle practical models and, in Finance

parallel, using these experiences to inform and
As a core strategy, participants proposed
develop a firmer scientific base.
shifting to performance-based payment models
that pay for performance and align incentives
It was suggested that if self-management is to
with evidence-based high-quality care. This
be recognized as an integral component of high-
approach assumes that the problem may not be
quality care, demand for these services must be
one of insufficient resources, but of substantial
created among clinicians and patients and
waste and variation in the current health care
incorporated into the mainstream health care
system (Fisher et al., 2003a,b). Thus any
culture. Barriers to widespread adoption of self-
changes to the present finance system would be
management practices include brief, rigidly
budget neutral—redirecting and redistributing
scheduled office visits, which are not conducive
revenue streams in the many organizations that
to more labor-intensive interactions, such as
make up the larger health care system, rather
completing a patient-generated action plan, and
than adding to the total funding for that system.
the lack of reimbursement for self-management
support. Additionally, self-management
Infusing evidence-based medicine into benefit
programs must be flexible enough to allow for
design was identified as another way to apply
tailoring to individual patient preferences, as
resources toward more effective care. For
well as culturally, linguistically, age, gender,
example, benefit packages could be created that
and lifestyle appropriate. Particular attention
would cover bundles of high-value services
should be paid to health literacy and the ability
known to work clinically for chronic illnesses—
to assimilate and process medical information
such as HbA1c monitoring, annual eye and foot
(IOM, 2004). As with care coordination,
exams, lipid testing, and blood pressure control
defining roles and making more efficient use of
for diabetics.
the talents and skills of all members of the
health care team are necessary, along with
The strategy of empowering consumers to
teaching these principles in academic and
modify their behavior by using monetary
clinical settings. Families and other caregivers
incentives or providing them with information
also need to be supported and provided
important to their health was also proposed. As
adequate resources to assist patients in
with all of the proposals in this area, the aim is
managing their condition.
not to simply shift costs to consumers—as is the
growing trend—but instead to institute cost
sharing with consumers, designed with the
specific intent of encouraging them to obtain the
Box ES-7. Finance: Key Strategies right care at the right time. Finally, as discussed
by participants addressing care coordination and
• Instituting performance-based self-management, reimbursement for these
payment models support services will require a shift from the
current piecemeal approach of paying for
• Implementing evidence-based
individual clinician encounters to paying for
benefit design
elements linked to systems of care involving a
• Providing payment for proven team of diverse practitioners.
quality support services—care
coordination and patient self-
management support
• Engaging consumers with
information and incentives
9
Once consensus has been reached around an

Box ES-8. Community Coalition actionable and manageable goal, the coalition
Building: Key Strategies must establish objectives and agree on how its
impact on the community will be measured,
both quantitatively and qualitatively. Care must
• Determining who is going to be
be taken in selecting metrics that are meaningful
involved in the coalition
to diverse members of the community and
• Getting people to agree on a relevant to multiple stakeholder groups.
common objective and Measurement has the dual purpose of
determining how to measure documenting progress while also supporting a
whether this objective has been shared accountability that solidifies community
achieved cohesion and directs the rational use of coalition
resources to areas of need. Documenting
positive outcomes—and reasons for negative
Community Coalition Building ones—helps coalitions acquire additional
support and resources.
Coalitions are organizational structures that
integrate and support the work of multiple
diverse stakeholders on a focused, shared goal. CONDITION-SPECIFIC ACTION
Input from participants prior to the summit PLANS
revealed the desire for additional knowledge
The cross-cutting sessions helped prepare
and skills in developing community
summit participants for the condition-specific
engagement. In response, a session in this area
work that followed. The composition of the
was added to identify strategies that
condition-specific working groups balanced
communities might use to establish and sustain
local- and national-level stakeholder groups,
a coalition, with particular attention to public–
individuals with proficiency in the cross-cutting
private partnerships and ways to gather the
areas, and nationally recognized experts in the
necessary human and financial resources. For
chronic conditions represented. Before the
the purposes of the summit, the aim of coalition
summit, the participating communities
building was identified as improving the quality
completed substantial preparatory work to
and efficiency of care at the community level.
identify gaps in their current care programs as
compared with “ideal” evidence-based care. As
The first step in the process of activating a
a result, it was possible to minimize the time
coalition is to ensure a proper balance among
spent reviewing past accomplishments and
stakeholder groups—at both the community and
obstacles during the summit and to focus on
organizational levels. Often this entails
shared learning and collaborative problem
bringing together groups with competing
solving.
interests. To minimize conflicts and avoid
potential gridlock once the coalition has been
In identifying strategies most relevant to each
assembled, it is critical to identify a common
priority condition, participants acknowledged
objective that supercedes differences in
that for these five conditions, health care
perspectives. Transparency regarding biases
disparities persist for minority/underserved
and conflicts of interest is paramount. Early on
populations within communities and that
in the process, it is prudent to determine what
addressing this issue should be a high priority
issues are most important to each participant
(IOM, 2002b). Several overlapping strategies
and then negotiate a workable solution that is
were proposed across the condition-specific
sensitive to those concerns (Sofaer, 2003).
working groups, echoing the themes that
emerged during the cross-cutting sessions.
10
EXECUTIVE SUMMARY
Restructuring the current finance system to redesign, some communities are making
reward well-integrated care and providing headway in the struggle to deliver health care
supports for patient self-management, for that embodies, at least in part, the six aims set
example, was a recurring topic. Information forth in the Quality Chasm report. Other
and communications technology figured communities can learn from and build on those
prominently as an enabling tool for data experiences. The summit offered a public
collection, decision support, and improved flow forum for “national champions” to step up and
of communication across providers. announce what they are willing to do to help
Measurement was a theme for all the facilitate community efforts, while also bringing
strategies—particularly to establish short- and national experts into the discussion to help
long-term goals. Proposals to support a patient- translate local experiences to speak to a larger
centered health environment ranged from audience. It is hoped that the summit will be
research to better understand the wants and the first of many such efforts dedicated to
needs of patients with diabetes, to concrete further implementing the vision laid out in the
actions such as ensuring that every patient has Quality Chasm report.
portable electronic health summaries.
Two working groups—addressing asthma and

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12
Chapter 1
Introduction
During the last decade, there has been growing recognition among organizations, experts, health
professionals, and more recently the American public that serious, widespread, and unacceptable
quality problems exist in the nation’s health care system (Blendon et al., 2001, 2002; Davis et al.,
2002). Numerous studies have documented the scope of this problem and its many facets, including
disparities based on race and ethnicity (Chassin, 1998; IOM, 2000, 2001, 2003a; Leatherman and
McCarthy, 2002; McGlynn et al., 2003). The 1st Annual Crossing the Quality Chasm Summit was
part of a series of efforts undertaken by the Institute of Medicine (IOM) to address this pervasive
problem.
BACKGROUND
The IOM report To Err Is Human: Building a Safer Health System (IOM, 2000) is credited with
helping to raise the public’s consciousness about the nation’s broken health care system. Its
troubling bottom-line finding—that tens of thousands of Americans die each year and hundreds of
thousands more suffer not because of their illnesses, but because of the care they are receiving in our
nation’s hospitals—elevated the quality problem from scientific journals to the evening news and the
policy arena. Both To Err Is Human and the subsequent IOM report Crossing the Quality Chasm: A
New Health System for the 21st Century (IOM, 2001) emphasize that placing the blame on
physicians, nurses, pharmacists, and others or asking them to just try harder will not solve this critical
problem. Patients are needlessly suffering and dying as a result of a faulty system that undermines
clinicians’ best efforts or does not help them succeed.
To address this urgent national issue, the Quality Chasm report challenges the country to undertake a
comprehensive reform of the health care delivery system and the policy environment that shapes and
13
influences it. To this end, the report provides effort by the IOM to bring together and catalyze
overall guidance for the systemic reforms it the various committed and innovative leaders
proposes, setting forth six quality aims for the across the country toward a highly targeted
health care system: it should be safe, effective, purpose: improving care for a selected set of
patient-centered, timely, efficient, and equitable clinical conditions within the Quality Chasm
(see Box 1-1). framework. This report serves as a summary of
that 2-day event, held January 6–7, 2004. The
Numerous private-sector organizations, the committee that planned the summit (see
federal and local governments, and communities Appendix A for biographical sketches) hopes
across the country have launched efforts to this report will serve to further activate,
redesign the nation’s health care system, guided coordinate, and integrate the quality efforts of
by the vision laid out in the Quality Chasm the leaders who attended, as well as other
report (AHRQ, 2004; CMS, 2004; JCAHO, reform-minded individuals from around the
2004; NCQA, 2004; The Leapfrog Group, nation. While the committee is responsible for
2004). These efforts are not always coordinated the overall quality and accuracy of the report as
to the extent they might be for maximum a record of what transpired at the summit, the
leverage. And despite what they have views contained herein are not necessarily those
accomplished, the system’s level of of the committee. It is also hoped that this
performance remains inadequate, some would summit will be the first of many such annual
say even unjust, given the resources our country events bringing together diverse leaders from
expends on health care (Millenson, 2003). across the country to further their work in
implementing the vision set forth in the Quality
The 1st Annual Crossing the Quality Chasm Chasm for a 21st-century health care system.
Summit: A Focus on Communities was an
Box 1-1. Six Aims for Health Care Improvement
• Safe—avoiding injuries to patients from the care that is intended to help them.
• Effective—providing services based on scientific knowledge to all who could
benefit and refraining from providing services to those not likely to benefit
(avoiding underuse and overuse, respectively).
• Patient-centered—providing care that is respectful of and responsive to
individual patient preferences, needs, and values and ensuring that patient
values guide all clinical decisions.
• Timely—reducing waits and sometimes harmful delays for both those who
receive and those who give care.
• Efficient—avoiding waste, in particular waste of equipment, supplies, ideas, and
energy.
• Equitable—providing care that does not vary in quality because of personal
characteristics such as gender, ethnicity, geographic location, and
socioeconomic status.
SOURCE: IOM, 2001:39–40.
14
INTRODUCTION
THE QUALITY CHASM SUMMIT Quality Chasm series. One of the central
premises of that report is that we must support
Since Crossing the Quality Chasm was released
innovations at the local level, which can inform
in 2001, the IOM has issued six reports focused
and guide comprehensive national policy. This
on implementing various facets of that report’s
was also a central premise behind the design of
vision for a 21st-century health system (IOM,
the summit, and one that informed many of its
2002a,b, 2003a,b,c, 2004). Each of these
deliberations.
reports helped lay the foundation for the
summit, with two of them being particularly
germane: Priority Areas for National Action: Goal and Objectives
Transforming Health Care Quality (IOM, At the start of the summit, Reed Tuckson, chair
2003c) and Fostering Rapid Advances in Health of the IOM organizing committee, asked
Care: Learning from System Demonstrations participants to “envision this summit as a
(IOM, 2002a). (See Appendix B for a list of practical and tangible next step in the process of
references and websites related to the Quality crossing the quality chasm.” Harvey Fineberg,
Chasm series.) president of the IOM, described the summit as
“an effort to bring together agents of change
At the behest of the Agency for Healthcare who can work in their communities and with
Research and Quality (AHRQ), the Priority their colleagues to (re)make the health system.”
Areas report identifies 20 areas—which account Tuckson delineated what the committee hoped
for the majority of the nation’s health care the summit would engender: an active
burden and expenditures—to be the focus of dialogue—and even alliances—between local
national and local efforts to redesign health leaders involved in shaping community health
care. Five of these 20 areas were selected to be systems and national leaders who influence the
the focus of the summit: asthma, diabetes, heart quality of the nation’s health care infrastructure,
failure, major depression, and pain control in which he described as a “two-way street.”
advanced cancer. These five areas were chosen Tuckson expressed what the committee hoped
at the advice of many experts in the field would result from such a dialogue: articulation
because collectively they touch on all age of on-the-ground experiences to inform and
groups from children to the elderly, are influence national-level policies, and the
important to a diverse set of payers, and fostering of national action and policy directed
encompass the full spectrum of care delivery; at the local level to sustain and encourage
moreover, many existing community efforts innovators or early adopters (Berwick, 2003).
addressing these areas can be shared, supported, Box 1-2 presents the objectives of the summit.
and disseminated. The committee anticipates
that subsequent summits will focus on
additional priority areas. Finally, in addition to
selecting the priority areas on which to focus at We are motivated by the reality of what is
the summit, the committee identified six cross- at stake…whether people shall live or
cutting topics applicable to all of these areas: whether they shall prematurely die….And
measurement, information and communications we have all been learning as we go,
technology, care coordination, patient self- learning as we lay the tracks and run the
management support, finance, and community trains over the chasms in our health care
coalition building. system. But much more progress is
needed, and much more quickly.”
Fostering Rapid Advances, written in response
to a request from Health and Human Services
Secretary Thompson, lays out ideas for health —Reed Tuckson, committee chair
system reform in the form of demonstrations
that draw on many of the ideas developed in the
15
Box 1-2. 1st Annual Crossing the Quality Chasm Summit: Objectives
• To stimulate and further local and national quality improvement efforts, consistent
with the IOM’s Crossing the Quality Chasm report, focusing on five priority
areas—asthma, depression, diabetes, heart failure, and pain control in advanced
cancer.
• To describe measurable aims and appropriate strategies for improving care in
the five targeted priority areas, including endorsing performance measures
necessary to assess progress over 3 to 5 years.1
• To stimulate supportive interrelationships and synergies between locally based
efforts and resources at the national level, and to make highly visible the
resulting commitments.
The summit participants included approximately champions” (see Box 1-4), which through their
45 leaders from 15 communities across the influence could expedite progress at the local
country, selected from a pool of 90 communities level.2 These national leaders and other experts
identified as innovative in improving quality of who attended the summit (see Appendix E)
care in at least one of the five targeted clinical represented a broad range of organizations,
areas (see Appendix C for a description of the including health plans, hospitals, physician
communities and Appendix D for selection groups, federal agencies, employer coalitions,
criteria). The 15 communities selected (see Box consumer advocacy groups, quality groups, and
1-3) are quite diverse, and while largely disease-specific organizations, among others.
anchored in a geographic region, they are not
solely defined by geography but rather by a The participants worked together to identify key
“community of interest.” For example, they strategies for enhancing care in the five clinical
include coalitions that encompass all of the areas that were the focus of the summit. These
stakeholders in a local market and others that strategies had many common themes, the most
comprise a more selective group; a state-level prevalent being focused on information and
initiative involving providers, schools, and communications technology, finance, and
others focused almost entirely on patient and measurement. The strategies also addressed
clinician education; and an integrated delivery comorbidities or, as one summit participant,
system that has established links to community Bruce Bagley from the American Academy of
resources, including the public health Family Physicians, noted, “the necessity of
department and community health centers. taking care of the patient as a whole patient and
not as a segment of disease.”
Participants also included leaders from national
organizations referred to as “national
1
Although performance measurement standards for each condition were called for by the participants—as noted at a
number of points in this report—the summit itself did not endorse any specific performance measures for the targeted
conditions.
2
There are many champions of health care quality improvement around the nation. Some play on a national stage in the
scope of their work, while some are regional and others are located in communities. Those listed are a number of key
players who work at the national level; some of them, as well as others not listed, make an impact at the international level
as well. It is hoped that others will join this list, and we emphasize that any omissions are unintentional.
16
INTRODUCTION
Box 1-3. Summit Communities
• Asthma communities
− Children’s Mercy Hospital/Kansas City Asthma Coalition
− Controlling Asthma in the Richmond Metropolitan Area (CARMA)
− The Pediatric/Adult Asthma Coalition of New Jersey
− Philadelphia Department of Health
• Depression communities
− Intermountain Health Care–Depression in Primary Care Initiative
− Mid-America Coalition on Health Care Community Initiative on Depression
• Diabetes communities
− The Asheville Project
− County of Santa Cruz, California
− Madigan Army Medical Center
− The Washington State Diabetes Collaborative
• Heart failure communities

− Grand Rapids Medical Education and Research Center
− Greater Flint Health Coalition
− The Oregon Heart Failure Project
• Pain control in advanced cancer communities

− Kaiser-Bellflower
− Rochester Health Commission
17
Box 1-4. National Champions
• Agency for Healthcare Research and Quality

• Alliance of Community Health Plans
• American Association of Retired Persons
• American Board of Internal Medicine
• American Cancer Society
• American Diabetes Association
• American Heart Association
• American Hospital Association
• American Pain Foundation
• America’s Health Insurance Plans
• Blue Cross and Blue Shield Association
• Bridges to Excellence
• Centers for Disease Control and Prevention
• Centers for Medicare and Medicaid Services
• General Electric Company
• Grantmakers in Health
• Institute for Healthcare Improvement
• Institute of Medicine
• Joint Commission on Accreditation of Healthcare Organizations
• Leapfrog Group
• MacColl Institute for Healthcare Innovation at Group Health Cooperative
• National Association of Community Health Centers
• National Business Coalition on Health
• National Business Group on Health
• National Cancer Institute
• National Center for Healthcare Leadership
• National Committee for Quality Assurance
• National Quality Forum
• Pacific Business Group on Health
• Substance Abuse and Mental Health Services Administration
• The Robert Wood Johnson Foundation
• UnitedHealth Group
• URAC
• VHA, Inc.
18
INTRODUCTION
John Lumpkin of The Robert Wood Johnson Don Berwick, president of the Institute for
Foundation, which funded the summit, Healthcare Improvement and the summit’s
characterized the larger environment in which keynote speaker, echoed the notion that the
the event was taking place in the spirit of patient must serve as the compass for the
Dickens’ A Tale of Two Cities—as the best and system. He asked the participants to develop a
worst of times. Among his characterization of “fundamentally new view of the patient, not as
what was the worst, he cited a recent New the object of our care, not as a guest in our
England Journal of Medicine article revealing house, but as the host of our work and as the
that Americans receive only about 50 percent of person who ultimately has the say in what we
the care that the evidence suggests they should do or do not do.” Berwick further challenged
get (McGlynn et al., 2003). He characterized the group by saying that “we must learn to
the best as including the many more tools the honor individual choices, respecting the
field has to improve quality and the varied, variability in need, the variability in ethnicity
committed, and talented stakeholders and diversity, and the need for structures [that
represented by the summit participants, who are respect] the habits and spirits of the people we
developing community-based approaches to serve.”
improving quality that hold promise for making
a real difference. Henry Gaines of the Greater Flint Health
Coalition in Genesee County, Michigan,
provided an example of how one community
Patients at the Center, with put a program in place to change the culture for
Community as a Focus the delivery of maternal and child health care
Reed Tuckson opened the 2-day summit by services. Friendly Access—developed to
emphasizing that the patient must be at the increase access, satisfaction, and utilization—is
center of all reform efforts. In this vein, he based in part on the well-regarded customer
introduced the consumer panel, which began service model developed by the Disney
with a patient’s story, relayed by a family Institute. Gaines described the model as making
member who is also a nurse. Martha it possible to better understand the wants, needs,
Whitecotton told of her son’s struggle with and emotions of the patients being served, and
major depression, highlighting the gaps and to translate those needs into policies and
dysfunctions that prevented him from receiving procedures, while motivating clinicians to
the best possible care. She touched on themes provide care that exceeds patient expectations.
that are endemic to care not just for depression,
but for all chronic conditions and across the
The Community Focus
entire health care system. In particular,
Whitecotton stated, drawing from the Quality With the patient as the central guiding force, the
Chasm report, “patients’ experiences should be Quality Chasm report calls for systemic,
the fundamental source of the definition of simultaneous changes at four levels of the
quality…[but] we have a long way to go.” health system—the patient/family and other key
Patient-centered care has different meanings for non–professionally trained caregivers who may
each patient. For some patients it may mean be involved with the patient; small-practice
care only for themselves; for others it includes settings or microsystems; health care
both patients and their families; while for others organizations; and the broader environment
it comprises non–professionally trained (e.g., payment, education, regulatory). These
caregivers who serve as a safety net. When the levels are nested within each other and interact
“patient” is referred to in this report, the term in many complex ways (Berwick, 2002).
implicitly represents this range of
circumstances. As Don Berwick noted, the community focus
for the summit was particularly exciting because
19
it encompasses each of these four levels, Working at the community level also provides
including the environment. Thus, he said, “You an opportunity for greater interaction between
have a chance to actually raise issues which the personal health system and the public or
normally can’t be raised because there aren’t population-based health system. Given that
enough payers in the room.” A community health care outcomes are determined by both
focus allows for a multiple-stakeholder health- and non-health-related factors—with
approach to the complex set of issues posed by behavioral patterns, social circumstances,
comprehensive redesign of the American health environmental exposures and genetics playing
care system. John Lumpkin concurred, “If substantial roles (McGinnis et al., 2002)—this
we’re going to fix this system, we have to focus interaction can maximize health for all by
on quality. And if we’re going to fix our allowing individuals to obtain needed care and
system, communities are where we have to do support for addressing broader health-related
the work.” behaviors. This benefit is particularly relevant
for children. For example, an approach to
diabetes care that spans the personal and
“Each of the communities that are population-based systems might include
participating is a building block. Each is individualized diabetic care, as well as
an experimental center. Each is a place of programs in local schools and worksites
innovation. And if we take advantage of designed to promote changes in diet and
our mutual learning in the course of this exercise, with the goal of reducing obesity and
day to renew our own sense of possibility better managing or preventing the disease.
and direction, then the objectives of our Many summit participants echoed the need for
meeting will have been accomplished.” such integration and for inclusion of a focus on
primary prevention. Box 1-5 describes the
Steps to a HealthierUS initiative, which is
—Harvey Fineberg, President, IOM taking such an approach.
Box 1-5. Steps to a HealthierUS
The Department of Health and Human Services (DHHS) is currently supporting 12

communities in their efforts to promote better health and prevent disease through the
newly launched Steps to a HealthierUS program. These DHHS awards, which
totaled $13.7 million in fiscal year 2003, are focused on helping communities reduce
the burden associated with diabetes, obesity, and asthma while addressing three
related risk factors—physical inactivity, poor nutrition, and tobacco use. The overall
goal of the effort is to help Americans live longer, better, and healthier lives. The
grants are being used by leaders in small and large cities, rural communities, and
one tribal consortium to implement community action plans that target racial and
ethnic minorities, low-income populations, uninsured and underinsured persons, and
others at high risk. Funded programs include those that focus on health care
organizations, schools, workplaces, and other organizations, and are tailored to meet
the needs of the particular community. In 2004, DHHS expects to award grants to
additional communities and to continue funding existing efforts (Steps to a
HealthierUS Initiative, 2004).
20
INTRODUCTION
“In the case of asthma, it seems to me that that without this commitment, failure is more
if you are not dealing with the likely than success given the myths, belief
environmental determinants of health, you systems, and habits, as well as system
are then involved in a very Sisyphean task fragmentation, that undermine efforts at
of rolling and rolling the rock up the hill, transformation.
and then having it roll right back down on
top of you.” Advance Work with the Communities
and National Champions
—Shoshanna Sofaer, summit participant To make the summit as action-oriented as
possible, the IOM organizing committee worked
in advance with leaders from the selected
communities to summarize what they had
Finally, there is value in working across accomplished and identify gaps in their current
communities as leaders share information about efforts. Committee members also contacted key
what does and does not work in their local national champions to inform them about the
health systems. Communities that collaborate summit’s objectives and ask them to consider in
may be able to learn from each other about advance what they might commit to at the
transferable approaches and share strategies for summit to further the vision of the Quality
delivering high-quality care. Chasm at both the community and national
levels. Armed with the results of this
substantial advance work, summit participants
Sustaining Community Innovators
were able to minimize the time spent reviewing
Throughout the course of the summit, IOM past accomplishments and focus more on shared
committee members, speakers, participants, and learning and cooperative strategizing about
others offered ideas about the best ways to future opportunities for improving care.
catalyze and sustain systemic reform at the
community level. National champions offered The community representatives shared the
specific kinds of support (see Chapter 9). In results of their considerable amount of advance
addition, two of the five condition-specific work in one of five groups focused on the
plans that emerged from the summit priority conditions cited above. Their efforts
deliberations included strategies for educating included the completion of two matrices, led by
and activating communities. These strategies a clinical expert on the IOM committee.
ranged from holding community-wide dialogues Sample matrices may be found in Appendix F.
about issues associated with heart failure care, These two tools afforded the community leaders
to supporting asthma coalitions, to developing an evidence-based approach to self-evaluation
innovative finance solutions that encompass and the chance to learn from others engaged in
both traditional and nontraditional methods of improving care for the same condition.
paying for services and span the personal and
public health systems. The first matrix aligned each component of the
process of “ideal” care against the six aims of
Don Berwick noted that communities must high-quality health care set forth in the Quality
begin with a shared vision for reform that he Chasm report and outlined above. The
described as a “change in purpose,” and must community representatives ranked where they
focus the system on the experience of the people thought they stood with regard to consistently
that it serves. He stated further that there must providing the recommended care, and these
be an acceptance of responsibility that is beyond scores were used to identify the areas most in
guilt, beyond blame, and beyond denial and is need of improvement. The second matrix was
coupled with intense commitment. He noted adapted from the Chronic Care Model (CCM),
21
developed by staff at the Improving Chronic interactions were explicitly compartmentalized.

Illness Care program of The Robert Wood Team members from the 15 communities
Johnson Foundation (Improving Chronic Illness assessed what system elements they had in
Care, 2004; Wagner, 2002). The CCM (see place to support evidence-based care for the
Figure 1-1) provides a scientific framework for chronic condition they were addressing (asthma,
organizing and delivering care at the level of the diabetes, depression, heart failure, or pain
small-practice setting or microsystem. Under control in advanced cancer) consistent with the
this model, patients are expected to participate five elements of the CCM—clinical information
actively in their care and play an integral role in systems, delivery system design, decision
both directing and managing their chronic support, self-management support, and
condition. They are supported in their self- community resources and policies. This
management efforts by their families and other approach also provided a way to consider the
key non–professionally trained caregivers who interface between the health system and
may be involved with the patient, as well as a community resources so that, in the words of
proactive and well-prepared team of clinicians Reed Tuckson, public health is considered “not
who provide regular follow-up. a competitive but a synergistic activity.”
The centerpiece of the CCM is facilitation of During the summit, Don Berwick described
“productive interactions” between patients and such evidence-based approaches to quality
their providers. To allow for greater specificity improvement as the way to be optimistic in the
in the participants’ advance work with respect face of all that is wrong with our current system.
to what infrastructure had been developed He noted, “The optimism we have is science.
within their communities to support such It’s the scientific understanding of what makes
interactions, the components of these quality happen in the first place. The qualities
Figure 1-1 Chronic Care Model

SOURCE: Reprinted with permission from Effective Clinical Practice. Copyright 1998 by Effective
Clinical Practice. (Wagner, 1998)
22
INTRODUCTION
we care about…these are qualities of design.” could be maximally productive. For those with
He further challenged the summit participants: experience in such interventions, these sessions
“Every system is perfectly designed to achieve afforded an opportunity to share what they have
the results it gets….If you don’t like your learned with a larger group. The sessions were
results, change your system.” facilitated by subject experts and included short
presentations from community representatives
Intensive planning by IOM committee members whose programs had focused on the particular
and input from the sponsor, liaisons, and others interventions. The sessions and cofacilitators
greatly contributed to the smooth execution and were as follows:
overall success of the summit. Appendix G
details this extensive preparation. • Measurement, with facilitators Judith
Hibbard, University of Oregon, and Arnold
The morning of the first day of the summit set Milstein, Pacific Business Group on Health
the context for the event. It shone a spotlight on
• Information and Communications
our broken health system from the patient’s
Technology, with facilitators David Kibbe,
perspective, highlighted ways in which
American Academy of Family Physicians,
communities are working to overhaul the
and David Brailer, Health Technology
dysfunctional design of local health systems,
Center
and challenged participants—both local and
national—to reach further and stretch higher in • Care Coordination, with facilitators Gerard
their efforts to remake American health care. Anderson, the Johns Hopkins Bloomberg
School of Public Health, and Christine
The summit welcome and introductions were Cassel, American Board of Internal
shared by Reed Tuckson, IOM committee chair Medicine
and senior vice president, UnitedHealth Group; • Patient Self-Management, with facilitators
Harvey Fineberg, president of the IOM; and Kate Lorig, Stanford University, and
John Lumpkin, senior vice president, The Russell Glasgow, Kaiser Permanente
Robert Wood Johnson Foundation. (See Colorado
Appendix H for the full summit agenda.) The
consumer panel was chaired by Allen Daniels, • Finance, with facilitators Peter Lee, Pacific
an IOM committee member and CEO of Business Group on Health, and Steve
Alliance Behavioral Care, and included Martha Udvarhelyi, Independence Blue Cross
Whitecotton, R.N., Carolinas Medical Center; • Community Coalition Building, with
William Bruning, J.D., Mid-America Coalition facilitators Shoshanna Sofaer, Baruch
on Health Care Community Initiative on College, and David Stevens, Agency for
Depression; Henry Gaines, Greater Flint Health Healthcare Research and Quality
Coalition; and Jay Portnoy, M.D., Children’s
Mercy Hospital/Kansas City Asthma Coalition.
The keynote speaker was Don Berwick, The working groups addressing the priority
President of the Institute for Healthcare areas met at the end of day one of the summit
Improvement. and for the first half of day two. The groups—
which included community representatives,
In the afternoon, summit participants attended national champions, and other experts––used
strategy sessions addressing the six cross- facilitation tools (see Appendix I) to develop
cutting topics. These sessions were intended to plans incorporating key strategies at both the
further prepare participants in the relevance of local and national levels for improving care for
particular interventions to their ongoing quality the targeted conditions. These plans describe
improvement efforts so that the subsequent who might spearhead such efforts, include time
working groups focused on the priority areas lines for implementation, and in most cases call
23
for measures to gauge the effectiveness of the effectively into the personal health care system;
proposed strategies. These plans were how clinical education must be transformed so
presented at the plenary session, where initial that health care professionals are best prepared
feedback was received from summit to practice in a transformed system; and how
participants. A diverse reactor panel— clinicians, particularly physicians, can be
including moderator Bruce Bradley, an IOM engaged in quality improvement efforts.
committee member and Director of Health Plan
Strategy and Policy, General Motors In summarizing the summit outcomes, this
Corporation; Al Charbonneau, Rochester Health report offers a vision, emerging from the
Commission; Helen Darling, National Business summit deliberations, for how care for a
Group on Health; Sylvia Drew Ivie, The Help targeted set of conditions can be improved by
Everyone Clinic; and George J. Isham, leveraging and integrating both community- and
HealthPartners, Inc.—provided further national-level strategies focused on key cross-
reflection on the plans and a candid reality cutting interventions:
check.
• Chapters 2 through 7 focus on the cross-
The final session of the summit, chaired by cutting strategies for improving care
Reed Tuckson and described by many as a identified in the Quality Chasm report and
revival session, focused on commitments by community leaders at the summit. These
articulated by national champions for furthering chapters highlight barriers and related
the vision of the Quality Chasm report. These solutions, based on discussions during the
commitments targeted both the community and cross-cutting sessions and among the
national levels, and included many that were condition-specific working groups. They
announced for the first time at the summit, as include examples from the participating
well as others aimed at strengthening existing communities illustrating how particular
relevant efforts. interventions can enhance care for one or
more conditions.
SCOPE AND ORGANIZATION OF • Chapter 8 provides a synopsis of the key
THE REPORT strategies for change at the local and
national levels proposed by the condition-
This report provides a synthesis of the outcomes specific working groups.
of the summit, and is not intended to contain an
exhaustive review of the literature for all of the • Chapter 9 delineates next steps, calling for
topics discussed. Its content reflects the action on the part of both national and local
committee’s commitment to carrying out its leadership. It identifies the major
charge, which was to plan and execute a commitments of the national champions and
national summit focused on the vision of the describes how they dovetail with the key
Quality Chasm report for improving quality of strategies identified both in the cross-cutting
care for a targeted set of conditions at both the sessions and by the five condition-specific
community and national levels. A number of working groups. It also includes comments
additional issues beyond this charge were from the reactor panel and summit
discussed by the committee during its participants.
deliberations and by some summit participants, • A series of appendices provides key summit
but are not captured in this follow-up report. documents, including the agenda,
Among others, these include how to enhance participant list, descriptions of participating
public health infrastructure and integrate it communities, and other related materials.
24
INTRODUCTION
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Care: Learning from System Demonstrations.
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Quality). 2004. Quality Research for Quality Washington, DC: National Academy Press.
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ahrq.gov/ [accessed April 5, 2004]. IOM. 2002b. Leadership by Example:
Coordinating Government Roles in Improving
Berwick DM. 2002. A User’s Guide for the IOM’s Health Care Quality. Corrigan JM, Eden J,
Quality Chasm Report. Health Affairs Smith BM, eds. Washington, DC: National
(Millwood, VA) 21(3):80–90. Academy Press.
Berwick DM. 2003. Disseminating innovations in IOM. 2003a. Patient Safety: Achieving a New
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Rosen AB, Schneider E, Altman DE, Zapert K, IOM. 2003b. Health Professions Education: A
Herrmann MJ, Steffenson AE. 2002. Views of Bridge to Quality. Greiner AC, Knebel E, eds.
practicing physicians and the public on medical Washington, DC: National Academy Press.
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(24):1933–1940. IOM. 2003c. Priority Areas for National Action:
Transforming Health Care Quality. Adams K,
Blendon RJ, Schoen C, Donelan K, Osborn R, Corrigan JM, eds. Washington, DC: National
DesRoches CM, Scoles K, Davis K, Binns K, Academy Press.
Zapert K. 2001. Physicians’ views on quality
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Washington, DC: National Academy Press.
Chassin MR. 1998. Is health care ready for six
sigma quality? Milbank Quarterly 76(4):510, JCAHO (Joint Commission on Accreditation of
565–591. Healthcare Organizations). 2004. JCAHO
Welcome Page. [Online]. Available: http://
CMMS (Centers for Medicare and Medicaid www.jcaho.org/ [accessed April 5, 2004].
Services). 2004. Centers for Medicare and
Medicaid Services. [Online]. Available: http:// Leatherman S, McCarthy D. 2002. Quality of
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New York, NY: The Commonwealth Fund.
Davis K, Schoenbaum SC, Collins KS, Tenney K,
Hughes DL, Audet AJ. 2002. Room for McGinnis MJ, Williams-Russo P, Knickman JR.
Improvement: Patients Report on the Quality of 2002. The case for more active policy attention
Their Health Care. Report 534. New York, to health promotion: To succeed, we need
NY: The Commonwealth Fund. leadership that informs and motivates, economic
incentives that encourage change, and science
Improving Chronic Illness Care. 2004. ICIC: that moves the frontiers. Health Affairs
Fostering Improvement: Learning Session #1. (Millwood, VA) 21(2):78–93.
[Online]. Available: http://www.
improvingchroniccare.org/improvement/ls1. McGlynn EA, Asch SM, Adams J, Keesey J, Hicks
html#lstools8 [accessed April 6, 2004]. J, DeCristofaro A, Kerr EA. 2003. The quality
of health care delivered to adults in the United
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LT, Corrigan JM, Donaldson MS, eds.
Washington, DC: National Academy Press. Millenson ML. 2003. The silence. Health Affairs
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Health System for the 21st Century. NCQA (National Committee for Quality Assurance).
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ncqa.org/index.asp [accessed April 5, 2004].
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Steps to a HealthierUS Initiative. 2004. Grantees, Wagner EH. 1998. Chronic disease management:
Steps to a HealthierUS Initiative. [Online]. What will it take to improve care for chronic
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[Online]. Available: http://www.leapfroggroup. Washington, DC:
org [accessed April 5, 2004].
26
Chapter 2
Measurement
DEFINITION AND OVERARCHING THEMES

The aim of the cross-cutting session on measurement was to identify strategies communities might
pursue for using performance measures to assess and improve quality of care, further the
accountability of health care organizations, and inform payer and consumer purchasing and decision
making. All of the communities participating in the summit had been involved in measuring the
effectiveness of their efforts, although their objectives—whether for quality improvement purposes
or public reporting—may have differed. Measurement was also an underlying assumption for all the
condition-specific action plans.
The following definition of measurement served as the springboard for discussion during this session
and had the general approval of the session’s participants (IOM, 2002):
To use quantitative indicators to identify the degree to which providers are delivering care
that is consistent with standards or acceptable to customers of the delivery system.
Performance measures may be used to support internal assessment and improvement, to
further health care organization accountability, and to inform consumer and payer selection
and purchasing based on performance.
27
KEY STRATEGIES conflicting measures collected against

competing or conflicting standards. It was
Overall, the participants view measurement as suggested that this common set of measures
crucial to accelerating performance would include assessment of success in meeting
improvement in health care. Four key strategies the Quality Chasm’s six aims for care—safe,
emerged from this session: (1) integrate effective, patient-centered, timely, efficient, and
measurement into the delivery of care to benefit equitable—and do so in the most parsimonious
the patient whose care is measured, (2) improve manner possible so as to not be overwhelming
information and communications technology
(IOM, 2001). These key measures should be
(ICT) infrastructure to reduce the burden of data
reviewed by professional societies and made
collection, (3) focus on longitudinal change in
readily available to purchasers and consumers.
performance and patient-centered outcomes in
addition to point-in-time measures, and
(4) improve public reporting by effectively “Institutional survival is not an aim of
disseminating results to diverse audiences. American health care. Patient well-being
is the aim of American health care.
Integrate Measurement into the Endorse the aims (IOM six aims) for
Delivery of Care improvement in measurable terms, and
link it to measurement. If you don’t know
The underlying principle behind this strategy is how you are doing you can’t get better.”
that measurement should be integrated into
routine clinical practice, so that the process of
providing care also enables measurement to —Don Berwick, summit keynote speaker
occur. Decreasing the burden of measurement
and increasing the likelihood of data collection
makes it possible to determine more accurately The Washington State Diabetes Collaborative—
the quality of care being delivered. Once the one of the 15 community participants at the
necessary data are available, health care summit—candidly shared with the participants
delivery systems can develop creative solutions in the measurement session some lessons
to address suboptimal performance—thus learned from that initiative regarding the need
continually improving the process of care. for standardized data collection of a discrete set
of measures. See Box 2-1 for a brief overview
In addition to posing a minimal data collection of this ground-breaking state-level project.
burden, performance measurement and
reporting cannot be overly time-consuming or
perceived as punitive. Moreover, as noted
throughout the condition-specific working
group sessions, national consensus on a core set
of performance measures should simplify and
bolster compliance with data collection by
eliminating the collection of multiple
28
MEASUREMENT
Box 2-1. Washington State Diabetes Collaborative
The Washington State Diabetes Collaborative was established in 1999 to address

the findings of a statewide project that identified significant gaps between existing
and desirable diabetes care. Based on the Institute for Healthcare Improvement's
Breakthrough Series approach, this first state-level collaborative on chronic disease
has engaged more than 65 teams from urban and rural, public and private, and small
to large care delivery systems and health plans in improving the delivery of patient-
centered diabetes care.
Given the voluntary nature of the project—there were no external incentives for
practitioners and facilities to participate—it was challenging at first to mandate a core
set of measures to be collected, particularly across such a diverse set of
stakeholders. As a result, during the first phase of the collaborative, considerable
flexibility was allowed regarding what measures the team would use to assess
progress related to glycemic control and blood pressure control. Although this
flexibility was useful in that it permitted individual teams to follow their own internal
quality improvement approach, it made meaningful comparisons or establishment of
benchmarks difficult.
Adjustments were made during the second phase of the project, and teams were
required to track the same four measures: HbA1c <9.5 percent, LDL (low-density
lipoprotein) cholesterol <130 mg/dl, blood pressure <140/90 mm Hg, and a
documented self-management goal. With these standardized measures, it became
possible to aggregate data more easily so the initiative could be evaluated as a
whole. Overall, teams demonstrated improvement on these four measures, with
higher gains in process-related than in outcome-related measures.
Note: A more detailed description of this collaborative and related case studies can
be found in the February 2004 issue of the Joint Commission Journal on Quality and
Safety (Daniel et al., 2004a,b).
29
The asthma working group suggested that Improve Clinical ICT Infrastructure
national organizations such as the American
Improving ICT infrastructure was identified as a
Board of Internal Medicine (ABIM), the
key strategy to ease the burden of incorporating
Centers for Medicare and Medicaid Services
data collection, performance measurement, and
(CMS), the Leapfrog Group, the National
results reporting into everyday clinical practice.
Quality Forum (NQF), accrediting agencies, and
Physician offices, hospitals, nursing homes, and
appropriate subspecialty providers agree on a
health centers will require incentives to
defined, well-validated set of quality
encourage the adoption of interoperable clinical
performance measurement tools for chronic
information systems. A strategy suggested
diseases—including patient self-management
during this session was to reward practices that
indicators—within 3 years. The depression and
have clinical information systems in place—
pain control working groups called on the NQF
such as patient registries or partial/full
to serve as a convening body to bring together
electronic health records—that are used to
the appropriate experts to establish metrics for
collect data on their patient populations for
effective and efficient care in these areas. Many
quality measurement and improvement
of the national champions at the summit
purposes. To this end, structural measures of
weighed in on this issue and offered their
ICT adoption by individual providers would
support. Box 2-2 provides a snapshot of some
have to be collected and reported.
of the commitments they made.
Box 2-2. Commitments Made by National Champions Regarding Performance

Measures
Steven Jencks, M.D., Centers for Medicare and Medicaid Services

“I want to be clear that CMS will work with you and other national partners and with
the National Quality Forum to identify and implement a uniform standard national
measure set involving the conditions discussed.”
Arnold Milstein, M.D., Pacific Business Group on Health

“Within the two national purchaser organizations in whose leadership I participate,
the Leapfrog Group and the Disclosure Project, I commit to accelerating national
consensus on, and public reporting of, measures of quality, efficiency, and care
redesign at multiple levels, including individual physician office teams, hospitals,
larger health care organizations, and communities.”
Greg Pawlson, M.D., National Committee for Quality Assurance

“We’ve been working already with the American Medical Association Consortium, the
Joint Commission on Accreditation of Healthcare Organizations, the American
Diabetes Association, the American Heart Association, the American Stroke
Association, CMS, Leapfrog, the Pacific Business Group on Health, and many others
to really try to populate the full spectrum of performance measures related to all six
aims of the Institute of Medicine, and also to reduce duplication and redundancy.”
30
MEASUREMENT
Once this structural change occurs, measuring Participants generally believe that widespread
performance for multiple conditions can readily adoption of ICT to assist measurement
be achieved. Box 2-3 describes the Bridges to collection at the physician office level will
Excellence initiative, which recently launched a necessitate partnering by public- and private-
program to incentivize structural change in sector purchasers.
clinical ICT capability in physician offices.
The condition-specific working groups also
Although incentives to build ICT capacity are touched on the essential role of ICT in
certainly important, they are only a piece of a supporting measurement efforts. For example,
complex puzzle. Unresolved issues related to recognized measurement experts in the asthma
interoperability standards (addressed in detail in group affirmed that metrics for processes of
Chapter 3) and consensus on measures also care for asthma are well established. The major
figure prominently. There is a critical need for challenge now is moving these measures closer
investment in this area, and participants called toward implementation. One hurdle is that
for the federal government to provide the these measures are based on patient reports and
necessary leadership. The federal government chart reviews, rather than on more easily
has provided grants to state mental health and accessible administrative data. Therefore, the
substance abuse agencies to embark upon this asthma group suggested that the focus needs to
effort, but limited resources impede the ability be on (1) mandating/pressuring providers to
to reach all providers at the local level. collect these data and (2) creating the necessary
Box 2-3. Bridges to Excellence Initiative
Bridges to Excellence—a coalition of employers, physicians, health plans, and

patients—is a program designed to improve the quality of care by acknowledging
and rewarding health care providers that have taken significant steps to build new
structural capability and achieve high performance levels to further the Quality
Chasm’s six aims of safety, effectiveness, patient-centeredness, timeliness,
efficiency, and equity. Initially, this effort will target three areas—diabetes care,
cardiovascular care, and the structure of care management systems—all of which
were highlighted during the summit.
One initiative currently under way is the Physician Office Link, which allows
physician practices to earn bonuses for implementing structural changes to increase
quality, such as investing in ICT and care management tools. These changes
include electronic prescribing to reduce medication errors, electronic health records
embedded with guideline-based prompts/reminders, disease registries and
management programs for patients with chronic conditions, and patient educational
resources available in multiple languages. Additionally, a report card for each
physician office assessing structural capability in these areas will be issued and
made available to the public.
Note: A more detailed description of Bridges to Excellence programs may be found

at their website (Bridges to Excellence, 2004).
31
ICT infrastructure so the data can be collected Focus on Longitudinal Change in

more easily. Performance and Patient-Focused
Outcomes
The depression working group identified ICT as
the basis for all transformation and for all of Another solution put forward by the strategy
their proposed solutions. They acknowledged session participants was for measurement
that, given concerns about privacy and stigma, it efforts to focus on longitudinal change in
will be challenging to incorporate behavioral patient health status over time. Implementing
health information into electronic health this solution would require evolving from the
records. The working group suggested that customary collection of process and outcome
behavioral health data should be treated in the measures—which tend to focus on provider
same way as all other health information, inputs—to a more multidimensional approach
consistent with the Health Insurance Portability that includes assessing patients’ self-reports on
and Accountability Act of 1996 (U.S. DHHS, their capabilities for self-management and their
2004). The group presented a strategy with the functional status. Using patient-reported health
initial 1-year goal of convening a group of 15 status to inform the medical encounter,
communities that would include all of the key essentially making it part of the “vital signs”
stakeholders and defining a shared dataset for taken at any visit, would improve individual
behavioral health in primary care. This first patient care, as well as enhance the ability to
year would see pilot collection of these data and gauge on a population basis how well care is
conclude with the formulation of being delivered for specific conditions and
recommendations for a national behavioral patient subgroups with each condition. A case
health data policy. Over the course of 3 years, in point provided during the session was the use
this effort would be expanded to include a of a standardized questionnaire to evaluate heart
broader base of community agencies and failure status. This type of feedback could quite
stakeholders. The process for the 3-year goals easily be obtained from patients while they are
would mirror that for the 1-year pilot, with an sitting in the waiting room, and providers could
expanded group of participants. use this information to customize and improve
care. Additionally, data could be plotted over
time to track patient-reported progress and/or
“The absence of electronic health records aggregated to support population-based
limits the ability to deploy performance comparisons.
measures and gather data. It’s a severe
limitation. People want to know why we The heart failure working group also suggested
don’t approve more performance collecting patient-reported health status as a
measures. It’s simply unaffordable when routine part of care. They emphasized the need
you’re collecting data by hand. for adopting multiple approaches to make the
Electronic health records become collection of information from patients more
critically important because they make it convenient—such as a computer in the waiting
possible to gather performance data as a room and web-based entry from home—as well
by-product of the care delivery process.” as for organizing the data for clinicians in an
easily interpretable format. Such information
should be made readily available to the
—Dennis O’Leary, summit participant physician/nurse at first contact during the office
visit and be automatically incorporated into the
patient’s electronic health record if entered at
home—coupled with an alarm to the health
provider if there is a negative change in status.
Additionally, patients should be provided with
32
MEASUREMENT
their “scores,” and these results should be most likely to occur. The group suggested that
graphed over time to assist patients in self- providers adopt a standardized patient flow
management of their condition and allow the chart that would be recorded electronically for
provider to examine trends. The group purposes of quality improvement, performance
proposed that measures of mental health status measurement, and patient education.
also be included and that comorbidities be
considered in interpreting quality-of-life scores,
as heart failure patients often have multiple
Improve Public Reporting by
chronic illnesses, such as depression and Disseminating Results to Diverse
diabetes. Audiences
This strategy had two prongs: first, to improve
The pain control working group proposed public reporting of performance measures by
making assessment of pain the “fifth vital sign” including the patient experience; and second, to
and suggested that measures be developed to package and disseminate this information in a
track and monitor the following: (1) percent of way that is useful and meaningful to different
patients being evaluated for pain, (2) inter- audiences. Underlying assumptions brought
ventions conducted, and (3) effectiveness of the forth by the working groups included the need
interventions (rate of overall decline in pain). for transparent public reporting and the use of
These measures would then be incorporated into this information to foster quality improvement
the Agency for Healthcare Research and at multiple levels of the health care delivery
Quality’s (AHRQ) annual National Health Care system. For example, patients could compare
Quality Report (AHRQ, 2003) and the National their diabetes outcomes against those of a
Committee for Quality Assurance’s Health Plan similar cohort as a stimulus to their self-
Employer Data and Information Set (HEDIS®) management, individual clinicians could judge
report (NCQA, 2004). their performance among their peers, and
communities could correlate local outcomes
The group also proposed taking a patient- with regional and/or national benchmarks.
centered approach to measuring pain control.
Strategies to achieve this goal include In response to the first part of this strategy, the
(1) providing cancer patients with multiple ways condition-specific working groups echoed the
to record their pain outside the clinician need for patient/consumer input in the
encounter, such as over the Internet or by development and selection of quality measures.
phone, so that results can be reviewed regularly The depression working group suggested
and acted on in a timely way; and (2) several strategies to this end: obtaining
establishing measures of family/caregiver feedback from objective patient advocates and
experience as part of a performance measures consumers; conducting focus groups among
set, for example, adding a question to the death patients with depression to identify key quality
certificate—which is often completed by a characteristics and outcomes of care; and
caregiver/family member—asking how rallying a collaborative group of stakeholders—
effective the care team was in treating end-of- patients, physicians, purchasers, and payers—to
life pain. achieve consensus on performance and
satisfaction measures.
Agreeing with the strategy session participants,
the pain working group recognized the need to The second part of this strategy—reporting
evaluate data on the prevalence of pain over measures at different levels of granularity and in
time for individual patients. Doing so is a variety of formats to divergent groups—is
particularly important during transitions critical to stimulating consumer demand for
between settings, such as from hospital to quality services and accelerating the uptake of
nursing home, when breakdowns in care are best practices by providers. The asthma
33
Another random document with
no related content on Scribd:
Anna: No?
(Matti Porkka tulee vauhdikkaasti vasemmalta. Heikki hänet

pysäyttää; jäävät yhdessä katselemaan tapausta.)
Vasili: Että itse saan sen kiinnittää kaulallenne.
Anna (epäröiden): Eikö mitenkään muuten?
Vasili: Näin vähäisestä ei enää tingitä rahtuakaan.
Anna: Pitääkö siihen sitten suostua?
Vasili (ottaa ketjun, asettaa sen kiirettä pitämättä Annan kaulaan,

lukkoa kiinnittäessään laskeutuu käsi hänen harteilleen): Noin, kas
noin! (Sovittelee vielä paremmin.)
(Heikki Ortelan kädessä välähtää samassa puukko, mutta

Porkka saa hänet estetyksi syöksymästä esiin.)
Matti Porkka (hillityllä äänellä): So, so, poika!
Heikki (hammasta purren): Perkeleen ryssä!
Porkka (rauhoitellen): Vaiti, pysy alallasi.
Heikki (hilliten raivoaan): Olette oikeassa — pitäköön. — Voi, nyt

se jo tulvii yli äyräittensä — häpeä — sääli pois —. Odottakoot! No
nyt, setä, mennään sitä patoa särkemään.
(Poistuu kiireellä, Porkka hänen jäljessään.)
Anna (väistyen Vasilia): No, eikö se jo ole — (koettelee, saa

käteensä korun.) Mitä, hyväinen aika, eihän tämä ole minun.
(Irroittaa sen kaulaltaan.) Mitä narripeliä tämä on!
Vasili: Mikä on vikana, puuttuuko siitä mitään?
Anna (katselee korua): Helmi vai mikä tämä on — (ottaa sen irti).
Ei tämä ole minun (tarjoo Vasilille).
Vasili (hartaana): Voi, neiti Anna, tehkää minut onnelliseksi

ottamalla vastaan tämä pieni koriste. Ei teidän, ei sinun tarvitse
koskaan muistella sen antajaa, kaukaista, kadonnutta Venäjän
miestä.
Äänet joelta: — katsokaas Heikkiä, siinä sitä on poika, joka ei

pelkää.
Anna (vavahtaa kuullessaan, katselee levottomana joelle): Ottakaa

takaisin tämä.
Vasili: Sinun sydämesi, kaunis tyttöseni, on kylmempi jäätä,

kovempi kiveä. Olen pelastanut ketjusi hukkaan joutumasta, ja sinä
et suo sen vertaista iloa minulle. Katso, kuinka hienosti tuo kivi
kimmeltää! Se on safiiri, sininen kuin yön taivas, joka kaartuu yli
rannattoman aromaan. Ja nuo tuossa ympärillä ovat pieniä
briljantteja, kirkkaat kuin taivaan tähdet. Kun sinä, Anna, joskus
katselet tätä, on Vasili poissa, kenties jo kylmänä hangen alla —
(kiihkeästi läheten). Oi Annushka, älä ole noin kova minulle, on synti
olla noin säälimätön.
Anna (silmäilee mieltymyksellä korua, mutta ojentaa sen jälleen

pois): Ei, en minä voi sitä ottaa.
Vasili (kuumasti läheten): Anna!

(Samassa kuuluu jäiden valtainen ryske ja murtuminen.)
Anna (kuuntelee, hätäisenä): Kuinka Heikin käy? (Tekee lähtöä.)

Ei, kyllä teidän täytyy ottaa tämä takaisin (tarjoo Vasilille, joka ei
ota). Minä panen sen sitten tähän. (Laskee korun maahan, astuu
muutaman askeleen vasemmalle, jää seisomaan ja katselee joelle.)
Äänet joelta: Varo nyt, poika — kiiruhda — poistu, ennenkuin on

myöhäistä — Näittekös — hyppäsi kuin ilves toisen jäälautan
reunalle — no, viimeinen hyppäys, — hyvä hyvä. Eläköön Heikki
Ortela, eläköön!
Anna (jännityksestä laueten): Pelastunut, jumalan kiitos! (Rientää

rantaan.)
(Vasili ottaa jalokiven maasta, pistää sen varovasti koteloon.

Kaksi tyttöä tulee rannalta.)
I tyttö: Kuinkahan olisi käynytkään ilman tuota Heikkiä.
II tyttö: Se sulku ei olisi itsestään särkynyt, eikä tuonne jäiden

sekaan näyttänyt kenelläkään olevan halua.
I tyttö: Mutta huomasitko, minkä näköisenä se poika tuli, niinkuin

olisi ollut vihoissaan jollekin, hyökkäsi suoraa päätä ryskyvien,
murtuvien jäiden päälle, lohkareelta lohkareelle vaan, ikäänkuin ei
olisi ollut mitään vaaraa.
II tyttö: Niin, vaikka aivan katsojaakin kauhistutti. Oli se

suorastaan ihme, että se sieltä vielä selvisi, kun virtakin oli niin kova,
että aivan jo koskena kohisi.
(Tytöt menevät sisälle Ahjolaan. Vasili on sivusta katsellut ja
kuunnellut tyttöjen puhetta hammasta purren, muoto synkeänä.
Nuorta väkeä tulee rannalta palaten Ahjolaan juhlan
valmisteluun.)
Iivana (tulee oikealta, laulaa humalaisena jotain venäläistä laulua.

Pysähtyy Vasilin eteen, jonka katse hänet ankarana kohtaa): Kah,
sinäkö, kyyhkyseni!
Vasili: Minä.
Iivana (juopuneen tavalla elehtien): Mutta mikä mikä sinun on —

mikä vaivaa, tarkoitan onko sinulle käynyt pahoin, veliseni?
Vasili (tarttuu häntä kauluksesta ja ravistaa): Koira!
Iivana: Sano kunnon koira, veliseni!
Vasili: Sait määräyksen, mutta kuinka olet sen täyttänyt?
Iivana: Ai, ai, malta, pyhä veli. Kaikki hyvin, ootshen harashoo!
Vasili (lauhtuen): Mitä? Kerro oitis!
Iivana (myhäilee salaperäisenä, kaivaa taskustaan savukelaatikon,

aukaisee ja läimäyttää kiinni): Kaikki loppu!
Vasili (ojentaa hänelle omansa): No, tiedätkö sinä mitään?
Iivana (sytyttää): Paljon, paljon.
Vasili (menettää malttinsa): Etkö saa suustasi ulos!
Iivana: Ah djengi niet, kyyhkyseni.

Vasili (työntää hänelle setelin):- No, tiedätkö Ortelasta mitään?
Iivana (nauraa virnistelee, vilkuttaa silmää): Yksi ryyppy pään

selvikkeeksi.
Vasili (sieppaa nagaikan saappaanvarrestaan ja peittoo häntä):

Joko riittää, kyyhkyseni?
Iivana (parkuu ja nikottelee, päästyään käsistä tekee kunniaa.

Varma Ortela, yksinkertaisessa tummassa puvussa, musta huivi
päässä, palaa viimeisenä rannalta, pysähtyy Ahjolan porraspäähän
seuraten ryssien ajatustenvaihtoa.)
Vasili (huomaamatta Varmaa): Nyt kerro tarkasti mitä tiedät.
Iivana (lähestyy ympärilleen katsellen, kertoo korvaan kuiskaten).
Vasili (kuuntelee jännittyneenä, huudahtaa): Heikki Ortela!

(Kuuntelee edelleen.) — vanhempi mies — sukulainen — sinä saat
ottaa selvän — ah Ortela — hyvä — hyvä!
(Varma säpsähtää kuullessaan Heikkiä mainittavan ja

kääntyy mennäkseen takaisin sinne mistä tuli, mutta Eemi
Harju tulee samassa portaita alas, rientää hänen luokseen.)
Eemi: Kah, Varma, täällähän sinä olet, tuolla sisällä sinua juuri
kysyttiin. Harjoituksista ei näet tahdo tulla mitään. Lyön vaikka
vetoa, että se näytelmäkappale menee penkin alle tänä iltana. Minne
se Heikkikin hävisi?
Varma: Lähti kotiin muuttaakseen kuivaa päälleen. Kyllä minunkin

nyt täytyy jäädä pois harjoituksista — mutta minun osani onkin niin
vähäinen.
Eemi: No mutta minkä tähden?
Varma (hiljemmin): Kuulin ihan varmaan tuon mustan miehen

äsken mainitsevan Heikin nimeä. Tunnen selvästi, että minun on nyt
mentävä kotiin.
Eemi (hämmästyen): Niinkö? Parasta sitten. Kuule, minä tulen

mukaan.
Varma: Kaipaavat sinua täällä.
Eemi (mietteissään): Tulisin Heikin puheille. Taitaakin tästä tulla

isompi näytelmä kuin tämä meidän tämäniltainen. Käyn vain tuolla
sisällä sanomassa, etteivät varro.
Varma: Tee niinkuin tahdot, menen jo edeltä (lähtee).
Eemi (kääntyy mennäkseen sisään, ovelta Varmalle): Vielä minä

sinut saavutan.
Varma (viittoo hänelle mennessään, poistuvat).
(Venäläiset ovat kaiken aikaa olleet kiinteässä keskustelussa.)
Vasili (taputtaa Iivanaa olalle): Hyvä on, poikaseni! Hyvät ovat

tietosi. Djengiä saat, saat tupakkaa ja viinaa. (Astuu muutaman
askeleen, puolittain itselleen.) Oikein olin arvellut. Asia oli kuten jo
jonkun aikaa olin epäillyt, vaikka ei ollut mitään varmuutta eikä
todisteita. (Katselee joelle päin Ortelaan, naurahtelee ilkamoiden.)
Nyt tuli pojalle lähtö. Jääsulun kyllä sait särkymään, mutta liian pieni
olet kaksipäisen kotkan kanssa taistelemaan.
Kaunis voitto! Tästä paljastuu vielä koko kapinallisten kopla —
ruplia tulee taskut täyteen — kunniamerkit rintaan — kohtapa
nähdään, kumpi meistä kahdesta enemmän painaa tuon ylpeän
tytön vaa'assa — Heikki Ortela vaiko Vasili Vasiljevitsh. Kun tuo
tshuhna on viety, niin silloin — (ravistaa Iivanaa). Kuule, tavaritsh,
onko Smirga Mihailovitsh kotona?
Iivana: Mikä sinua vaivaa — niin, santarmiko?
Vasili: Onko hän kotona?
Iivana: Äsken oli.
(Eemi tulee ovelle, kuuntelee.)
Vasili: Nyt emme saa hukata aikaa. Juokse heti Mihailovitshin luo
ja sano, että laittautuu kiireen kaupalla matkaan.
Iivana: Ortelaanko?
Vasili: Nauta, aasi!
Iivana: Minä ymmärrän.
Eemi (itselleen): Niin minäkin. Oikopolkua ehdin minä perille

ennen teitä.
Vasili (tutkii pistoliaan, huutaa Iivanan jälkeen): Sano santarmille,

että ottaa auton.
Eemi (itsekseen): Ollappa minulla nyt Hanneksen potkurit!
(Painaa hatun syvälle päähänsä ja pyyhältää pitkin

harppauksin vasempaan.')
Väliverho.
TOINEN NÄYTÖS.
Ortelan tupa, tilava, tavallista pohjalaista mallia. Taustalla keskellä

ovi, sivulla vasemmalla toinen. Oikealla ovipielessä kaksikerroksinen
sänky leveäraitaisine esivaatteineen, sivuseinustalla penkki, sen
edessä pitkä ristikkojalka pöytä, nurkkauksessa astiakaappi.
Vasemmalla takkamuuri, sen takana matalahko uuninpäällys,
uuninnurkassa vesikorvo, nurkkauksessa etualalla vanha leikkauksilla
koristettu kaappikello. Ikkuna kummallakin sivustalla. Katosta riippuu
yksinkertainen öljylamppu. On yö, lampunvalo himmeä. Heikki
Ortela, joka jo ollut muutamia kuukausia Saksassa, on lähetetty
aselaivan mukana kotimaahan tutkimaan tilannetta ja lähettämään
täältä uusia miehiä Saksaan. Hän istuu pöydän päässä tukien
väsynyttä päätään käsillään. Kello lyö.
Heikki (lukee lyöntejä): Yksi — kaksi — kolme — (haukottelee) —

ohhohhoi — pitäisi — pitäisi niiden jo ruveta tulemaan — (kävelee
ikkunasta toiseen haukotellen hirveästi, aukaisee oven ja kuuntelee,
ottaa napolla vettä korvosta, kastelee silmiään ja näyttää olevan
pääsemättömissä yhä ankarammin ahdistelevan unen kanssa. Ovi
aukenee ja lyhyviin turkkeihin puettu mies kurkistaa varovaisesti
sisään.)
I mies (ovenraosta): Oletko yksin, Heikki?
Heikki (ilostuu): Ahaa, joko sieltä tultiin. Käykää vaan tupaan ja

tuokaa tuomisennekin.
(I mies astuu sisään, hänen jäljessään lyhyviin turkkeihin

pukeutunut, vaiteliaasti liikkuva miesjoukko, kantaen raskaita
pieniä puulaatikolta, mitkä lasketaan varovasti lattialle.)
Heikki (laskee laatikot): Yksi — kaksi — kolme — viisi — seitsemän

— yhdeksän — kaksitoista — viisitoista — kahdeksantoista —
kaksikymmentä — kaksikymmentä, on niinkuin pitikin. No, hyvä on,
miehet, mutta peittelittekö heinillä hyvin ne jäljellä olevat laatikot,
etteivät ne sieltä luhtaladosta siirry vieraisiin käsiin?
Miehet: Peitetty on ja hyvin.
Heikki: Eikö teille siellä matkan varrella sattunut mitään erikoista?
I mies: No eipä mahdottomia. — Tuossa vain kun tulimme sillan

yli, niin siitä rantalepiköstä pujahti kaksi varjoa esiin, loikkivat
peltosaran yli ja hävisivät jälleen ladon taakse. Odotimme kyllä
laukauksia selkäpuolelta ja sormi liipaisimessa olimme mekin joka
mies, mutta ei sieltä mitään kuulunut, jotta rauhassa saimme
matkaamme jatkaa.
Heikki (mietteissään): Vai niin, vai niin. (Vetää lattiasta luukun

ylös.) Nyt on meidän pikimmiten saatava piiloon nämä.
(Miehet avustavat ja laatikot kätketään lattian alle,

luukku suljetaan.)
Heikki: Eivät taida olla toimettomia tänä yönä ryssätkään. Kunhan
vain ennättäisimme nämä jakaa, ennenkuin mitään tapahtuu.
(Hetken vaiti ja miettii, miehet pistävät tupakan.) Tuolla lattian alla ja
siellä luhtaladossa ovat nyt Suomen kansan ensimmäiset aseet,
lukuunottamatta niitä vanhoja haulipyssyjä ja ruostuneita luodikoita,
joista jokunen on vielä onnistunut säilymään ryssien
takavarikoimisilta. Mutta kuulkaahan nyt, miehet. Jos minä tästä taas
piankin häviäisin, niin jakakaa näiden laatikkojen sisällys kyläkuntien
kesken. On välttämätöntä jakaa aseet niin pian kuin mahdollista,
ettei menisi kaikki yhdellä kertaa, jos ryssät löytäisivät kätkömme.
Tulkaa siis tänne ensi yönä uudelleen. Jos minä olen poissa, hakee
sisareni tänne sedän. Matti Porkka asettelee kyllä aseet kuntoon ja
neuvoo teille niiden käytön, nämä tavarat kun ovat hiukan outoja
meille suomalaisille. Mutta tulkaa tänne vähissä erin, siten paremmin
vältämme huomion.
Miehet: Hyvä, hyvä. Teemme niinkuin käsket. Hyvää yötä vaan.
Heikki: Hyvää yötä, miehet. Tottapa jo olettekin väsyksissä.

(Haukottelee.) Minuakin — minuakin nukuttaa niin kamalasti. Olin
tässä jo ihan lujalla tuon unenlahjan kanssa odotellessani teitä.
(Pienentää lampun.) Ryssät saattavat olla väijyksissä ja voivat minä
hetkenä tahansa piirittää tuvan. Mutta olkoot! (Saattaa miehet
ovelle.) Vaikka nyt olisi pataljoona paholaisia tuolla lasien takana,
niin tämä poika — nukkuu. (Ovelta ulos puhellen): No hyvästi,
hyvästi vaan. (Sulkee oven, riisuu päältään takin ja housut, menee
alasänkyyn, vetää edustavaatteen eteen. Lampun valo himmenee,
näyttämö tyhjänä hetken.)
(Ovi vasemmalta sivustalta avautuu, isoäiti tulee tupaan,

sytyttelee tulta takkaan. Pian aukenee ovi ja leski-Maijan
Miina koreassa kukallisessa huivissa tulee sisään.)
Leski-Maijan Miina: Hyvää huomenta, emäntä.
Isoäiti: Huomenta. Varahinpa Miina on liikkeellä.
Miina: Siell' on pieni pakkanen, ja luntakin satoi koko yön.
Isoäiti: Yökaudenkos Miina on ollut kulussa? — Istumaan.
Miina: Joo. Kaupungista lähdettiin iltayöstä, ja se Tapolan Santun

koni kun on hiukan laiskanlainen, niin aamuun meni, eikä vielä olla
kotona asti.
Isoäiti (panee kahvipannuun vettä, asettaa takalle): Vai niin.
Miina: Emäntä suinkaan tiedäkään, millä asioilla…
Isoäiti: Mistäs minä.
Miina: Kun ihan kihloilla tässä vielä minäkin lopuksi, ikä-ihminen.
Isoäiti: Soo-o!
Miina: Ei emäntä ole tainnut kuullakaan koko asiasta?
Isoäiti: En ole kuunnellut kulkupuheita.
Miina: Niin kerran se tuli mullekin ilon päivä. On sitä harmia ja

tuskaa ollutkin koko elämä. (Lämmittelee.) Se on tuo livana-mestari
semmoinen mies, että ei toista parempaa.
Isoäiti: Mikä mestari?

Miina: Niin se Iivanako? — Suutarimestari se on Iivana,
suutarintyötä on tehnyt kasarmillakin, ja nyt siitä saakka kun
svabooda tuli, on asunutkin meillä ja suutaroinut.
Isoäiti: Sielläkö sinun mökissäsi se ryssä ja lapset siinä samassa?
Miina: Sielläpä se vain on nakutellut. Ensin paikkasi niiden

pentujen kenkärajat, ja sitten ovat tehtaalaisten akatkin tuoneet
sinne jalkineitaan. Hyvä suutari se Iivana onkin ja aimo mies
muutenkin ja hyvänsuuntainen kaikinpäin. Pitää niistä mukuloistakin
niinkuin omistaan, ja limppua on piisannut, vaikka onkin kova aika.
Kuka se sillä lailla toisen tenavista, ei ikänä kukaan suomalainen,
vaikka ryssää täällä aina morkataan. — On sitä niin sopiva kuulla,
kun ne penskat sitä vain paapuskaksi puhuttelevat ja polvelle
kiipeävät partaa repimään (ottaa huivin päästään). Katsokaas,
emäntä, tätä pastiakin minkä osti minulle. Kolmet neljät puotit
kuljettiin, parempaa ja parempaa se vain haki, eikä tahtonut kelvata
mikään. Sanoinkin jo, että kaipa se nyt tämmöiselle kelpaa
huonompikin. Ja rinkin osti ja murua tenaville — kuka suomalainen
sillä tavalla, sanokaas, kuka! (Katselee tuleen, yhä lämmeten.) Ja on
se niin somaa ajatella, että se tuli oma vielä minullekin, ihmiselle,
jota sillä tavoin on poljettu maailmassa, enemmän kuin ketään
muuta. Onhan siihen ollut omaakin syytäni, mutta yhtä viattomana
olen kerran tähän maailmaan tullut kuin kaikki muutkin.
(Vaikenevat.) Kovuutta olen kokenut joka taholta, onkos ihme, jos
siinä kovettuu lopuksi itsekin ja panee kovan kovaa vastaan.
Isoäiti (huokaisee): Kovaahan se usein on, elämä.
Miina: Kuudentoista olin, tenava vielä itsekin, kun sain

ensimmäisen lapsen, enkä maailman menosta ymmärtänyt mitään.
Kun tulin kotiin turvaa hakemaan, niin isä aukaisi oven: »Saakelin
hylkiö, tuosta saat mennä!» En silloin vielä ollut, mutta sitten
minusta tuli hylkiö. En ole perustanut mistään mitään. Lapsia olen
tehnyt monta, viinaa keittänyt ja linnassa istunut. Monta nälkäpäivää
on Miinan mökissä pidetty, tyhjällä vatsalla olen pannut usein maata,
mutta ei yhtenäkään iltana ole lapsien tarvinnut mennä makuulle
ilman syömistä, uskookos emäntä sen.
Isoäiti: Miina parka. Kunhan vain ei tälläkin asialla olisi vielä huono
loppu.
Miina: Toisin ne nyt ovatkin asiat tästä puolin. Mestari viekin

meidät kaikki nyt Venäjälle. Me mennään kohta, kun siellä
vallankumouksen jälkeen vähän rauhoittuu. Se on toista siellä kuin
täällä, maata on kaikilla — maata joka kasvaa. Siellä tuleekin nyt
köyhälistön valtakunta, jossa meikäläisetkin ovat ihmisiä.
Isoäiti: Niin ovat täälläkin.
Miina: Harvojen mielestä. En tarkoita emäntää, joka aina on ollut

hyvänlaatuinen minunkinlaiselleni. Mutta voi voi sentään, kun jäin
tähän pitkäksi aikaa, ja mestari tuolla ulkona pitelee hevosta.
Kylmäkin sen on siellä. Tuota, olisikos emännällä hiukan antaa
minulle voita, kun on meidän kulmalla siitä lehmällisestä semmoinen
puute. Aikanen ihminen kyllä pärjää ilmankin, mutta pitäisihän niille
mukuloille olla joskus voitakin leivän päälle.
Isoäiti: Ei sitä paljon ole, tämä talo ei nykyisin tuota omaa

tarvettakaan, kun ei ole työvoimaa, mutta annan nyt sentään sen
verran, että makuun pääsette. (Etsii aitan avaimen.)
Miina (muhoillen): Katsokaas nyt, emäntä, aittaan mennessänne

sitä Iivanaa, kun en saanut sisään tulemaan, minut vaan lähetti sitä
voita kysymään. On se vaan semmoinen mies, että kehtaa sen
näyttää, ja niin sillä on hellä sydän (lähenee emäntää). Tietäkääs,
emäntä, kun minä ensin en olis huolinut siitä, vaan käskin pois
tuvasta, niin se itki niinkuin pieni tenava ja ampua lupasi itsensä,
ellen ota. Ja olisi se sen tehnyt, niin sillä on rakas luonto.
Isoäiti: Minun on tällä kertaa paha sanoa mitään, mutta tunnen

niinkuin pakotuksen puhumaan suuni puhtaaksi. Olisi taitanut olla
sinulle paras, jos olisit sen vain lähettänyt menemään.
Miina (keskeyttäen): Luuleekos emäntä, että se Iivana ei rakasta?
Isoäiti: Sitä en epäile.
Miina: Mitä sitten emäntä tarkoittaa?
Isoäiti: Meinaan vaan, että se ryssä on aina ryssä. (Menee ulos.)
Miina (jälkeen): Siinäpä se on, köyhän onnea kaikki kadehtivat.
Iivana (kurkistaa oven raosta): Maamushka! Onko sinne ketä

olemas?
Miina (menee vastaan): Tule, kyyhkyseni, tule, ei ketään, ei

ketään.
Iivana (tulee sisään, siviililakki päässä, sinelli yllä, taputtaa Miinaa

pakaroille): Maamushka!
Miina (hyväillen): Miilaja paapushka.
Iivana: Sie Heikki Ortela näkemää?
Miina: Njet njet.

Iivana: Ah njet harashoo. (Kulkee ja katselee, kuulee Heikin
hengityksen, ilostuu, tekee eleitä, lähenee vuodetta, vetää
edusvaatteen syrjään ja kurkistaa sänkyyn, lähenee varpaisillaan
Miinaa, kuiskaa): A vot vot vot vot, ootshen harashoo. Vasili minul
raha antamas, paljo raha. Tule pois, maamushka, tule tule! (Menee
ulos.)
Miina (ällistyy): Mitä, miksi, älä mene, Iivana, älä mene, varro
minuakin.
Isoäiti (tulee ja tuo Miinalle voipaketin): Ei siinä paljoa ole,

vähäsen niinkuin muruksi vain, eikä siitä tarvitse maksuakaan tuon
vertaisesta.
Miina: Kiitosta vaan, olisin minä sen mielelläni maksanut. Niin,

pitänee mennä, kun se mestari vartoo kylmässä. Hyvästi vaan ja
kiitosta paljo. (Hyvästelee, menee.)
(Isoäiti istuu mietteissään takan ääreen.)
Varma (tulee kamarista, aukaisee ikkunauutimet): Yöllä onkin

satanut vahvasti lunta. (Katselee ikkunasta, äänettömyys.) Jokohan
pitäisi tuo Heikki herättää? (Menee vuoteen viereen, vetää peitettä
syrjään, laskee jälleen alas.) Nukkuu niin sikeästi. En mitenkään
hennoisi herättää.
Isoäiti: Maatkoon nyt vielä hetken.
Varma (ottaa lavitsan, istuu takan ääreen): Senkin Tuomaalan

Nikolain ovat ryssät vieneet pois lääninvankilasta viime viikolla. Ei
kukaan tiedä minne, ja taiteilija Viitasalo, jolta syksyllä löydettiin
luvatonta kirjallisuutta, on viety Shpalernajaan.
(Äänettömyys.)
Isoäiti (jauhaa kahvia): Leski-Maijan Miina kävi täällä äsken, ryssä

odotti pihalla.
Varma: Niinkö. Ei ne sellaiset linnut lentele hyvän ilman edellä.
Isoäiti: Eivät taida. Sitä minäkin tässä rupesin ajattelemaan. —

Miina parka, yksi lankeemus seuraa toista, ja kun pahalle antaa
pikkusormen, vie se koko käden.
Varma: Kuulikos isoäiti eilen, kun Porkan setä kertoi Heikin

kiinniottamispalkkion puolella koroitetun. Kymmenentuhatta ruplaa
saisi se, jonka onnistuisi pidättää velipoika. Se taitaa tehdä vähän yli
kaksikymmentätuhatta markkaa — pienen talon hinta.
Isoäiti: Peloittaakos sinua?
Varma: Peloittaa mua joskus tuon pojan puolesta, soisin sen

mieluummin kuolevan kuin joutuvan ryssien käsiin.
Isoäiti: Emme saa edeltäkäsin murehtia sitä, mikä tapahtuvaksi

säädetty on.
Varma (hiukan levottomana, käyden välillä silmäilemässä

ikkunasta pihalle): En tiedä, miksi tänä aamuna tuntuu niin
kamalalle. On niin kylmäkin täällä tuvassa. Nukuin huonosti koko
viime yön, heräsin vähän väliä, kun luulin kuulleeni kolkutusta ovelle.
Hevoset ne vain tallissa kolistelivat, lienee se varsa taas päässyt irti
— — — jokohan pitäisi — (on menossa sängyn luo, mutta tulee
jälleen takaisin). Mummo, tiedän teidän näkevän asioita edeltäkäsin,
kuinka luulette tämän kaiken päättyvän?
Isoäiti: Suuret asiat ovat kynnyksellä. Viime yönä näin isäsi ja
isoisän. Edesmenneetkin ovat mukana. Uskon, että Herra on tekevä
ihmeitä tämän kansan keskuudessa.
Varma: Se tuntuu joskus niin mahdottomalle, vaikka tietääkin että

eteenpäin meidän täytyy — peräytyä ei tästä enää voi enkä sitä
tahtoisikaan.
Isoäiti: Kaidoista kohdista sitä on ennenkin lävitse menty. Muistan

senkin syksyn, jolloin poltetauti tappoi äitinne ja minä, vanha
ihminen, sain ruveta hänen tilalleen. Heikki oli silloin kuusivuotias ja
sinä Varma vielä rintalapsi. Niin avuttomana jäit käsiini, että tuskin
sain sinussa hengenhievaroista säilymään. Vielä oli tämä talouskin
hoidettavana, ja huonot olivat meillä muutenkin ajat silloin. Siinä
vain päivät kuluivat, välistä paremmin, joskus huonommin. Olisi jo
hyvinkin mennyt, silloin tuli taas uusi isku, isäsi vietiin pois, ja minä
jäin yksin teidän lasten kanssa. Kummallisen synkälle se silloinkin
näytti ja olisi luullut, että hullusti nyt käy, mutta huomispäivä toi aina
neuvon tullessaan — (kohentelee tulta ja istuu takkakivelle,
vaikenee). Edeltäpäinnäkemyksen lahjaa ei ole ihmiselle annettu,
tottapa se ei liene hänelle tarpeellinen, mutta meillä on lupa rukoilla
Taivaallista Isää ja odottaa Hänen apuaan. (Hiljaisuus.) Mutta koeta
nyt saada se poika henkiin, kahvikin on jo valmista. (Ottaa kaapista
kahvikupit ja asettelee pöydälle, seisahtuu askarrellessaan akkunan
ääreen, huomaa ulkona jotakin, menee kiireellä vuoteen viereen,
missä Varma veljeään herättelee.) Heikki hoi, nouse nyt nopiaan,
herrat sieltä jo tulevat, aiotko tavata heitä, vai kuinka?
Heikki (kohottautuu puoleksi istuvilleen, hieroo unisena silmiään):

Montakos niitä sieltä nyt sitten tulee?
Isoäiti: Kaksi venäläistä ja yksi suomalainen virkapukuinen, poliisi
näyttää olevan, vaikka ei tämä meidän oma, mahtanevat nuo
venäläiset tuoda sen kaupungista joukossaan.
Heikki (panee maata toiselle kyljelleen): Hyvä on, ei kolmen

miehen edestä viitsi pakoonkaan mennä. Pyydä, Varma, vieraat
istumaan, kun tupaan tulevat. (Vetää peitettä korvilleen.)
Varma: Et sentään huolisi olla noin uhmaileva.
Heikki: Älä ollenkaan, sisko, hätäile. Pahinta tässä on se, että

minua niin riivatusti nukuttaa, on näes jo kolmen viikon unirästit
suorittamatta. (Haukottelee ja venyttelee.) Ohhohhoi — joko ne
herrat ovat kohta täällä?
(Ovi taustalla avautuu, sisään astuu kaksi

santarmia, poliisi heidän perässään.)
Poliisi: Huomenta, emäntä! Mikäli olen saanut tietää, on Heikki

Ortela nyt kotosalla.
Isoäiti: Kotona on. Vieraat käyvät istumaan.
(Tulijat vaihtavat silmäyksiä, istuutuvat sitten emännän

osoittamille lavitsoille asettuen siten, että voivat vartioida
taustalla olevaa ovea.)
Heikki (työntää syrjään edusvaatteen): Jaa-ha, no huomenta,

huomenta! Varahinpa nyt ovat vieraat liikkeellä.
Poliisi: Arvannet kaiketi asiamme. Kehoitan sinua, Heikki Ortela,

pikimmiten pukeutumaan.
Heikki (naureskellen): Mistäs minä — herrojen asioita arvailemaan
— mutta olikos sillä muorilla siellä pannussa kahvin tilkkaa, kun
takoo ja jyskyttää tuolla päässä niinkuin olisi siellä seitsemän
seppää. — Ohhoi — ja, taisi tulla siellä matkalla maisteltua vähän
liikaa.
(Vieraat silmäilevät toisiaan.)
Poliisi (jo ankarammin): Pue yllesi joutuin. Matkoilla sanoit olleesi.

Niin, niiden matkojen tähden olemme tänne tulleet. Sinun on nyt
annettava niistä täydellinen selostus.
Heikki (naureskelee kiirettä pitämättä): No minnekäs tässä nyt

semmoinen kiire näin aamusta päivin. — Ettäkö siitä matkastani — ei
ole mulla siitä reisusta täydellistä selvyyttä itsellänikään — niin, ja
mitäpä tuosta nyt kenellekään tiliä tekemään, kun en kerran tiedä
suurempia pahoja tehneeni. (Istuu sängyn laidalle, vetää housut
jalkaansa ja siirtyy velton ykskaikkisena vähän väliä haukotellen
pöydän ääreen.)
Poliisi: No, anna tulla.
Heikki: Eihän siinä oikeastaan pitäisi olla kummempaa — tosin olin

surkeasti humalassa, ja nyt kun tuo pää — ohhoi, oijoi — tottapahan
nämä herrat kyllä tietävät, millä tämmöinen tauti parannetaan —
Poliisi (iskee nyrkkinsä pöytään): Sinä, sinä uskallat yrittää pilaa,

kalliiksi se sinulle tulee, sen voin vakuuttaa.
Heikki (yksinkertaisena): Onpas perhana, vai vielä tämäkin, ja kun

tuli jo se matkakin niin turkasen tyyriiksi — ihan tässä on ihme —
Poliisi: Eihän tästä päästä sen pidemmälle. Lopeta nuo lorusi ja
kerro lyhyesti, missä olet ollut nämä kuukaudet. Poistuit
paikkakunnalta toukokuussa karaten etsivien käsistä, ja nyt on
joulukuuta kulunut jo yli puolen. Sillävälin ei sinua ole näillä mailla
nähty.
Heikki: Mitenkäs mua olis voitukaan nähdä, kun poissa olin.
Poliisi (tuskastuu): Äsh!
(Emäntä istuutuu takkakivelle ja katselee vaieten Heikkiä.

Varma aikoo ovesta ulos.)
I santarmi: Njet njet, pois pois! (Viittoo ja tekee eleitä

täydentääkseen vajavaista kieltään.)
Poliisi: Ulos saat tyttö mennä, mutta takaisin et enää tule.
Varma: Tästä ovesta minä menen ja tulen ihan oman mieleni

mukaan. (Menee.)
Poliisi: Sepä nähdään. (Heikille.) Annappa kuulua.
Heikki (venytellen ruumistaan): No, se on sitten pian kerrottu,

kunhan ensin alkuun päästään. Ensin kävin, nähkääs, Etelä-
Suomessa, muuten vain piloillani, katsomassa mille se maailma
sieltäpäin näyttää — olin minä Helsingissäkin — ovatkos nämä herrat
olleet Helsingissä?
I santarmi: Äh, tshuhna — sine durak!
Heikki (poliisille): Mitähän hän tarkoittaa — (nyökkää santarmiin

päin) — joo, se on suuri kylä sekin Helsinki ja paljon siellä oli väkeä
ja suuria asuinratia oli toinen toisen vieressä. Millähän sielläkin ne
ihmiset elävät, kun ei peltoja näkynyt ollenkaan eikä tunkioita
missään. — Niin, mutta olin minä kuullut, että suurempiakin kyliä on
olemassa ja vielä komiampia, jotta tuumasin, että lähdetäänpäs
silmäilemään nyt sitä maailmaa hiukan edempääkin ja sitten
pistäysin Amerikassa.
Poliisi (viheltää): Vai Amerikassa.
Heikki: Nii-in.
Poliisi: Jo puhut pötyä, kuinka sinne olisit passittomana päässyt.

Mitenkä esimerkiksi pääsit rajan yli?
Heikki: Niin rajanko yli? Sitä ei totisesti tiedä itse se vanha

erkkikään, miten minä sen rajan yli pääsin. Humalassa kun olin enkä
tietänyt tuon taivaallista, mutta luulen minä vaan, että huonosti ne
vartioivat sitäkin rajaa.
Poliisi: No annetaanpas pojan nyt itse solmiutua sanoissaan —

kerroppas nyt esimerkiksi, minkä linjan laivalla matkustit ja paljonko
maksoi piletti?
Heikki: Linjoistako minä tiesin, kun täydessä seilissä olin koko

matkan, ja rahat, niin rahat tiedättekös menivät niin tarkkaan, että
takaisin tullessani sain myydä kelloni jo Torniossa ja kotia päästyäni
kilisi vain pari piikkiä tuolla massin pohjalla, joo, että tyyriiksi ne
tulevat matkat tähän aikaan.
Poliisi: Valhetta alusta loppuun.
Heikki: Ei tämä suinkaan mikään uskonkappale ollutkaan.

Poliisi: Onko sinulla aseita?
Heikki (vetää vitkastellen puukon vyöltään): Ei ole muuta kuin

tämä, vaarivainajan vanha tuppiteräs.
(Katselee ja koettelee terää. Poliisi vaistomaisesti

vetäytyy kauemmaksi.)
Heikki: On kait tämä joskus ollut teräväkin — tiedä, tainnut jo

tylstyä — ole tullut häntä koeteltua.
Poliisi: Puukko tänne! (Santarmit vetävät esiin pistolinsa.)
Heikki (naurahtaa): Peloittaakos herroja tämä, eikä muakaan

peloita nuo teidän aseenne — no, tästähän tämän saatte (tarjoaa
poliisille), sopii ottaa vaan.
Poliisi (aikoo ensin ottaa puukon, mutta ei tohdi): Pane siihen

pöydälle se puukko.
Heikki (pannen puukon pöydälle työntää sitä vähän kerrallaan

poliisia kohti, naurahdellen): Siinä se on, kyllä sen ottaa tohtii.
(Varma ilmestyy ovelle, pitää kättään vyöliinansa alla.)
I santarmi: Seis, flikuski! (Viittoo takaisin.)
II santarmi (ojentaa pistolin ovea kohti).
Poliisi: Jos tulet, tyttö, niin ammutaan.
Varma. Ampukaa vaan, jos haluttaa, mitäpä minun hengestäni olis

teille hyötyä. (Astuu santarmien keskestä Heikin luo ja pistää toisten
huomaamatta revolverin hänen taskuunsa.)
Poliisi (ottaa pöydältä puukon): Heikki Ortela! Lain nimessä minä
nyt vangitsen sinut.
Heikki: Jos laki teidät siihen velvoittaa, niin täyttäkää vaan

tehtävänne. (Nousee ylös.) Tässä minä olen.
(Poliisi ja santarmit seisovat paikallaan, hetken hiljaisuus.)
Heikki (astuu keskemmälle, näyttää paljaita käsiään): No

vangitkaa nyt.
Poliisi (astuu askeleen kohti, Heikki katsoo häntä tiukasti silmiin.

Poliisin käsi, joka oli jo tarttumaisillaan kiinni, putoaa herpautuneena
alas.)
Heikki (lähestyy häntä, katse yhä kiinteästi hänessä): No, mitäs

tuumaat?
(Poliisi peräytyy vähä vähältä, Heikki seuraa tinkinaurua

naurahdellen, poliisi ajautuu oven puolelle.)
Poliisi (santarmeille): Uskokaa minua, herrat, tuolla miehellä on

piru mielessä.
Heikki (yhä läheten): Niin se on, hyvät herrat, että minä en tykkää
pitkistä puheista, joko te tahi minä.
(Poliisi ja santarmit ovat ovensuussa, epäröivät,

eivät tiedä mitä tehdä.)
Heikki (osoittaa ovea): Niin, niin tuosta paikasta juuri on viis hirttä
poikki, kas siitä vaan kauniisti ulos. (Poliisi ja santarmit lähtevät.
Heikki katselee heidän jälkeensä ovesta, käy vielä hakemassa
lakkinsa naulasta.) Jos tässä lähtisin minäkin hiukan jaloittelemaan.
(Astuu ovesta ulos. Tuvassa tuntuu vielä pingoitettu

jännitys. Emäntä istuu kädet ristissä takkakivellä, Varma
katselee ikkunasta ulos.)
Matti Porkka (tulee tupaan): Hyvää huomenta tähän taloon.

Aikaisinpa teillä on vieraita käynyt, kun tuolla jo ovat paluutiellä.
Varma: Näittekö Heikkiä, setä?
Porkka: Enkä nähnyt, pääsi tiemmä livistämään.
Isoäiti: Herratpa ne näkyivät edeltä menevän.
Porkka (lämmittelee takkatulen ääressä käsiään, hykertelee

mielihyvissään): Jassoo, vai niinpäin, että herrat edeltä — kas sitä
poikaa, oli se hieno temppu, olisi sitä kelvannut katsella.
Isoäiti: Kun täällä hetken vartoilet, niin jotakin näet sinäkin, ei se

siihen vielä loppunut.
(Samassa Heikki tulee tupaan, heittää lakkinsa

penkille ja käy kättelemään Porkkaa.)
Heikki: Varahinpa on setäkin tänään liikkeellä. Meillä on tänään

täällä näytelty pieni yksinäytöksinen pila. (Kääntyy isoäitiin.) No,
mitäs sanotte, isoäiti, eikös se sentään käynytkin kätevästi?
Isoäiti: Lopussa se vasta seisoo kiitos, mutta parasta lienee nyt,

että alat varustautua sitä toista näytöstä varten.
Heikki (taputtaa isoäitiä harteille): Älkää olko, mummo,
milläänkään, ei tässä hätää ole.
Isoäiti (ottaa Heikkiä kädestä): Olkoon onni mukanasi.

Kaikkivaltiaan siunausta minä sinulle rukoilen — sen sanon vain
hyvästiksi siltä varalta, että jos sattuisi tästä sulle vielä kiireellinen
lähtö.
Heikki (lämpimästi): Kunpa vain näkisin teidät terveenä takaisin

tullessani. (Luo pitkän silmäyksen isoäitiin, sitten Porkkaan kääntyen
tarjoo savukkeen). Mutta ei tässä sentään niin kiirettä liene, ettei
savuja ennättäisi vetää.
Porkka (tarjoo omiaan): Pidä ne vain siellä matkan varrelle,

otetaan täältä. (Sytyttävät.) Mutta oikein todella, mitäs nyt meinaat?
Ethän vain aikone niitä äskeisiä vieraitasi toista kertaa vastaan ottaa?
Heikki: — tiedä, eipä tässä juuri osaa mitään

matkasuunnitelmiakaan ruveta laatimaan, tottapa hätä taas keksii
keinon. — Mutta ehkäpä setä sitten hiukan taas huolehtii tästä
meidän väestä minun mentyäni ja hoitaa sen asejaonkin ja nämä
muut paikalliset järjestelyt. (Kääntyy Varmaan.) Mutta katsoppa sinä,
sisko, minulle jotakin eineheksi. Olen kovin nälkäinen, jotta pitäisi
tässä vielä ehtiä hiukan haukkaamaankin, ennenkuin ne äskeiset
herrat toistamiseen tulevat. Toisen kerran nyt niistä suoriusin eikä
kahta kolmannelta.
(Varma tuo pöytään leipää, silakoita ja puisen viiliastian.)
Varma: Siinä sitä nyt olis.

Heikki (istuu pöydän ääreen): Ohoh, kun on niin nälkä, että oikein
on häijy olla. (Taittaa leivän ja aloittaa ateriansa.) Mutta miksikähän
ne minua luulivat äsken, kun niin lähtivät. Kiltisti vain painelivat
ovesta ulos. Kyllä mua nauratti hengessäni. Luulivatkohan ne, että
minulla täällä jossain oli apulaisia piilotettuna, vai pelkäsivätkö niin
kovasti yhtä aseetonta miestä — niin, olihan Varma pistänyt
revolverin tuonne takataskuuni, mutta en sitä huomannut ennenkuin
vasta perästäpäin.
Porkka: Nätisti se tosiaan taas kävi, mutta älä nyt sentään rupia
liiaksi noihin temppuihisi luottamaan. (Rykäisee, sylkee takkaan ja
hetken vaiettuaan.) Tuota, minäkin tulin niinkuin hyvästiä sanomaan,
matkaan tässä nyt pitää minunkin lopuksi.
Isoäiti (hämmästyy): Saksaanko?
Porkka: Sinne. Olenhan tässä jo hankkinut pitemmän aikaa, vaikka

ei ole tullut valmista. Mutta nyt tästä lähin en voi enää täälläkään
toimittaa mitään, koska olen joutunut silmälläpidon alaiseksi.
Sanovat minun jo ilmiannetun osallisena poikien värväykseen, joten
lähtö tässä on edessä. Mutta toistaiseksi voin vielä määrätä suunnan
ja valita tien.
Heikki: Jassoo, silläkö kannalla nyt ovat asiat. Äkkilähtö tuli teille
niinkuin minullekin viime keväänä.
Varma (pysyttelee ikkunan ääressä, vähän väliä ulos silmäillen):

Kyllähän me isoäidin kanssa tulemme toimeen, ja osaanhan minäkin
jakaa ne — tuolta lattian alta.
Isoäiti: Niin, eipä senpuolesta, kyllähän me täällä. Muuten minua

vain vähän ihmetytti, että sinäkin, ikämies, jota tarvittaisiin niin kovin
täällä nuorukaisia opastamassa. Mutta koska asiat ovat kerran
niinkuin sanoit, ei siinä silloin ole varaa valita.
(Kuuluu auton törähdys, kaikki hämmästyvät.)
Varma: Tulevat.
Heikki: Joko nyt! Niiliäpä vasta on kiire! (Lopettaa syöntinsä,

menee Varman luo ja ottaa häntä hartioista.) Sinun haltuusi, tyttö,
jää nyt noiden kalliiden laatikoiden hoito. (Viittaa lattialuukkuun.)
Tuon jos löytävät ja tyhjentävät, on vahinko korvaamaton. (Porkkaan
kääntyen.) No, näkemiin nyt sitten. Luulen, että teidän on parasta
pistäytyä nyt'tuonne kamarin puolelle. Sieltä löydätte portaat ylös.
Teidän ja ryssien tapaamisesta ei ole nyt väliä, muuten vievät teidät
väärään suuntaan.
(Eteisestä kuuluu kolinaa. Samassa tuokiossa lennättää

Heikki uuninpäälle. Porkka pujahtaa kamariin. Molemmat
äskeiset santarmit ja kaksi poliisia astuvat sisään.)
Poliisi (sisäänastuessaan tylysti isoäidille): Missä on poikanne poika

Heikki Ortela?
Isoäiti (vastaa vaiteliaalla katseella).
Varma (on kulkenut ikkunasta toiseen): Koko talo on nyt piiritetty.

Pistimet välkkyvät jokaisen ikkunan alla.
Poliisi (astuu Varman eteen): Vastaa, tyttö, missä on veljesi, koska

isoäitisi suvaitsee vaieta.
Varma: Teillekö minun pitäisi hänen olinpaikkansa ilmoittaa.

Poliisi: Älä huoli tyttö mahtailla. Tällä kertaa ette meistä niin
vähällä selviäkään.
Varma: Ei meitä teidän uhkauksenne pelolta.
(Alkaa yleinen tarkastus, joka kestää tuokion. Santarmit

löytävät Heikin saappaat sängyn alta ja pöytälaatikosta
valokuvan, jonka ottavat mukaansa. Kamariinkin katsotaan.
Heikki seuraa piilopaikastaan virkamiesten puuhia. On
pingoittunut hiljaisuus, kunnes I santarmi kiinnittää
huomiotaan lattian poikki sahattuihin lautoihin ja alkaa
sapelinkärjellä niitä koettelemaan. Silloin viskaa Heikki hänen
eteensä pullon, jonka sisällys räiskyy ympäri ja santarmin
vaatteille.)
Heikki: Voi hyvät ihmiset, kun putos tuo muorin pikiöljy pullo! —
No herrat, taasko te olette tulleet tänne minun untani häiritsemään?
Poliisi: Heikki Ortela, astu alas uunilta. Nyt seuraat meitä, ja kaikki
vastustus vaan pahentaa asiaa.
Heikki (naurahdellen): Olenkos minä herroja ennen vastustanut?
Poliisi: Keskustelut ovat nyt tarpeettomia.
Heikki: Sitähän minäkin, mitä noista turhista puheista.
Poliisi: Nyt lähdet matkaan.
Heikki: Ee-hei. Siitä ei nyt tällä kerralla hikoa mitään. Olisitte

ottaneet äsken, kun niin olin tulemassa, mutta nyt en enää ole sillä
päällä.
Poliisi (vetää esiin revolverin, samoin tekevät santarmit): Sinä
vastustelet.
Heikki: No, nyt leikki pois! (Vetää esiin mauserin.) Tässä on

kymmenen panosta ja jok'ainoa niistä tappaa jokaisen, joka
yrittääkin lähestyä tätä linnoitusta. (Katsoo poliisiin, joka seisoo
syrjemmässä.) Sinä poliisi Pulkka, joka olet oman pitäjän miehiä ja
suuren lapsilauman isä, en sinua mielelläni, — sentähden pysy
kauempana. Miehet, oletteko siunanneet itsenne kuolemaan?
(Piirittäjät hämmästyneinä silmäilevät toinen toistaan.)
Heikki (kohottaa aseensa): No, nyt se alkaa — yks — kaks —

(piirittäjät väistyvät kauemmaksi, muutamat tähtäävät Heikkiin.)
Heikki: — kolme! (Syöksyy salamannopeudella uunilta alas ja

ryntää ovesta ulos, ennenkuin kukaan ehtii pidättää. Poliisit ja
santarmit perässä, huutoja, laukauksia. Emäntä painaa käden
sydämelleen ja vaipuu takkakivelle.)
Varma: Heikin jos tappavat, niin hänen kuolemansa minä…

(juoksee ulos).
Väliverho.

The 1st Annual Crossing The Quality Chasm Summit Institute of Medicine

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Health and Behavior The Interplay of Biological

Priorities for the National Vaccine Plan 1st Edition

Who Will Keep the Public Healthy 1st Edition Institute

Preserving Public Trust Institute Of Medicine

Facilitating Interdisciplinary Research 1st Edition

Evolution of Translational Omics Lessons Learned and

Multiple Sclerosis Current Status and Strategies for

Exploring the Biological Contributions to Human Health

Board on Health Care Services

Karen Adams, Ann C. Greiner, and Janet M. Corrigan, Editors

International Standard Book Number 0-309-09303-1 (Book)

Copyright 2004 by the National Academy of Sciences. All rights reserved.

Printed in the United States of America.

KAREN ADAMS, Co-Study Director

Board on Health Care Services

JANET M. CORRIGAN, Senior Director, Board on Health Care Services

THOMAS M. MADDOX2, Gustav Leinhard Fellow in Health Sciences Policy

RONA BRIERE, Briere Associates, Inc.

GEORGE ISHAM, HealthPartners, Inc., Bloomington, MN

Reed V. Tuckson, M.D.

Harvey V. Fineberg, M.D., Ph.D.

3 INFORMATION AND COMMUNICATIONS TECHNOLOGY ....................................37

4 CARE COODINATION .......................................................................................................47

5 PATIENT SELF-MANAGEMENT SUPPORT .................................................................57

7 COALITION BUILDING ....................................................................................................77

8 CONDITION-SPECIFIC ACTION PLANS .......................................................................85

APPENDIX A—BIOGRAPHICAL SKETCHES OF COMMITTEE MEMBERS .............111

To achieve these objectives, the committee

Box ES-1. Summit Communities

• Heart failure communities

• Pain control in advanced cancer communities

Box ES-2. National Champions

• Agency for Healthcare Research and Quality

At the summit, participants first heard from

To create relevant measurement sets,

• Aligning financial incentives

from rapid-cycle practical models and, in Finance

Once consensus has been reached around an

Two working groups—addressing asthma and

Box 1-1. Six Aims for Health Care Improvement

Box 1-3. Summit Communities

• Heart failure communities

• Pain control in advanced cancer communities

Box 1-4. National Champions

• Agency for Healthcare Research and Quality

Box 1-5. Steps to a HealthierUS

The Department of Health and Human Services (DHHS) is currently supporting 12

developed by staff at the Improving Chronic interactions were explicitly compartmentalized.

Figure 1-1 Chronic Care Model

REFERENCES IOM. 2002a. Fostering Rapid Advances in Health

DEFINITION AND OVERARCHING THEMES

KEY STRATEGIES conflicting measures collected against

Box 2-1. Washington State Diabetes Collaborative

The Washington State Diabetes Collaborative was established in 1999 to address

Box 2-2. Commitments Made by National Champions Regarding Performance

Steven Jencks, M.D., Centers for Medicare and Medicaid Services