Discussion

Crossing the Global Health Care Quality Chasm A Key Component of Universal Health Coverage

Despite years of investment and research, the quality of health care in every country is much worse than it should be. Problems range from disrespect of people when they are interacting with the health care system, to preventable mistakes and harm, to high rates of in- correct and ineffective treatment.

Among low- and middle-income countries (LMICs) the exact burden of poor quality is difficult to quantify because of a dearth of data, lack of standard metrics, and insufficient research on quality interventions. But new estimates suggest that globally between 5.7 and 8.4 mil- lion people die every year from poor-quality care in LMICs.1 These deaths, plus disabilities from poor- quality care, account for lost productivity totaling an es- timated $1.4 trillion to $1.6 trillion dollars annually.1

Wealthier countries have similar experiences in terms of death, disability, and needless cost due to frag- mented care, waste, and care organized around facili- ties instead of patients. One estimate suggests that 15% of all hospital costs in Organisation for Economic Co-operation and Development (OECD) countries can be attributed to patient harms from adverse events.2

In 2001, the Institute of Medicine published a land- mark report on the quality of US health care: Crossing the Quality Chasm: A New Health System for the 21st Cen- tury. The report starkly documented major defects in 6 dimensions of quality: safety, effectiveness, patient- centeredness, timeliness, efficiency, and equity. In the nearly 2 decades since, reports have demonstrated that many defects persist and that the “quality chasm” is global.

TheNationalAcademiesofSciences,Engineering,and Medicine (NASEM) has issued another report on global health care quality, with an emphasis on low-resource set- tings: Crossing the Global Quality Chasm: Improving Health CareWorldwide.Thecommitteeincludedscholarsandlead- ersfromnationsacrossthespectrumofwealth.1 Thisreport joins 2 recent analyses of problems in global health care quality.3Thereportstatesthatwithoutcorrectionofdefects in health care quality, especially in LMICs, universal health coverage, a key component of WHO’s Sustainable Devel- opment Goals,4 will give many people access to care that will not help them and may even be harmful.

Yet there is reason for hope: momentum and com- mitment by the global community to achieve universal health coverage offer an opportunity for nations to im- prove the quality of care while they broaden access. But this will not happen automatically; so far, many nations seem to be focused on expanding access only. Equity and quality of care will arrive together, or not at all.

Embracing Systems Design in Health Care The report espouses an emerging, idealized vision of health care that reflects systems thinking and adopts

fundamental principles of design and human factors. The route to improvement places the “user”—patient, indi- vidual, community—at the center. This report recom- mends design principles that include full transparency; co- design with users, staff, and communities; care that is anticipatory, not merely reactive; care reflective of soci- etal values; and care that bases decisions on clear evi- dence, continuous feedback, and learning (Box).

Redesign like this is evident, for example, in Kenya’s Clinical Information Network, which was developed in 2013 as a mechanism to promote continuing improve- ment. Their leaders understand that health care is a com- plex adaptive system that requires multidisciplinary work, soft skills, and flexibility for ongoing change.5

The NASEM report’s idealized system empowers health care workers to solve problems at the front lines of care and integrates and coordinates care across the pa- tient’s “journey.” Adherence to these principles supports a “learning health care system”—one that learns from both successes and failures and encourages innovation. This culture of continuous learning demands strong leader- ship, commitment, cooperation, and feedback to con- tinually update policies, protocols, and systems.

Leveraging Universal Health Coverage The path to achieving effective universal health cov- erage will be different for every country, but existing levers can be used in almost any setting to ensure and improve quality. Common levers include financial mechanisms (such as accreditation, strategic purchasing, and pay-for- performance schemes), policy mechanisms (such as pub- licreportingandastrongcommitmenttoinvolvingpatients andcommunitiesinhealthsystemdesignandgovernance), andtechnicalmechanisms(suchasclinicaldecisionsupport, health literacy outreach, and workforce training).

A System of the Future Billions of people already have access to cell phones and the internet. Forty-seven of the least-developed coun- tries have launched 3G services and are on track to meet Sustainable Development Goal 9 of universal and af- fordable internet access by 2020.6 The speed at which digital capacity is increasing offers unprecedented op- portunities to usher in a transformation.

This proliferation of infrastructure, coupled with ad- vances in software and the capacity of the digital “cloud,” allows users of care to become more actively involved in the decision-making that affects their health. They can ac- cess their health care records from their phone and com- municate with clinicians through a variety of virtual chan- nels, such as telemedicine, email, and social media. As of 2017, the WeChat app in China had been enabled in more than 38 000 medical facilities, allowing patients to view

VIEWPOINT

Donald Berwick, MD Institute for Healthcare Improvement (IHI), Editorial Affairs, Boston, Massachusetts.

Megan Snair, MPH Center for Populations Health Research, Cleveland Clinic, Cleveland, Ohio.

Sania Nishtar, PhD, FRCP Heartfile, Islamabad, Pakistan.

Corresponding Author: Donald Berwick, MD, Institute for Healthcare Improvement (IHI), Editorial Affairs, 53 State St, 19th Floor, Boston, MA 02109 (donberwick@gmail .com).

Opinion

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their medical records, schedule appointments, and pay bills from their phones, positively affecting national challenges of fragmentation and wait times.7 These technological changes, as well as the expansion of the roles of trained community health workers, can help care be- come more anticipatory, person-centered, and preventive. Primary care services can be delivered in the community, and the system can be far more responsive to the substantial global increase in noncom- municable diseases.

But this promising technological future is not without peril and cannot be guaranteed everywhere. Many countries lack the regu- latory environment to ensure patient safety, achieve equity, and avoid institutional bias in the digital era. Governments and organiza- tional leaders need to initiate new educational curricula to better equip the workforce for this emerging surge of digital care.

Formidable Problems in the Current System Compounding the typical challenges of the current complex health care systems in many countries are 3 additional, formidable issues.

First, informal health workers (ie, those without formal training, licensing, or supervision) provide care to large proportions of the

world’s population, in some nations exceeding 75% of all care.8 Though the informal health sector provides many benefits in areas where health care is difficult to access, it also brings risks. These workers typi- cally operate outside formal and regulated health care systems, so the care they give is usually not measured, accountable, or coordinated with other providers. To raise overall quality of care, governments should acknowledge the numerous interactions of informal health workers and work actively to assess and improve their care.

Second, people living in fragile states and contexts of humani- tarian crisis may lack health care entirely. The austerity of the set- tings makes it difficult, if not impossible, to provide continuity, needed referrals, or even basic treatment. Nearly 2 billion people live in these environments of extreme adversity, but little research has been done to elucidate the state of quality or the interventions that work best in these settings. Efforts to understand and improve qual- ity under extreme adversity should become a priority worldwide.

Third, corruption and institutionalized collusion plague the health care sector across the world, with estimates that $455 bil- lion of the $7.35 trillion spent annually on health care is lost to fraud or abuse.9 The NASEM report states that integrity, if not a dimen- sion of quality, is an essential precondition of health care quality. In the pursuit of universal quality care it is critical for governments and societies to create better governance structures that are account- able and transparent, and to fund health systems well enough to de- crease reliance on and tolerance of corruption.

Research Needs Enormous gaps exist in the needed research base for addressing qual- ity improvement, especially with respect to LMIC settings, making it difficult to recommend prioritized approaches. A broad research agenda is needed, including rigorous clinical trials and primary re- search and also implementation research. The diversity of environ- ments in low-resource settings, and across countries of all income levels, demands that interventions be contextualized and vali- dated locally before they are deployed at a larger scale.

Conclusions The welcome commitment to universal health coverage needs a par- allel and equally intense commitment around the world, from gov- ernments and the private sector alike, to the ambitious and con- tinual improvement of the quality of care. This can be achieved, but it will require the redesign of health care systems and new think- ing, if humankind is to benefit not just from access to care, but ac- cess to care that can help and heal them.

ARTICLE INFORMATION

Published Online: August 31, 2018. doi:10.1001/jama.2018.13696

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Drs Berwick and Nishtar served as co-chairs of the NASEM committee whose work is summarized in this article. No other disclosures were reported.

Additional Contributions: We thank the NASEM committee for their invaluable input to this project: Donald Berwick, Sania Nishtar, Sheila Leatherman, Ashish Jha, Neeraj Sood, Pascale Carayon, Margaret Amanua Chinbuah, Vincent Okungu, Marcel Yotebieng, Tianjing Li, Mohammed K. Ali, Mario dal Poz, Jeanette Vega, and Ann Aerts.

REFERENCES

1. National Academies of Sciences, Engineering, and Medicine. Crossing the Global Quality Chasm: Improving Health Care Worldwide. August 28, 2018. doi:10.17226/25152

2. Slawomirski L, Auraaen A, Klazinga N. The economics of patient safety. Paris, France: OECD Publishing; 2017.

3. Berwick DM, Kelley E, Kruk ME, et al. Three global health-care quality reports in 2018. Lancet. 2018;392(10143):194-195.

4. SDG3: Ensure healthy lives and promote wellbeing for all at all ages. http://www.who.int/sdg /targets/en/. Accessed August 17, 2018.

5. Irimu G, Ogero M, Mbevi G, et al. Approaching quality improvement at scale: a learning health system approach in Kenya. Arch Dis Child. 2018. doi:10.1136/archdischild-2017-314348

6. ICTs, LDCs, and the SDGs: Achieving Universal and Affordable Internet in the Least Developed Countries. https://www.itu.int/en/ITU-D/LDCs /Pages/ICTs-for-SDGs-in-LDCs-Report.aspx. 2018.

7. Lew L. How Tencent's medical ecosystem is shaping the future of China's healthcare. https://technode.com /2018/02/11/tencent-medical-ecosystem/. 2018.

8. Sudhinaraset M, Ingram M, Lofthouse HK, Montagu D. What is the role of informal healthcare providers in developing countries? PLoS One. 2013;8(2):e54978.

9. Gee J, Button M. The Financial Cost of Fraud. London, UK: PKF Littlejohn; 2015.

Box. Design Principles From Crossing the Global Quality Chasm1

1. Systems thinking drives the transformation and continual improvement of care delivery.

2. Care delivery prioritizes the needs of patients, health care staff, and the larger community.

3. Decision making is evidence-based and context-specific. 4. Trade-offs in health care reflect societal values and priorities. 5. Care is integrated and coordinated across the patient journey. 6. Care makes optimal use of technologies to be anticipatory and

predictive at all system levels. 7. Leadership, policy, culture, and incentives are aligned at all

system levels to achieve quality aims and promote integrity, stewardship, and accountability.

8. Navigating the care delivery system is transparent and easy. 9. Problems are addressed at the source, and patients and health

care staff are empowered to solve them. 10. Patients and health care staff co-design the transformation of

care delivery and engage together in continual improvement. 11. The transformation of care delivery is driven by continuous

feedback, learning, and improvement. 12. The transformation of care delivery is a multidisciplinary

process with adequate resources and support. 13. Thetransformationofcaredeliveryissupportedbyinvestedleaders.

Opinion Viewpoint

1318 JAMA October 2, 2018 Volume 320, Number 13 (Reprinted) jama.com

© 2018 American Medical Association. All rights reserved.

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Crossing the Global Health Care Quality Chasm A Key Component of Universal Health Coverage

Despite years of investment and research, the quality of health care in every country is much worse than it should be. Problems range from disrespect of people when they are interacting with the health care system, to preventable mistakes and harm, to high rates of in- correct and ineffective treatment.

Among low- and middle-income countries (LMICs) the exact burden of poor quality is difficult to quantify because of a dearth of data, lack of standard metrics, and insufficient research on quality interventions. But new estimates suggest that globally between 5.7 and 8.4 mil- lion people die every year from poor-quality care in LMICs.1 These deaths, plus disabilities from poor- quality care, account for lost productivity totaling an es- timated $1.4 trillion to $1.6 trillion dollars annually.1

Wealthier countries have similar experiences in terms of death, disability, and needless cost due to frag- mented care, waste, and care organized around facili- ties instead of patients. One estimate suggests that 15% of all hospital costs in Organisation for Economic Co-operation and Development (OECD) countries can be attributed to patient harms from adverse events.2

In 2001, the Institute of Medicine published a land- mark report on the quality of US health care: Crossing the Quality Chasm: A New Health System for the 21st Cen- tury. The report starkly documented major defects in 6 dimensions of quality: safety, effectiveness, patient- centeredness, timeliness, efficiency, and equity. In the nearly 2 decades since, reports have demonstrated that many defects persist and that the “quality chasm” is global.

TheNationalAcademiesofSciences,Engineering,and Medicine (NASEM) has issued another report on global health care quality, with an emphasis on low-resource set- tings: Crossing the Global Quality Chasm: Improving Health CareWorldwide.Thecommitteeincludedscholarsandlead- ersfromnationsacrossthespectrumofwealth.1 Thisreport joins 2 recent analyses of problems in global health care quality.3Thereportstatesthatwithoutcorrectionofdefects in health care quality, especially in LMICs, universal health coverage, a key component of WHO’s Sustainable Devel- opment Goals,4 will give many people access to care that will not help them and may even be harmful.

Yet there is reason for hope: momentum and com- mitment by the global community to achieve universal health coverage offer an opportunity for nations to im- prove the quality of care while they broaden access. But this will not happen automatically; so far, many nations seem to be focused on expanding access only. Equity and quality of care will arrive together, or not at all.

Embracing Systems Design in Health Care The report espouses an emerging, idealized vision of health care that reflects systems thinking and adopts

fundamental principles of design and human factors. The route to improvement places the “user”—patient, indi- vidual, community—at the center. This report recom- mends design principles that include full transparency; co- design with users, staff, and communities; care that is anticipatory, not merely reactive; care reflective of soci- etal values; and care that bases decisions on clear evi- dence, continuous feedback, and learning (Box).

Redesign like this is evident, for example, in Kenya’s Clinical Information Network, which was developed in 2013 as a mechanism to promote continuing improve- ment. Their leaders understand that health care is a com- plex adaptive system that requires multidisciplinary work, soft skills, and flexibility for ongoing change.5

The NASEM report’s idealized system empowers health care workers to solve problems at the front lines of care and integrates and coordinates care across the pa- tient’s “journey.” Adherence to these principles supports a “learning health care system”—one that learns from both successes and failures and encourages innovation. This culture of continuous learning demands strong leader- ship, commitment, cooperation, and feedback to con- tinually update policies, protocols, and systems.

Leveraging Universal Health Coverage The path to achieving effective universal health cov- erage will be different for every country, but existing levers can be used in almost any setting to ensure and improve quality. Common levers include financial mechanisms (such as accreditation, strategic purchasing, and pay-for- performance schemes), policy mechanisms (such as pub- licreportingandastrongcommitmenttoinvolvingpatients andcommunitiesinhealthsystemdesignandgovernance), andtechnicalmechanisms(suchasclinicaldecisionsupport, health literacy outreach, and workforce training).

A System of the Future Billions of people already have access to cell phones and the internet. Forty-seven of the least-developed coun- tries have launched 3G services and are on track to meet Sustainable Development Goal 9 of universal and af- fordable internet access by 2020.6 The speed at which digital capacity is increasing offers unprecedented op- portunities to usher in a transformation.

This proliferation of infrastructure, coupled with ad- vances in software and the capacity of the digital “cloud,” allows users of care to become more actively involved in the decision-making that affects their health. They can ac- cess their health care records from their phone and com- municate with clinicians through a variety of virtual chan- nels, such as telemedicine, email, and social media. As of 2017, the WeChat app in China had been enabled in more than 38 000 medical facilities, allowing patients to view

VIEWPOINT

Donald Berwick, MD Institute for Healthcare Improvement (IHI), Editorial Affairs, Boston, Massachusetts.

Megan Snair, MPH Center for Populations Health Research, Cleveland Clinic, Cleveland, Ohio.

Sania Nishtar, PhD, FRCP Heartfile, Islamabad, Pakistan.

Corresponding Author: Donald Berwick, MD, Institute for Healthcare Improvement (IHI), Editorial Affairs, 53 State St, 19th Floor, Boston, MA 02109 (donberwick@gmail .com).

Opinion

jama.com (Reprinted) JAMA October 2, 2018 Volume 320, Number 13 1317

© 2018 American Medical Association. All rights reserved.

Downloaded From: https://jamanetwork.com/ by a Chamberlain College of Nursing User on 10/22/2023

their medical records, schedule appointments, and pay bills from their phones, positively affecting national challenges of fragmentation and wait times.7 These technological changes, as well as the expansion of the roles of trained community health workers, can help care be- come more anticipatory, person-centered, and preventive. Primary care services can be delivered in the community, and the system can be far more responsive to the substantial global increase in noncom- municable diseases.

But this promising technological future is not without peril and cannot be guaranteed everywhere. Many countries lack the regu- latory environment to ensure patient safety, achieve equity, and avoid institutional bias in the digital era. Governments and organiza- tional leaders need to initiate new educational curricula to better equip the workforce for this emerging surge of digital care.

Formidable Problems in the Current System Compounding the typical challenges of the current complex health care systems in many countries are 3 additional, formidable issues.

First, informal health workers (ie, those without formal training, licensing, or supervision) provide care to large proportions of the

world’s population, in some nations exceeding 75% of all care.8 Though the informal health sector provides many benefits in areas where health care is difficult to access, it also brings risks. These workers typi- cally operate outside formal and regulated health care systems, so the care they give is usually not measured, accountable, or coordinated with other providers. To raise overall quality of care, governments should acknowledge the numerous interactions of informal health workers and work actively to assess and improve their care.

Second, people living in fragile states and contexts of humani- tarian crisis may lack health care entirely. The austerity of the set- tings makes it difficult, if not impossible, to provide continuity, needed referrals, or even basic treatment. Nearly 2 billion people live in these environments of extreme adversity, but little research has been done to elucidate the state of quality or the interventions that work best in these settings. Efforts to understand and improve qual- ity under extreme adversity should become a priority worldwide.

Third, corruption and institutionalized collusion plague the health care sector across the world, with estimates that $455 bil- lion of the $7.35 trillion spent annually on health care is lost to fraud or abuse.9 The NASEM report states that integrity, if not a dimen- sion of quality, is an essential precondition of health care quality. In the pursuit of universal quality care it is critical for governments and societies to create better governance structures that are account- able and transparent, and to fund health systems well enough to de- crease reliance on and tolerance of corruption.

Research Needs Enormous gaps exist in the needed research base for addressing qual- ity improvement, especially with respect to LMIC settings, making it difficult to recommend prioritized approaches. A broad research agenda is needed, including rigorous clinical trials and primary re- search and also implementation research. The diversity of environ- ments in low-resource settings, and across countries of all income levels, demands that interventions be contextualized and vali- dated locally before they are deployed at a larger scale.

Conclusions The welcome commitment to universal health coverage needs a par- allel and equally intense commitment around the world, from gov- ernments and the private sector alike, to the ambitious and con- tinual improvement of the quality of care. This can be achieved, but it will require the redesign of health care systems and new think- ing, if humankind is to benefit not just from access to care, but ac- cess to care that can help and heal them.

ARTICLE INFORMATION

Published Online: August 31, 2018. doi:10.1001/jama.2018.13696

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Drs Berwick and Nishtar served as co-chairs of the NASEM committee whose work is summarized in this article. No other disclosures were reported.

Additional Contributions: We thank the NASEM committee for their invaluable input to this project: Donald Berwick, Sania Nishtar, Sheila Leatherman, Ashish Jha, Neeraj Sood, Pascale Carayon, Margaret Amanua Chinbuah, Vincent Okungu, Marcel Yotebieng, Tianjing Li, Mohammed K. Ali, Mario dal Poz, Jeanette Vega, and Ann Aerts.

REFERENCES

1. National Academies of Sciences, Engineering, and Medicine. Crossing the Global Quality Chasm: Improving Health Care Worldwide. August 28, 2018. doi:10.17226/25152

2. Slawomirski L, Auraaen A, Klazinga N. The economics of patient safety. Paris, France: OECD Publishing; 2017.

3. Berwick DM, Kelley E, Kruk ME, et al. Three global health-care quality reports in 2018. Lancet. 2018;392(10143):194-195.

4. SDG3: Ensure healthy lives and promote wellbeing for all at all ages. http://www.who.int/sdg /targets/en/. Accessed August 17, 2018.

5. Irimu G, Ogero M, Mbevi G, et al. Approaching quality improvement at scale: a learning health system approach in Kenya. Arch Dis Child. 2018. doi:10.1136/archdischild-2017-314348

6. ICTs, LDCs, and the SDGs: Achieving Universal and Affordable Internet in the Least Developed Countries. https://www.itu.int/en/ITU-D/LDCs /Pages/ICTs-for-SDGs-in-LDCs-Report.aspx. 2018.

7. Lew L. How Tencent's medical ecosystem is shaping the future of China's healthcare. https://technode.com /2018/02/11/tencent-medical-ecosystem/. 2018.

8. Sudhinaraset M, Ingram M, Lofthouse HK, Montagu D. What is the role of informal healthcare providers in developing countries? PLoS One. 2013;8(2):e54978.

9. Gee J, Button M. The Financial Cost of Fraud. London, UK: PKF Littlejohn; 2015.

Box. Design Principles From Crossing the Global Quality Chasm1

1. Systems thinking drives the transformation and continual improvement of care delivery.

2. Care delivery prioritizes the needs of patients, health care staff, and the larger community.

3. Decision making is evidence-based and context-specific. 4. Trade-offs in health care reflect societal values and priorities. 5. Care is integrated and coordinated across the patient journey. 6. Care makes optimal use of technologies to be anticipatory and

predictive at all system levels. 7. Leadership, policy, culture, and incentives are aligned at all

system levels to achieve quality aims and promote integrity, stewardship, and accountability.

8. Navigating the care delivery system is transparent and easy. 9. Problems are addressed at the source, and patients and health

care staff are empowered to solve them. 10. Patients and health care staff co-design the transformation of

care delivery and engage together in continual improvement. 11. The transformation of care delivery is driven by continuous

feedback, learning, and improvement. 12. The transformation of care delivery is a multidisciplinary

process with adequate resources and support. 13. Thetransformationofcaredeliveryissupportedbyinvestedleaders.

Opinion Viewpoint

1318 JAMA October 2, 2018 Volume 320, Number 13 (Reprinted) jama.com

© 2018 American Medical Association. All rights reserved.

Downloaded From: https://jamanetwork.com/ by a Chamberlain College of Nursing User on 10/22/2023