Help more than hurt. Choose partnerships over charity. Create sustainable solutions rather than temporary relief. These are familiar themes at global health conferences around the world. Interestingly this month’s issue of Lancet Global Health features a work by Kruk et al that draws us to consider, Quality Improvement (QI). U.S. institutions are placing an ever increasing emphasis on QI. Even my own training institution has developed a “QI pathway” for interested residents. Kruk et al propose the need for a Quality Revolution in Global health and indeed a focus on providing quality care aligns well with many of the aforementioned popular themes of today’s global health discussion. It isn’t just about being there anymore, but on finding ways to ensure that the care provided is truly improving health outcomes in the world’s most under resourced populations. Since the Institute of Healthcare Improvement’s (IHI) landmark To Err is Human study from 1999 the IHI has developed six principles that they believe should be used to guide health systems and improve quality. They ask for care that is safe, effective, patient centered, timely, efficient, and equitable. Kruk et al sought to apply these quality dimensions to countries in sub-Saharan Africa with outcomes they felt were reflective of one of these six dimensions. For example in “safety” they chose a metric like “facility has water on site nearby” or “effective” metrics like how many women aged 18-69 had received a pelvic exam. They highlight that only 18% of women received a pelvic exam. Does this mean care for these women was not effective? I’d be interested to learn how many of those lucky 18 of 100 women had access to treatments that an abnormal pelvic exam would demand. Is simply getting a pelvic exam a measure of effectiveness or is it more similar to a women’s health clinic that only gets pelvic exams on 18% of women? Examples like this shows just how difficult measuring the quality of a health system can be. We must choose metrics that when improved will lead to better care. Perhaps practitioners in these clinics weren’t resourced with the solutions to the pathology they might find. Would I want to screen a woman for a cancer I had no treatment for? One area of quality care across institutions in the U.S. is a well-documented code status. The idea is to prevent an invasive and painful attempt to save a life that may be against the patient’s wishes, beliefs, or clinical situation. As I write this one of my night float colleagues is surely trying to discuss the code status with a recently admitted patient. This patient is inevitably tired from the day in the ED, likely feeling very ill or in pain, has met six doctors for the first time today and now the seventh is asking them very quickly “what would you like us do if your heart stopped?” For many patients this is first time they’ve been asked this question. Yet, every patient will have a verified code status by the time I arrive tomorrow morning. Did the quality of our admissions improve? I’m not so sure. Whether local or global we unquestionably need to seek opportunities to improve the care we provide. I only hope that our “quality revolution” in global health is a mindful pursuit because the health of the world’s most vulnerable populations depends on it.
Time for a quality revolution in global health. Kruk ME1, Larson E2, Twum-Danso NA3.
Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century.National Academy Press, Washington, DC; 2001