Committee on Improving the Quality of Health Care Globally
Board on Global Health
Board on Health Care Services
Health and Medicine Division
A Consensus Study Report of
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This activity was supported by contracts between the National Academy of Sciences and the Institute of Global Health Innovation at Imperial College London, Johnson & Johnson, Medtronic Foundation, National Institutes of Health, U.S. Agency for International Development, U.S. President’s Emergency Plan for AIDS Relief, and Wellcome Trust. Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project.
International Standard Book Number-13: 978-0-309-47789-5
International Standard Book Number-10: 0-309-47789-1
Digital Object Identifier: https://doi.org/10.17226/25152
Library of Congress Control Number: 2018959710
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Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2018. Crossing the global quality chasm: Improving health care worldwide. Washington, DC: The National Academies Press. doi: https://doi.org/10.17226/25152.
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COMITTEE ON IMPROVING THE QUALITY OF HEALTH CARE GLOBALLY
DONALD M. BERWICK (Co-Chair), Institute for Healthcare Improvement, Boston, Massachusetts
SANIA NISHTAR (Co-Chair), Heartfile, Islamabad, Pakistan
ANN AERTS, Novartis Foundation, Brussels, Belgium
MOHAMMED K. ALI, Emory University, Atlanta, Georgia
PASCALE CARAYON, University of Wisconsin–Madison
MARGARET AMANUA CHINBUAH, PATH, Accra, Ghana
MARIO ROBERTO DAL POZ, Instituto de Medicina Social, UERJ, Human Resources for Health, Rio de Janeiro, Brazil
ASHISH JHA, Harvard Global Health Institute, Harvard T.H. Chan School of Public Health, Harvard Medical School, Boston, Massachusetts
SHEILA LEATHERMAN, Gillings School of Global Public Health, University of North Carolina at Chapel Hill
TIANJING LI, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
VINCENT OKUNGU, PharmAccess, Nairobi, Kenya
NEERAJ SOOD, Sol Price School of Public Policy, University of Southern California, Los Angeles, California
JEANETTE VEGA, Chilean National Health Fund, Santiago, Chile
MARCEL YOTEBIENG, College of Public Health, Ohio State University, Columbus, Ohio; and University of Kinshasa, Democratic Republic of Congo
MEGAN SNAIR, Study Director (through July 2018)
EESHAN KHANDEKAR, Research Associate
SARAH ANNE NEW, Senior Program Assistant
JULIE PAVLIN, Director, Board on Global Health, and Study Director (from August 2018)
SHARYL NASS, Director, Board on Health Care Services
RONA BRIERE, Arlington, Virginia
JENNIE KWON, National Academy of Medicine Fellow, St. Louis, Missouri
IRENE PAPANICOLAS, Department of Health Policy, London School of Economics, London, United Kingdom; Harvard Global Health Institute, Boston, Massachusetts
LIANA WOSKIE, Harvard Global Health Institute, Boston, Massachusetts
This Consensus Study Report was reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the National Academies of Sciences, Engineering, and Medicine in making each published report as sound as possible and to ensure that it meets the institutional standards for quality, 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 thank the following individuals for their review of this report:
Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations of this report, nor did they see the final draft before its release. The review of this report was overseen by ENRIQUETA C. BOND, Burroughs Wellcome Fund Partner, and BRADFORD H. GRAY, Urban Institute. They were responsible for making certain that an independent examination of this report was carried out in accordance with the standards of the National Academies and that all review comments were carefully considered. Responsibility for the final content rests entirely with the authoring committee and the National Academies.
This report minces no words about the magnitude and costs of the “global quality chasm.” Although evidence is scattered and incomplete, the conclusion is inescapable: For billions of people, universal health coverage—the important mainstay of the World Health Organization’s (WHO’s) Sustainable Development Goal (SDG) 3—will be an empty vessel unless and until quality improvement, for all nations, becomes as central an agenda as universal health coverage itself. In view of the immense dedication and effort of tens of millions of health care workers worldwide, often against massive obstacles of resource limitations, political and social fragmentation, corruption, collusion, and even threats to personal security, the central assertion that the current system too often fails to provide high-quality care is not to be made lightly or with disrespect. The study committee vehemently rejects the idea that the workforce is generally at fault, neglectful, or uncaring. On the contrary, without doubt, they deserve credit and the world’s gratitude for a large proportion of the extraordinary progress in population health of the Millennium Development Goal (MDG) and early SDG eras.
What we do believe, informed by the guiding intellectual framework of this report—“systems thinking”—is that many of these workers, the would-be healers of the world, are ill served by being embedded in and dependent on systems of care that impede excellence rather than supporting it, and that drain their energy rather than nurturing it. Systemic conditions—such as fragmentation, malaligned payment, unclear goals, poor training, unreliable supply chains, burdensome rules, inadequate information flows, lack of
useful data, corruption, and fear—prevent even the most willing workforce from carrying out its daily tasks successfully and contributing to the success of the whole system. As a result, patients suffer needlessly; communities squander scarce resources; and the workforce itself becomes frustrated and exhausted as a part of the ill-functioning system.
The good news in this report is that all these problems are remediable—indeed, preventable. Foundational, of course, are adequate social investments in health care supplies, personnel, equipment, and space; these are preconditions for excellence. But alone, they do not assure excellence. To mobilize change, system leaders must reassess values, principles, and systems designs. Even in wealthy settings, where resources are abundant, quality can and does fail because of improper care designs and poor systemic conditions, such as those listed above. Keys to success, given adequate resources, lie in modern, evidence-based methods of quality assurance and improvement. They also lie in full-hearted embrace of the new digital age of medical care, and in making sure that the well-being of patients and the integrity of their care journeys are the compass bearings for all that we do. It is leaders, above all, who have the opportunity and responsibility to nurture those methods and to continually reinforce those aims.
The committee is convinced, after 1 year of study and reflection, that these values—especially person-centered care—and these systems-based methods hold as much promise in low- and middle-income settings as in wealthy ones. This report sets out an agenda for action on policy, management, and clinical care that, we believe, can deliver far better outcomes for the people who depend on us and far more satisfying and respectful conditions of work for those who try to help.
This report joins two others from important organizations: one from a consortium of WHO, the World Bank, and the Organisation for Economic Co-operation and Development, and another from The Lancet Global Health Commission on High-Quality Health Systems in the SDG Era. Together, this report and these two sibling efforts offer the entire global health community evidence-based guidance and, we hope, further motivation to engage in comprehensive health care redesign in pursuit of continual quality improvement as a priority equal to what is now, happily, assigned to universal health coverage. The combination can save lives, financial resources, and pride and joy in the workforce, all at the same time.
If 2018 has been a year of study and reports on quality, let 2019 and beyond be an era of action on quality.
Donald M. Berwick, Co-Chair
Sania Nishtar, Co-Chair
Committee on Improving the Quality of Health Care Globally
This Consensus Study Report would not have been possible without the invaluable contributions from many experts and stakeholders dedicated to global health. The committee would like to thank all of the speakers (whose full names and affiliations are found in Appendix A) and participants who played a role in the public workshops conducted for this study, as well as the many others who provided valued insight and responded to rapid requests for information to accommodate our short and demanding timeline. Many of these contributors are listed below:
Joseph Ali, Johns Hopkins Berman Institute of Bioethics
Gerald Bloom, Institute of Development Studies
Kathryn Coburn, Murphy Cooke Kobrick
Mohammed Dalwai, Open Medicine
Ara Darzi, Imperial College London
Wen Dombrowski, Catalaize
Kate Ettinger, Mural Institute
Kelsey Flott, Imperial College London
Gianluca Fontana, Imperial College London
Isaac Holeman, Medic Mobile
Benoit Kebela Ilunga, Ministry of Health, Democratic Republic of the Congo (DRC)
Alain Kakule, Ministry of Health, DRC
Edward Kamnuhangire, Ministry of Health, Rwanda
Yaseen Khan, Open Medicine
Nardo Manaloto, Catalaize
Emmanuel Manazikira, Gisenyi Hospital, Rwanda
Monique Mrazek, International Finance Corporation (IFC)
Kambale Mughuma Joachim, Ministry of Health, DRC
Kanza Muhindo K. Eric, Ministry of Health, DRC
Solange Mukuayiranga, Gisenyi Hospital, Rwanda
Camila Murga, Hospital Italiano de Buenos Aires
Kasareka Murotso Pius, Ministry of Health, DRC
Zuberi Muvunyi, Ministry of Health, Rwanda
Isaac Muyonga, ComBaptist at the Center of Africa
Nathalie Umutoni, Ministry of Health, Rwanda
Sam Wambugu, ICF International
The committee would also like to thank the sponsors of this study for their generous financial support: Johnson & Johnson, National Institutes of Health, U.S. Agency for International Development, and U.S. President’s Emergency Plan for AIDS with additional support from the Institute of Global Health Innovation at Imperial College London, Medtronic Foundation, and Wellcome Trust. A special thanks and acknowledgment go to the Institute of Global Health Innovation and the National Institute for Health Research Imperial Patient Safety Translational Research Centre for its time and intellectual contribution in planning the committee’s March meeting on the future of health care. We also thank Peter Buckle and colleagues for their white paper testimony on the role of human factors and Alain Labrique for his paper on technology and the future of health care; special thanks also goes to the Harvard Global Health Institute’s Initiative on Global Health Quality for the analysis estimating the burden of poor quality health care and its economic consequences.
Finally, deep appreciation goes to staff at the National Academies of Sciences, Engineering, and Medicine for their efforts and support in the report process: Lauren Shern and Maryjo Oster on the Report Review Committee; Greta Gorman and Tina Ritter in the Communications office; Rebecca Morgan and Jorge Torres-Mendoza at the Research Center for their assistance in fact checking the report; and Victor Dzau for his assistance in and support of the project.
PART I: THE IDEAL VISION FOR FUTURE HEALTH CARE
PART II: THE CURRENT STATE OF QUALITY IN HEALTH CARE
PART III: THE PATH TO CONTINUAL GLOBAL IMPROVEMENT
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Boxes, Figures, and Tables
|ACT||artemisinin-based combination therapy|
|ADDO||Accredited Drug Dispensing Outlet|
|AFRO||African Regional Office (WHO)|
|AGP||Abel Gilbert Pontón|
|AMI||acute myocardial infarction|
|ASHA||accredited social health activist|
|BMAT||BioMedical Admissions Test|
|BMI||body mass index|
|BPHS||Basic Package of Health Services|
|CBHI||Community-Based Health Insurance|
|CDS||clinical decision support|
|CHW||community health worker|
|CIN||Clinical Information Network|
|COPD||chronic obstructive pulmonary disease|
|CRISPR||clustered regularly interspaced short palindromic repeats|
|DALY||disability-adjusted life year|
|DHS||Demographic and Health Surveys|
|DRC||Democratic Republic of the Congo|
|EHIS||electronic health information system|
|EHR||electronic health record|
|EMRO||Eastern Mediterranean Regional Office (WHO)|
|FDA||U.S. Food and Drug Administration|
|FHS||Family Health Strategy|
|FMOH||Federal Ministry of Health|
|FSI||Fragile States Index|
|GBD||Global Burden of Disease|
|GDP||gross domestic product|
|GPW||General Program of Work|
|HCAC||Health Care Accreditation Council|
|HDA||Health Development Army|
|HEW||Health Extension Worker|
|HFE||human factors and ergonomics|
|HIV/AIDS||human immunodeficiency virus/acquired immunodeficiency syndrome|
|HMC||Hamad Medical Corporation|
|ICHOM||International Consortium for Health Outcomes Measurement|
|ICT||information and communication technology|
|IDB||International Development Bank|
|IOM||Institute of Medicine|
|ISIS||Islamic State in Iraq and Syria|
|ISO||International Organization for Standardization|
|ITU||International Telecommunication Union|
|JICA||Japan International Cooperation Agency|
|LHCS||learning health care system|
|LMIC||low- and middle-income country|
|MCH||maternal and child health|
|MDG||Millennium Development Goal|
|MESH MH||Mentoring and Enhanced Supervision at Health Centers for Mental Health|
|MOH||ministry of health|
|NAM||National Academy of Medicine|
|NICU||neonatal intensive care unit|
|NIH||National Institutes of Health|
|NPR||National Public Radio|
|NQPS||National Quality Policy and Strategy|
|NQS||National Quality Strategy|
|OECD||Organisation for Economic Co-operation and Development|
|ORS||oral rehydration salt|
|ORT||oral rehydration therapy|
|P4P||pay for performance|
|PHA||Private Hospital Association|
|PREM||patient-reported experience measure|
|PRI||Panchayati Raj Institution|
|PROM||patient-reported outcome measure|
|PTSD||posttraumatic stress disorder|
|QEWS||Qatar Early Warning System|
|RCT||randomized controlled trial|
|RSBY||Rashtriya Swasthya Bima Yojana|
|SDG||Sustainable Development Goal|
|SEIPS||Systems Engineering Initiative for Patient Safety|
|TBA||traditional birth attendant|
|UHC||universal health coverage|
|VAS||Vajpayee Arogyashree Scheme|
|WHO||World Health Organization|
|YLD||years of life lived with disability|
|YLL||years of life lost|