This issue examines ambulatory care research as framed by the "Specific Aims" presented in Crossing the Quality Chasm: Health Care in the 21st Century, a report released March 1, 2001, by the Institute of Medicine (IOM). The findings and recommendations within this "Chasm Report" were awaited with great anticipation. In 1999 the IOM released another report, To Err Is Divine, which dealt with medical errors and patient safety. Together these reports raise serious concerns about the quality of health care within the existing system of health services. Both reports place a high priority on the role of information technology to support the improvement of quality in health organizations. To a large degree, the quality of information that health care organizations have at their disposal facilitates the ability of the organization to measure and improve health care. These innovations in organizational redesign need to take place across the entire spectrum of organizations engaged in the delivery of health care.
In the Chasm Report, six specific aims are set forth as guidelines for the quality of health care. High-quality health care must be (1) safe, (2) effective-i.e., scientific or evidenced-based, (3) patient-centered, (4) timely, (5) efficient, and (6) equitable. These six aims make up the points of navigation for the articles presented in this second special issue of JACM (25:2).
EFFECTIVE CARE
The first article, by Monica Smith, Barry Greene, and William Meeker, examines the case of chiropractic care within a wide range of complementary and alternative care systems. Chiropractic care may be considered either inside or outside conventional medicine, depending on the criteria for classification. From the standpoint of the National Institutes of Health and its National Center for Complementary and Alternative Medicine, consumer demand is well ahead of scientific knowledge in complementary and alternative medicine (CAM), and the need to integrate evidenced-based CAM care with conventional medical care is a major issue to be addressed by both clinical and health service researchers. This article stretches that point to consider health services research and organizational devices, such as practice-based networks, that have provided promise in primary care.
In the second article, Thomas Vaughn and colleagues look at smoking cessation as a function of provider and organizational characteristics. The Chasm Report cited above recommends adherence to clinical guidelines, and this research looks precisely at such guidelines relative to one of the most important health problems of our time.
PATIENT-CENTERED CARE
Peter Damiano and colleagues look at patient-centered care as evidenced by the Consumer Assessment of Health Plan Study (CHAPS(R)) demonstrations and the effort to inform consumers with a basis for quality-related information at the time they are selecting a health plan. This information is presented in the form of a report card designed specifically from the consumer's perspective, and the demonstrations in Iowa involved both public and private health plans and health systems. This fact makes the Iowa experience important as a demonstration project, and the article emphasizes the lessons learned from this experience.
In the article by Thomas Wickizer and colleagues, the project focuses on three targeted conditions-low back sprain, carpal tunnel syndrome, and fractures-and incorporates three delivery system components to track patients, employer satisfaction, and health outcomes. The authors look at several quality-improvement initiatives, including integration and coordination of services, and the role of communication with the patients receiving disability services. The experiences and findings of the Occupational Health Service Project is relevant to clinicians, administrators, and policymakers who may be engaged in community and health resource linkages both within and outside occupational health care.
PATIENT-CENTERED CARE AND ORGANIZATIONAL SUPPORT SYSTEMS
In "Providers of Primary Care to Homeless Women in Los Angeles County," Jeff Luck's group provides research on the access barriers to homeless women in the Los Angeles community. This research surveyed administrators and clinicians (physicians, nurse practitioners, and physician assistants) who provided care, and the unit for analysis was the actual clinic site of care. The researchers looked at the structural characteristics of the sites, the characteristics of the clinical providers, and those characteristics of the patient populations who used the sites. These factors and the barriers were compared among major and secondary sites of care for the homeless women.
LEADERSHIP
In the article on leadership, Samuel Levey, James Hill, and Barry Greene relate the extraordinary leadership requirements inherent in the Chasm Report to the literature on leadership within organizations and the leadership literature in general. The academic and popular press literatures are reviewed with a focus on the importance of the leader as a strategist in the systems context. The qualities of a leader perhaps are relative to the changes called out by the systems context. Such a leader leads both events and people and enters into the outer environment. Redesigning health organizations will require leadership on that surface, at least, which is probably more difficult than simply designing them. Change and professional cultures must be constantly negotiated. The leadership discussion is also placed into context of the criteria of the Baldridge National Quality Program and the high priority that award has placed on the visioning capacity of the leader.
The issue is rounded out with "How Do You Know That Your Care Is Improving? Part II," the second in a series of articles by Raymond Carey on statistical methods in analyzing ambulatory care practice. A report by Barbara Ayotte, "Women's Health and Human Rights in Afghanistan: Continuing Challenges," describes the situation in that country and points out what health professional providers can do to work for improved health and human rights worldwide. The final word is again from Mark Holt, who reports from the Republic of Texas.