Week 8: Week 8: Reflection on Achievement of Outcomes
Purpose
The final week will focus on Global Policy Reform and the impact on patient care. Students read the Berwick article and respond to the required discussions. In addition, students reflect on what they have learned in NR506NP and how it is applicable to their upcoming clinical courses.
Activity Learning Outcomes
Through this discussion, the student will demonstrate the ability to:
1. Understand the role of advanced practice nursing in the International Context (CO2)
2. Research global aspects of healthcare and the effect on the US healthcare system (CO5)
3. Discuss the implications of global health on your clinical practice (CO5)
Requirements:
Berwick, D., Snair, M., & Nishtar, S. (2018). Crossing the global health care quality chasm: A key component of universal health coverage. Journal of American Medical Association, 320(13), 1317-1318.
Read the Berwick article and reflect on the concepts and practices you have learned in NR506 on healthcare systems, politics, and health policy. Reflections should include:
1. How to make informed decisions on nursing practice and patient outcomes on a global basis. In addition, state how you will apply what you have learned in this course to your upcoming practicum experience.
2. Describe how one will apply content from NR506NP to the upcoming clinical courses.
DISCUSSION CONTENT
Category Points % Description
Making informed decisions 40 40% Provides relevant evidence of scholarly inquiry sharing insights as how to make informed decisions on nursing practice and patient outcomes on a global basis. Uses valid, relevant, and reliable outside sources to contribute to the threaded discussion.
Application to Clinical Practice 35 35% Provides relevant evidence of scholarly inquiry stating how one may apply content learned in this course to future clinical practice. Uses valid, relevant, and reliable outside sources to contribute to the threaded discussion.
Total CONTENT Points= 75 pts
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
manydefectspersistandthatthe“qualitychasm”isglobal.
TheNationalAcademiesofSciences,Engineering,and
Medicine (NASEM) has issued another report on global
health care quality, with an emphasis on low-resource set-
tings:CrossingtheGlobalQualityChasm:ImprovingHealth
CareWorldwide.Thecommitteeincludedscholarsandlead-
ersfromnationsacrossthespectrumofwealth.1 Thisreport
joins 2 recent analyses of problems in global health care
quality.3 Thereportstatesthatwithoutcorrectionofdefects
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.
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’spopulation,insomenationsexceeding75%ofallcare.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.
Copyright of JAMA: Journal of the American Medical Association is the property of
American Medical Association and its content may not be copied or emailed to multiple sites
or posted to a listserv without the copyright holder\’s express written permission. However,
users may print, download, or email articles for individual us
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