Crossing the Global Quality Chasm (Aug 2018)

The National Academies of Sciences, Engineering, and Medicine undertook a study to examine the global impacts of poor-quality health care and to recommend ways to improve quality while expanding UHC, particularly in low-resource areas.

The resulting report, Crossing the Global Quality Chasm: Improving Health Care Worldwide; the report calling attention to the gaps in health care quality that still remain globally and suggesting approaches to bridge them.

The Scope of the Problem

Defects in health care quality deny many people and communities the benefits of effective care. In LMICs, 134 million adverse events (one form of poor-quality care) occur in hospitals each year, contributing to 2.5 million deaths annually.

The problem is by no means limited to LMICs: Studies from the United States, the United Kingdom, and elsewhere reveal similar deficiencies.

Thus, even when people can receive care, quality problems are widespread. For instance, one study found that providers adhered to August 2018 evidence-based treatment for such conditions as asthma, chest pain, diarrhea, and tuberculosis only 25 to 50 percent of the time.

High levels of excessive and inappropriate care are also pervasive. In the United States, for example, 30 percent of estimated prescriptions for antibiotics are found to be unnecessary, posing risk to patients and contributing to the global problem of antimicrobial resistance.

The Committee’s Recommendations

The Committee on Improving the Quality of Health Care Globally has the following recommendation :

Improving the quality of healthcare will require investment, responsibility, and accountability on the part of health system leaders.

This should be the daily work and constant responsibility of all health care leaders, including ministers of health.

Embracing principles of transparency, accountability, continual learning, and health system−patient co-design, countries will need to work with patients to design health system strategies, policies, and clinical care delivery, as well as mechanisms for monitoring, evaluating, and reporting progress.

A system thinking and person-centered approach should inform the redesign of health care systems, with a focus on the needs of the patient.

It is crucial to examine each level of a healthcare system the environment, the organization, the front line care delivery, and the patient—and how they interact and either help or inhibit one another.

Appropriate, meaningful metrics—including patient- and population-based outcome data—should be captured to understand the quality of care and inform improvements.

Beyond commitment and strategy development, implementation is key. As countries move toward UHC, governments can use specific mechanisms, such as strategic purchasing or selective contracting, to only purchase services from health facilities that are providing high-quality health care.

Due to an explosion of digital health technologies, health care systems of the future will differ radically from those of the past.

As such, health systems need to embrace emerging technologies, guided by a vision of patient care that is anticipatory rather than reactive; thoroughly integrated across time and space; and wholly centered on continually improving the experience of patients, families, and communities.

A shift in care delivered directly to people wherever they are—in schools or in homes—will require new skills, attitudes, and culture among healthcare providers.

It will also necessitate new, multi-sector governance mechanisms and regulatory oversight appropriate for these new technologies.

In many parts of the world, people seek care outside of the formal health system, from the so-called “informal sector,” in which care may not be regulated, measured, or coordinated.

All told, alternative care systems subject billions of people to care of largely unknown quality.

Governments should assess and integrate informal providers into national health strategies in the pursuit of improved quality.

In addition, settings of extreme adversity, such as conflict zones, failed states, and refugee camps, pose severe quality challenges.

Research on these settings should be a priority for governments, NGOs, and donors, to identify common quality problems, and to tailor and quickly implement improvement strategies to reduce both preventable deaths and the waste of scarce resources.

To achieve the needed improvements in health care quality in all settings, healthcare leaders should strive towards the vision and creation of a learning health care system: one that adopts bold aims for iterative improvement, is guided by systems thinking, and fosters a culture of continual learning and feedback.

Unless nations and their leaders adopt a philosophy that improvement depends on learning, progress toward a future of high-quality health care will be slow.


National Academies of Sciences . Engineering . Medicine

Crossing the Global Quality Chasm, Improving Health Care Worldwide, Consensus Study Report, Aug 2018

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Dr. Khalid Abulmajd

Healthcare Quality Consultant

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