Crossing the Global Quality Chasm Improving Health Care Worldwide (2018) / Chapter Skim
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The SDGs include an explicit commitment to achieving universal health coverage (UHC) by 2030 "so that all people and communities receive the quality services they need, and are protected from health threats, without suffering financial hardship." Accordingly, UHC is the central theme of global health policy today.
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are not being treated, and more than 4 million avoidable qualityrelated deaths each year are attributable to ineffective care for NCDs. In total, between 5.7 and 8.4 million deaths occur annually from poor quality of care in LMICs for the selected set of conditions the committee analyzed (see Figure S-1)
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In sum, defects in the quality of health care deny patients and communities the potential benefits of effective care. The currently prevailing forms, habits, and models of care worldwide are incapable of bridging this global quality chasm.
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The committee does not offer this dramatically worrisome picture of the quality of global health care lightly. We understand fully that millions of health care workers, managers, executives, and policy makers are struggling daily to offer patients better care and better health, often in the face of great obstacles.
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Finally, the 2001 report does not address a crucial contextual element of the global health care scene: integrity. It is now recognized that corruption takes far too great a toll on health care systems, and therefore integrity, accountability, and transparency are key in trying to improve health system performance in every dimension.
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Global resources are widely available, including technical and policy guidance on how to set national quality policies and strategies. Embracing principles of transparency, accountability, continual learning, and co-design, countries will need to work with the end users
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The committee en dorses the recent Global Quality report and recommendations of the World Health Organization, World Bank, and Organisation for Eco nomic Co-operation and Development, and further recommends the following steps: • Every ministry of health should develop a national health care quality strategy, together with supporting policies, and should agree to be held accountable for progress. • Every ministry of health should adopt goals for achieving high quality care, adapted to their national context, but considering all the dimensions of quality highlighted in this report.
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Countries should gather and report on quality metrics in global frameworks and across a range of quality dimensions. Steps within nations should include: • using financing and coverage mechanisms in UHC that support the provision of high-quality care, such as strategic commissioning and purchasing of services and products, selective contracting, and paying for the value of care; • carrying out monitoring and evaluation, including clinical audits, community involvement and co-design, and customer satisfaction surveys, to generate data that can be used to ensure that UHC resources are fostering high-quality, continuously improving care; and • conducting research and evaluation on the impact of policy levers on the quality of care received to improve the evidence base on what interventions lead to better care at a systems level.
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The committee considered many candidates for such redesign principles for Care Processes SAFETY EFFECTIVENESS FRONT-LINE CARE EQUITY Quality ACCESSIBILITY/ DELIVERY Aims TIMELINESS OR N G A N I Z AT I O EFFICIENCY PERSON CENTEREDNESS E N VIR T ON MEN FIGURE S-2 Guiding framework for the transformation of care delivery.
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To guide that new care system, health care leaders should adopt, adapt, and apply the following design principles: 1. Systems thinking drives the transformation and continual improve ment of care delivery.
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The Proper Use of Metrics In addition to design principles, appropriate and meaningful measurements are necessary to gain an understanding of the quality of care delivered, and eventually to support learning and to guide improvement. The vast majority of current indicators do not measure outcomes, focusing instead on structural inputs or processes of care.
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• Health care leaders should prioritize patient-reported outcome measures and patient-reported experience measures as well as health outcome metrics for assessing quality whenever possible. • Governments and organizations should track metrics frequently to assess performance and improvement over time.
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Recommendation 3-1: Build a Global Community for Digital Advances in Health and Health Care Delivery The United Nations System should convene an international task force with multisectoral representation to provide guidance to the global community on advances in digital health technologies. This task force should develop: • data standards, norms, ethical frameworks, and guidance for mod ernized regulation and human resource capacity to enable countries to better benefit from the transformative technologies in the health sector; • engineering and design standards that emphasize interoperability, human factors, and human-centered design to align technologies
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HIGH QUALITY FOR EVERYONE: MAKING INFORMAL CARE VISIBLE AND ADDRESSING CARE UNDER EXTREME ADVERSITY In many parts of the world, significant proportions of the population choose to seek care in the informal sector, either because they lack access to formal health care providers or, sometimes, because they do not trust the formal system. For millions of people -- in some countries more than 75 percent of the nation's population -- this means receiving care from providers who lack formal training but are often well known in the community.
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Recommendation 5-1: Incorporate the Informal Care Sector in the Pursuit of Improved Care Delivery Country governments should integrate informal care providers into their national health strategies and quality monitoring and improve ment efforts. To this end, they should acknowledge that these informal providers exist and undertake efforts to assess and improve the care they provide, such as through education, training, and incentives, to the full extent possible.
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• Multilateral organizations and the United Nations System should create multistakeholder collaborations for purposes of review ing and vetting the available evidence; developing consensus on promising interventions for improvement; and identifying issues of leadership and accountability for quality of care in particular circumstances, such as conflict zones, humanitarian crises, and fragile states. THE ADVERSE IMPACTS OF CORRUPTION Corruption, in all its forms, is an enormous contributor to poor quality of care worldwide.
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One of the important properties of sound systems is the capacity for improvement through learning over time. Quality, in any of its domains, is not a static property, and continual quality improvement, encompassing the processes of assessment, learning, and continual redesign, as well as the incorporation of data streams and feedback loops into current guidelines and practice, needs to be actively nurtured and intentionally maintained in organizations that seek always to do better.
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This need has become even more acute with the shift in the global burden of disease toward chronic illnesses and conditions associated with aging, which beg for attention to patient journeys over time and space. A culture of continual improvement (adopting bold aims for improvement, guided by systems thinking, continual learning, and innovation and devoted to redesign and implementation guided by new design principles)
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With proper methods and leadership, improvement can soar. Recommendation 8-1: Encourage a Culture of Learning to Fundamen tally Redesign Health Care Health care leaders in all settings should master and adopt the vision and culture of a learning health care system, striving for continual learning and avoiding an approach that relies primarily on blame and shame.
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• What are the roles of various actors in quality management across LMICs? • Which digital health technologies can best contribute to better quality of care in resource-constrained settings?
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• What strategies can reduce overuse of health care services in low resource settings, especially when regulatory capacity is limited or absent? • How can strategic purchasing best help improve the quality of care delivery?
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The longer-term promise of fully transformed care, technological modernization, and personalized care may as yet be far out of reach for some, but the first steps are not. As the momentum for UHC continues, so, too, is it time to seek quality care for all.
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