Crossing the Global Quality Chasm Improving Health Care Worldwide (2018) / Chapter Skim
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8 Establishing a Culture of Continual Learning
8 Establishing a Culture of Continual Learning
Pages 269-292
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The essence of an LHCS is an organizational ecosystem that enables and encourages continual learning, information exchange, and improvement, illustrated in the third level of the committee's framework in Figure 2-2. The committee 269
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Figure 8-1 d epicts the learning cycle that characterizes an LHCS. Collecting data from routine patient care and using proper analytic techniques, learning organizations can feed back valuable and timely information to clinicians, public health officials, health care managers, and patients to help them continually improve the quality of health care (Foley and Fairmichael, 2015)
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. Conventionally, health care organizations rely on clinical research or health systems and services research to determine how to change care practices.
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. Baobab Health Baobab Health is a Malawi-based nongovernmental organization that uses tech nology and tools to improve health care for HIV treatment, antenatal care, chronic care, and trauma care.
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Baobab uses other clinical modules, such as an antenatal module, a maternity module, a diabetes and hypertension module, and a chronic care module. Each of these modules allows Baobab to collect demographic information, manage laboratory results, enhance case management and discharge, and manage chronic care needs longitudinally (Baobab Health, n.d.; Center for Health Market Innovations, 2018a)
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Benefits of a Learning Health Care System Although traditional approaches to improving health care quality, such as auditing, accreditation, inspections, and public reporting (when used in conjunction) are essential and have important and generally favorable effects on basic quality assurance (that is, reducing egregiously bad care)
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The LHCS components of real-time access to knowledge and digital capture of the care experience embody an essential feature of the future of health care envisioned by the committee: Continuous feedback and learning generates knowledge to make decision making evidence-based and locally relevant, anticipatory, and cognizant of true sources of adverse events. This vision requires knowledge that is gathered rapidly and implemented quickly.
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Full transparency A learning health system systematically monitors the safety, quality, processes, prices, costs, and outcomes of care, and makes information available for care improvement and informed choices and decision making by clinicians, patients, and their families. Continual Learning Culture Leadership-instilled culture of learning A learning health system is stewarded by leadership committed to a culture of teamwork, collaboration, and adaptability in support of continuous learning as a core aim.
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Engaged, Empowered Patients The committee has spoken repeatedly about the centrality of the patient experience, the importance of streamlining the entire patient journey, and the value of co-design and co-production of health care systems with patients and communities. A commitment to these precepts requires both culture change, to shift the balance of power between those who give and those who receive care, and practice change, to support ongoing, authentic conversations among patients, caregivers, and the organizations that serve them.
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As a result, the purposeful act of empowering and engaging patients will help create a system that is easy and transparent to navigate. Related design principles: • Care delivery prioritizes the needs of patients, health care staff, and the larger community.
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It can not only identify priority areas for focused improvement by highlighting problems, but also support identification of so-called "positive deviants,"3 organizations and systems that significantly outperform expectations. These 3 Positive deviancy denotes a behavioral and social change approach based on the observa tion that in a group or organization, individuals may use uncommon but successful strategies to deliver better solutions than their colleagues despite facing similar challenges and having no extra knowledge resources (Sternin and Coo, 2000)
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• The transformation of care delivery is driven by continuous feed back, learning, and improvement. Leadership-Instilled Culture of Learning Developing an LHCS is a structural commitment to a culture of continual learning and improvement that has implications for all parties interacting with the health care system.
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Indeed, one can find a growing number of examples in low-income settings of organizations that have begun to practice continual improvement and have reaped the benefits, as described previously in Box 8-1. Related design principles: • Leadership, policy, culture, and incentives are aligned at all system levels to achieve quality aims, and to promote integrity, steward ship, and accountability.
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• The transformation of care delivery is a multidisciplinary process with adequate resources and support. A RESEARCH AND DEVELOPMENT AGENDA Throughout this report, the committee has identified gaps in knowledge about the prevalence, patterns, costs, and causes of and remedies for quality defects in global health care.
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Instead, to support the existing and emerging learning networks and collaboratives aiming to improve health care quality, there is also great potential for bidirectional information sharing, as discussed in Chapter 1. It is increasingly recognized that while countries may be different, health challenges and populations across borders can be quite similar.
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In the future the committee envisions, in which digital health care and traditional health care as a whole increasingly overlap, measuring the impact of digital health care on health outcomes will become vital. The committee highlights the following two questions in these arenas: • What is the impact of the digitization of health care on population health outcomes?
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Research on Payment and Policy Strategies to Motivate and Support Improvement Chapters 5 and 7 identify several areas of major deficits in knowledge about strategies for improving the quality of care in specific settings and using specific levers. Chapter 5 identifies these deficits for settings of extreme adversity and for the informal sector, while Chapter 7 highlights uncertainties about the effects of policy and payment tools and raises questions about the roles that patients could play in demanding improvements in health care quality.
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SUMMARY AND RECOMMENDATIONS The basic technical principles of systems thinking, quality improvement, and a learning organization are generic in that they apply to improvement at all levels and in all sizes of systems, from very local enterprises, such as one's chess game or weaving, to very large-scale enterprises, such as national policy frameworks or the strategy of corporations. In the case of health care quality, this means the same approaches that can help improve antibiotic use in a clinic or pain control in surgery can also be used at the level of health care policy and finance.
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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
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• Leaders should ensure that health care systems harness new digital health technology to help reduce costs and improve care through real-time use of data. Conclusion: There is a clear need for a much more locally relevant, robust research agenda related to quality of care.
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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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2016. Building learning health systems to accelerate research and improve outcomes of clinical care in low- and middle-income countries.
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2002. Identification of model newborn care practices through a positive deviance inquiry to guide behavior-change interventions in Haripur, Pakistan.
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2018. Delivering quality health services: A global im perative for universal health coverage.
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