FROM CHALLENGES TO OPPORTUNITIES
SUSTAINIA
a part of
MONDAY MORNING
ACKNOWLEDGEMENTS DNV GL and Monday Morning Sustainia would like to thank the following for their contribution to the publication: The participants at the roundtables in Shanghai, Brussels and Washington DC. For each roundtable we were happy to see a diverse group of patient representatives, professionals, policy makers, providers and researchers working together on mapping challenges in their region and pointing towards opportunities for the future. Their willingness to share experiences and thoughts has been an invaluable part of this publication. The regional experts. Thank you to Mr. Alex Lam, Ms. Weiwei Zhang, MEP Christel Schaldemose, Professor Francesco De Lorenzo, Professor Bob Smith and Ms. Britanni Kessler for sharing their perspectives on the present challenges and future possibilities for healthcare in China, Europe and the USA. The change-makers. Thank you to Ms. Susan Sheridan, Professor Jeffery Lazarus and Professor Stephen MacMahon for sharing their stories of creating change in the healthcare system and thereby inspiring others to dare dream of a safer, smarter and more sustainable future for healthcare. Š DNV GL and Monday Morning Sustainia 2015 Print: Rosendahls ISBN: 978-87-93038-30-1
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FROM CHALLENGES TO OPPORTUNITIES
FOREWORD
The unfolding science of patient engagement
Over the last 5 years of evangelizing a new view of the role of the patient in medicine, it has become apparent to me that changing the cultural conversation about who is capable of what is challenging because it creates a shift in the balance of power. The people that had been viewed as the responsible leaders can experience a loss of power and authority. While the Scientific Revolution brought an understanding of how medicine works, one of the unintended side effects was the disenfranchisement of anyone without medical training. Today, we are in an era of awakening that recognizes the need to better incorporate patients in their own treatment programs. We cannot co-create healthcare systems if providers do not accept patient engagement as both helpful and necessary. In my case, my oncologist agreed to be quoted in the British Medical Journal saying that the information I got from a patient community about how to cope with side effects of a treatment that sometimes kills people increased my chances of survival. Clearly, change is possible when knowledge in the patient community is harnessed. I propose that we need a new scientific approach to understanding the role of the patient.
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In order to create that, we must acknowledge the clear evidence that activated, engaged and informed patients today are quite capable of truly improving their outcomes. If we create a scientific model for patient engagement, one of the parameters will be usability. In any other industry, if what you want the customer to do is too difficult, you go out of business. In medicine, you blame the victim. The art of culture change – in healthcare as well as any other matter – is to see clearly what is newly possible without giving up what has always been valuable. This publication helps guide us to that goal by outlining our current state of affairs and offering exciting opportunities for change. One of the most wonderful things that could happen in my view is for the doctors and nurses and researchers whose work saved my life to find that they themselves now have a better life because their contributions can unfold in a richer more effective environment. That is co-creation.
E-PATIENT DAVE BIO Dave deBronkart, known on the internet as e-Patient Dave, is the author of the highly rated Let Patients Help: A Patient Engagement Handbook and one of the world’s leading advocates for patient engagement. After beating stage IV kidney cancer in 2007 he became a blogger, health policy advisor and international keynote speaker. An accomplished speaker in his professional life before cancer, he is today one of the best-known spokesman for the patient engagement movement, attending nearly 300 conferences and policy meetings internationally, including testifying in Washington for patient access to the medical record under Meaningful Use. e-Patient Dave was a participant at the Co-Creating Healthcare Roundtable in Washington DC  
By e-Patient Dave deBronkart, healthcare expert, author and cancer survivor dedicated to patient engagement and advocacy
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Table of Contents 8
INTRODUCTION
10 EXECUTIVE SUMMARY
13 WHAT WE DID AND WHY 14
MAPPING THE STATE OF HEALTHCARE
16
ROUNDTABLES WITH KEY STAKEHOLDERS
17
HIGHLIGHTING OPPORTUNITIES, INSPIRING CHANGE
18
WHAT YOU SHOULD KEEP IN MIND WHEN READING THIS PUBLICATION
25 GLOBAL HEALTHCARE OUTLOOK 28 AFRICA 30
THE AMERICAS
43 HEALTH SYSTEMS IN FOCUS 44
FROM EAST TO WEST
46
CHINA – RECALIBRATING A SYSTEM FOR NEW DISEASE PATTERNS
32 EASTERN MEDITERRANEAN
48 Physical and social inequalities
34 EUROPE
50
SOUTH-EAST ASIA
38
WESTERN PACIFIC
52
40
GLOBAL OVERVIEW
54
6
21
CO-CREATING HEALTHCARE
22
SEEING THE WHOLE SYSTEM
22
STANDARDS FOR COCREATION
The patient is a resource The economic burden of no gatekeeping
56
19 SYSTEMS THINKING AND CO-CREATION
Safety is a challenge for patients and professionals
36
Effectiveness is improving but not incentivized
58
Worth the wait?
60
In need of a breath of fresh air
62
Shanghai roundtable
64
Expert insight
66
EUROPE– SHARING A HEALTHCARE GOAL
68
Protecting universal care
71
Creating a patient safety culture
75
Towards co-creation at different speeds
79
Growing demand and shrinking budgets
81
EU guides the way to more effective care
84
Timing is everything
86
A healthy environment
88
Brussels roundtable
90
115 ROADMAP TO CHANGING HEALTHCARE 116
118
A JOURNEY TOWARDS OPPORTUNITIES
Case in Kenya: A doctor to the masses
121 122
Case in USA: Bringing the patient safety
Expert insight
Healthcare: more than the
Case in Australia: Strong alliances create integrated healthcare
94 96
THE UNITED STATES OF AMERICA – BALANCING THE SCALES Watch the access gap
98
103 106
108
128
Case in Germany: Improving quality by measuring the
130
131
133
134
154 WHO’S BEHIND THIS PUBLICATION 155 FURTHER READING 156 REFERENCES
Case in England:
Bridging time lags with
Case in China: It’s time for a change in healthcare
Towards a sustainable
provision
healthcare agenda
Expert insight
– Steven MacMahon, China
better communication
Healthcare on time…
112
Chronic disease management in rural China
Knowledge sharing helps
increases effectiveness
Washington DC roundtable
148
healthcare do its job
worth?
110
– Susan Sheridan, USA
true value of care
Commissioning for Value
sometimes
Improving patient safety through advocacy
Knowing the value of
Getting your money’s
Too much and not enough
144
healthcare is key
Towards healthcare of, by and for the people
101
127
The fight to improve patient safety
– Jeffrey V. Lazarus, Europe
sum of its parts 125
92
Bridging the “Knowing-Doing” Gap
The patient as the expert
patient voice to the world of
125
140
Mobile health apps open the door to universal healthcare
119
139 THE CHANGE MAKERS
136
Green thinking is becoming the new normal
137
Case in USA: Hospitals are leading the green battle
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INTRODUCTION
A Journey Towards Co-Creating Healthcare DNV GL and Sustainia share a vision of a future with safer, smarter and more sustainable healthcare systems throughout the world. The two organizations wish to help bridge the gap between the systemic healthcare challenges and the opportunities, solutions and people that are creating the healthcare systems of tomorrow, today.
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In April 2014, at the BMJ IHI International Forum on Quality and Safety in Healthcare, we launched our guide to Person-Centred Care: Co-Creating a Healthcare Sector for the Future. That guide analyzes the benefits of putting the patient at the center and promoting co-creation between the different stakeholders of health systems. Since then, we have traveled around the world disseminating the publication in different cultural settings and discussing the state of healthcare with experts and influential stakeholders in each region we visited. We presented knowledge and insights from the publication at 10 healthcare conferences in 10 different regions across four continents. On top of these events, we conducted roundtables to discuss the work ahead with key participants in China, Europe, and the USA in order to uncover the barriers to and the opportunities for co-creating more sustainable healthcare systems. Furthermore, we have engaged people online, creating a network of health experts to share opinions, frustrations and solutions with each other in order to scale and spread opportunities. The ambition of our journey is twofold. On one hand, we wish to give an overview of the challenges that global healthcare systems face and how these issues determine the quality of care that these systems produce. One the other hand, we want to highlight the good news, which is that many of the healthcare solutions we need already exist today. There are people, initiatives and organizations all over the planet that are currently developing innovative ways of solving problems faced by healthcare systems. With this publication we hope to inspire the process of change by highlighting and promoting co-creation within healthcare systems around the world. Equipped with a thorough understanding of the current state of the world’s healthcare systems and the challenges they face, this publication moves us closer to realizing the healthcare innovations of tomorrow. There is still a long way to go before global healthcare systems are truly economically, socially and environmentally sustainable, and before they are able to co-create healthy, happy and independent lives. We believe that in order to succeed we must make the journey a co-created effort that reaches across sectors and fields and includes stakeholders from all parts of the healthcare system. Regardless of whether you participate in the healthcare system as a patient, professional, policy maker, researcher or provider, we hope that this publication will inspire you and that we can join together on a journey towards safer, smarter and more sustainable healthcare systems.
HENRIK O. MADSEN
ERIK RASMUSSEN
President & CEO DNV GL Group
Founder of Sustainia and CEO of Monday Morning
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Executive Summary “We cannot solve our problems with the same thinking we used when we created them.� This quote from Albert Einstein hits the nail on the head when it comes to the publication you hold in your hands.
The aim of this publication and the
On the following pages, we take a
GLOBAL HEALTHCARE
process that went before it is to
closer look at healthcare systems
OUTLOOK
enrich the conversation about the
around the world in order to exam-
future of healthcare by including
ine what is holding the quality of
solutions, innovations and people
care back and what solutions exist
that are co-creating greener and
today. This publication is the result of a process of stakeholder engagement
The overall challenge that this pub-
throughout 2014 and the first half
lication addresses is the fact that
of 2015. Over the last 18 months we
quality improvement1 and evidence
have met with people from around
based practice movements2 have
the world who are showing that
not been able to change health sys-
change in healthcare is possible.
tems so that they deliver consistent care that improves both individual
Our findings are presented in the
and population well-being.
following chapters: Global Healthcare Outlook, Health Systems in
A key reason for this is that such
Focus and Roadmap to Changing
attempts at change have tended
Healthcare.
to focus on preventing the reoc-
regions. The data offer insight into the challenges faced in different regions. For instance, NCDs cause 87% of deaths in Europe, but only 28% in Africa. However, developing countries struggle with a lack of healthcare resources compared to more industrialized regions.
health problems in due time.
ing co-creation between different stakeholders. 3
10
placing it in the context of the WHO
regions hoping to avoid the same
the underlying system and promot-
Greenhalgh T et al. Evidence Based Medicine: A Movement in Crisis? BMJ 2014; 348: 1-7.
of healthcare. We frame this by
be seen as warning signs for other
understanding and strengthening
2
around the world to give a snapshot
ing figures from one region can
their immediate causes rather than
Dixon-Woods M et al. Explaining Matching Michigan: An Ethnographic Study of a Patient Safety Initiative. Implementation Science 2013; 8(70):1-13.
today. In this section we synthe-
Importantly, when compared, alarm-
currence of particular ailments and
1
we need to know where we stand size data on health systems from
smarter pathways towards the healthcare systems of tomorrow.
Before making an improvement,
World Health Organization. Systems Thinking for Health Systems Strengthening. 2009. 3
HEALTH SYSTEMS IN FOCUS This section of the publication
ROADMAP TO CHANGING HEALTHCARE
And we hear the story of Stephen MacMahon and Lifeseeds, a pro-
sets out to examine the healthcare
Challenges in healthcare systems
gram tackling the challenge of NCDs
systems in China, Europe and the
can seem so enormous and sys-
in rural China. It is our hope that the
USA in order to map out the differ-
temic that it may feel impossible
stories of their efforts will inspire
ences and similarities and flesh out
to separate them from each other.
and galvanize each reader to take
how and why healthcare systems
But improvement is possible and is
charge of healthcare in his or her
struggle to deliver the best quality
happening.
own community.
selected because they face similar
This final chapter of the publication
challenges in terms of rising demand
puts the spotlight on seven case
CO-CREATION
and costs, concerns with quality
studies highlighting opportunities
and changing disease patterns.
for improvement within the seven
They represent different underlying
dimensions of healthcare. From
causes, different types of health
mobile health apps in Kenya to
systems and different responses. A
cost-efficiency measurements at
comparison of these three health-
clinics in Germany, the solutions that
care systems offers valuable insight
will form the healthcare systems of
into changing healthcare dynamics
tomorrow are popping up all around
in the world today.
the world to address the specific
of care. These three regions were
needs of specific locations. China, Europe and the USA are examined through seven dimensions
Finally, revolutions need leaders, and
of healthcare quality: equity, safety,
healthcare is no exception. To guide
person-centered care, effective-
the reader from learning about the
ness, cost-efficiency, timeliness
inspirational performances of others
and environmental sustainability.
towards creating change in their
Healthcare in China is challenged by
own system of healthcare, three
its extreme urban and rural divide,
change makers tell the story of how
while in the USA, historical social
they saw a need and created a solu-
inequalities continue to have an
tion to meet it.
– FRONT AND CENTER Voices of patients, professionals, policy makers and researchers are all vital in collecting the puzzle pieces that constitute a healthcare system. Without this complete picture, long term, systemic change is unlikely. Through our roundtables in Shanghai, Brussels and Washington DC; interviews with experts at each location; and in-depth profiles of three leading change makers, healthcare experts – in every sense of the word – have helped outline the current challenges and illuminate the future opportunities. This publication is a truly co-created effort.
impact on the healthcare systems of today. Europe, meanwhile, is
We learn how Susan Sheridan, after
performing a balancing act between
her family experienced two serious
leaving health issues to the nations
medical system failures, succeed-
and consolidating policymaking at
ed in changing the standards of
an EU level.
care. We meet Jeffrey Lazarus, who co-founded the HIV in Europe
But despite the differences, all three
Initiative as a way of closing the gap
regions have been subject to polit-
between what we know and what
ical reforms and policy change on
we do.
the subject of health and healthcare, pointing to the fact that the unsustainability of current healthcare systems is on the top of the agenda for decision makers in all three regions.
11
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WHAT WE DID AND WHY THE GOAL OF THIS PUBLICATION IS TO GIVE AN OVERVIEW OF THE CHALLENGES THAT ARE MAKING HEALTHCARE SYSTEMS WORLDWIDE UNSUSTAINABLE. MORE THAN POINTING TO THE PROBLEMS, IT ALSO AIMS TO SHIFT THE FOCUS FROM CHALLENGES TO HEALTHCARE SOLUTIONS AND INITIATIVES THAT ARE READY AND AVAILABLE TODAY.
This publication builds on Monday Morning Sustainia and DNV GL’s 2014 publication: Person-Centred Care: Co-Creating a Healthcare Sector for the Future. In our writing, we have used different approaches and sources of knowledge in order to gather relevant information. Hence our analysis and synthesis triangulates a critical literature review, expert interviews and roundtables with key stakeholders.
13
1) Mapping The
State Of Healthcare
The challenges that healthcare systems around the
HEALTH SYSTEMS IN FOCUS
world are facing are known – they are documented and
Here, we present the reader with an examination of
communicated in various indices, reports and fore-
healthcare systems in China, Europe and the USA
casts. A key element in our work has been to gather
by using 7 quality dimensions of healthcare as an
the newest information on the challenges, select the
analytical framework, outlined on page 15. The health
relevant data and present them in an easy to under-
systems profiled in this section are chosen due to
stand and engaging way that enables comparison
their importance and impact on the global economy,
between regions.
the sheer size of their populations, and their different healthcare schemes. They each represent different
The result of the literature review is presented in the
funding models but each are going through periods of
Global Healthcare Outlook and in the Health Systems
significant change.
in Focus section. The data used to create the Global Healthcare Outlook THE GLOBAL HEALTHCARE OUTLOOK
and Health Systems in Focus are found by gathering
This chapter uses the WHO-defined 6 world regions
knowledge and research from leading global health-
and highlights key and comparable figures on health-
care organizations and institutions such as the Com-
care and society in every region, each time touching
monwealth Fund, the WHO and EU institutions. We’ve
down in 10 specific spots to shed some light on exam-
analyzed and synthesized data from leading regional
ples of healthcare in action.
and national healthcare authorities and institutions to compile a snapshot of current performance and
The data we have chosen for the Global Healthcare
challenges.
Outlook gives the reader a quick overview of the healthcare system and health in society for each region.
The following data has been used for the global healthcare outlook:
DATA USED FOR THE HEALTHCARE SYSTEM OVERVIEW
Physicians
Hospital beds
Total
General
Out-of-pocket
Per capita total
per 10,000
per 10,000
expenditure
Government
expenditure
expenditure
people
people
on health as %
Expenditure
as % of private
on health
of GDP
of total
expenditure on
at average
expenditure on
health
exchange rate
health
DATA USED FOR THE HEALTH IN SOCIETY OVERVIEW
14
Life expectancy
Under-five
Deaths
HIV
Obesity
Alcohol
mortality rate
caused by
mortality rate
rate
consumption
NCDs
and tobacco use
THE 7 QUALITY DIMENSIONS OF HEALTHCARE
By adding it to the existing quality dimensions, we
We have adapted the six quality dimensions of
provide a framework for identifying priority areas
the Institute of Medicine by adding sustainabili-
that, if improved, would increase healthcare’s abili-
ty. The impact of healthcare on the environment
ty to meet the needs of service users and commu-
and the environment on healthcare is increasingly
nities today and tomorrow.
recognized as an important factor in the ability of healthcare to deliver services that meet the needs of individuals and populations.1
EQUITY
SAFETY
PERSON-CENTERED
EFFECTIVENESS
Providing care that does
Avoiding harm arising from
CARE
Providing services based
not vary in quality because
the way care is delivered.
Providing care that is
on scientific knowledge to
of personal characteristics
respectful of and respon-
all who could benefit, and
such as gender, ethnicity,
sive to individual patient
refraining from providing
geographic location, and
preferences, needs, and
services to those not likely
socioeconomic status.
values, and engaging them
to benefit.
as equal partners in co-creating care.
COST-EFFICIENCY
TIMELINESS
ENVIRONMENTAL
Avoiding waste, including
Reducing waits and some-
SUSTAINABILITY
waste of equipment, sup-
times harmful delays for
Limiting the negative
plies, ideas, and energy.
both those who receive
impact of the healthcare
and those who give care.
sector on the environment and simultaneously better managing the impact of the environment (including, climate change) on the healthcare sector2
NHS Sustainable Development Unit. Sustainable, Resilient, Healthy People & Places: A Sustainable Development Strategy for the NHS, Public Health and Social Care system. 2014. 1
The definitions are adapted from the 2001 Institute of Medicine report, Crossing the Quality Chasm, except for the sustainability dimension, which we have defined. 2
15
WASHINGTON DC 9TH OF FEBRUARY 2015
BRUSSELS 18TH OF NOVEMBER 2014
SHANGHAI 28TH OF OCTOBER 2014
2) Roundtables With Key Healthcare Stakeholders Although gathering and analyzing existing knowl-
The roundtable participants were selected by com-
edge gives the publication a strong foundation,
bining DNV GL and Monday Morning Sustainia’s
we also wanted to listen to key stakeholders in our
networks, and reaching out to experts in each loca-
three core regions and extract what they consid-
tion. This process ensured that each participant list
ered to be the biggest challenges and opportuni-
included patients, professionals, providers, policy
ties for healthcare in their region. The roundtable
makers and researchers.
locations were chosen to match the policy epicenters of each of our three Health Systems in Focus:
After the roundtables, we conducted interviews
Shanghai, Brussels and Washington DC.
with two participants from each region in order to harvest even more of their knowledge within the
The roundtables were in the format of one-day
field, giving the reader a more in-depth under-
interactive workshops. Each roundtable included
standing of the different healthcare systems.
an inspirational talk from an expert participant, followed by structured group-work and discussions.
16
3) Highlighting Opportunities, Inspiring Change An overview of the challenges for global health-
We identified numerous cases that fit the above
care systems lets us know where we stand. But a
criteria and then focused on the 7 selected based
focus on opportunities helps us share the solu-
on their quality, potential and diversity.
tions. Therefore, this publication includes seven inspirational performances from across the globe.
In order to inspire the reader to initiate change in
They illustrate the fact that innovative, sustainable
his or her own healthcare setting, we also present
developments already exist and are tackling some
three change maker interviews with people that
of the challenges within healthcare.
have a proven track record for tackling healthcare challenges and changing healthcare systems for
THE CRITERIA FOR SELECTING THE CASES
the better.
The aim of this chapter is to highlight a variety of solutions which demonstrate that opportunities are
The change makers, and the initiatives for which
created all around the world and come in different
they are responsible, correspond to the three loca-
shapes and sizes.
tions of the Health Systems in Focus: China, Europe and the USA. An interview was conducted with
The seven inspirational performances reflect our
each change maker using core questions in order
7 quality dimensions of healthcare. They span
to extract common threads and best practices for
different countries, costs, and scopes of change.
success in transforming healthcare sectors around
Some are multi-million dollar, large scale initiatives,
the world.
while others are home grown and locally supported campaigns. They also differ in terms of where they are in the implementation process. This breadth of coverage is important in order to stress that solutions to healthcare issues exist at every level of operation.
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What you should keep in mind when reading this publication In the pursuit of creating a publication that is accessible and inspiring for a broad group of readers, we have created a narrative that gives an overview and a taste of the different challenges and opportunities. It is not an extensive review of all the challenges and opportunities. We are aware that with a different focus, we could have found other inspirational performances or other experts with different viewpoints and included other challenges that would have painted a different picture of the healthcare landscapes. For the purposes of this publication, we have used the WHO global regions to frame our analysis. The exception is in relation to Europe where we have drawn on both the broader WHO region as well as the narrower European Union (EU) that sits within it. The WHO includes 53 countries within its definition of Europe; the EU consists of 28 Member States. Although we have included examples from across the 53 countries defined by the WHO, we have also focused particualrly on the policies and regulations of the EU as these represent an attempt to create a common ambition to improve the well-being of populations across national borders. In order to allow easy comparisons between the different regions and health systems, we have converted all currency to American dollars through Google Finance’s currency exchange system. The figures express the exchange rates from 2 March 2015.
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This publication does not target one specific type of reader but rather is meant to inspire all the different stakeholders across healthcare systems worldwide and to encourage discussion and debate on how we can collectively change healthcare for the better.
SYSTEMS THINKING AND COCREATION BEYOND MAPPING THE STATE OF GLOBAL HEALTHCARE AND THE CHALLENGES IT FACES, THIS PUBLICATION HIGHLIGHTS EXAMPLES FROM LOW, MIDDLE AND HIGH INCOME COUNTRIES IN WHICH PATIENTS, HEALTH PROFESSIONALS, MANAGERS AND POLICY MAKERS ARE PROVING, FROM MICRO TO MACRO LEVELS, THAT CHANGE IS BOTH DESIRED AND ACHIEVABLE.
What connects each of these stories is their focus of patient empowerment, systems-thinking approaches to problem-solving, and cultivation of healthcare environments that allow for and encourage the co-creation of person-centered care.
19
CO-CREATING SAFER, SMARTER AND MORE SUSTAINABLE SYSTEMS Healthcare has changed greatly over the last century. New technology and advances in treatment mean that a girl born in 2012 can expect to live around 73 years and a boy to the age of 68 years. This is six years longer than average global life expectancy for a child born in 1990.1 Yet, as the regional analyses in the following chapters show, all countries are currently struggling to deliver safe and sustainable healthcare. Ageing populations, the pandemic of non-communicable diseases, rising costs, disparities in access between rich and poor and unacceptably high rates of patient harm are clear and significant threats to sustainable healthcare around the world. The growing complexity of healthcare, with care becoming ever more sub-specialized, poses an additional challenge. Increasing numbers of health and social care professionals are involved in each patient’s journey through the system, particularly those with multiple co-morbidities. Within this complexity the patient is in danger of becoming lost as different parts of the health and social care system struggle to coordinate with one another. 2 Too often services are fractured and fragmented: reflecting the evolution of abstract political ambitions rather than a purposeful and coherent system design based on what patients need or want. Attempts to improve healthcare have relied on narrowly defined, technocratic approaches with inadequate attention to context and engagement of local providers, practitioners and patients as co-creators of health systems. 3 There is, therefore, a clear need to look for ways that build on the knowledge of quality improvement and evidence based practice by involving stakeholders in strengthening health systems as a whole. Such change is possible. Beyond mapping the state of global healthcare and the challenges it faces, this publication highlights examples from low, middle and high income countries in which patients, health professionals, managers and policy makers are proving, from micro to macro level; that change is both desired and achievable. What connects each of these stories is their focus on patient empowerment, systems-thinking approaches to problem-solving, and cultivation of healthcare environments that allow for and encourage the co-creation of person-centered care.
20
Co-Creating Healthcare Co-creation means delivering services “… in an equal and reciprocal relationship between professionals, people using services, their families and their [communities … so that both services and communities] become far more effective agents of change”.4 Engaging patients as active partners in the design and delivery of services is a powerful tool for transformational change, resulting in:
1) IMPROVED COSTS Patients who are actively engaged have better health outcomes at lower costs compared with less activated patients. For example, patients with the lowest activation scores (i.e. people with the least skills and confidence to participate in their own healthcare) can cost 8 to 21% more than patients with the highest activation levels, even after adjusting for health status and other factors. 5
2) IMPROVED OUTCOMES Working with patients and their family members to co-create person-centered care is proven to have a positive impact on outcomes in low, middle, and high income countries, including: health status6, knowledge7, adherence 8 , and patient and practitioner satisfaction. 9, 10 But to achieve this requires an understanding of how systems and their different components work together to produce results.
1
WHO. World Health Statistics. 2014.
Donaldson L in Monday Morning Sustainia & DNV GL. Person-Centred Care. 2014. 2
Hibbard JH et al. Patients with lower activation associated with higher costs; delivery systems should know their patients’ “scores”. Health Affairs 2013; 32: 216-22. 5
Leyshon S & McAdam S. The importance of taking a systems approach to person-centred care. BMJ Spotlight Supplement on Patient Centred Care. 2015.
6
Boyle D & Harris M. The challenge of co-production: How equal partnerships between professionals and the public are crucial to improving public services. 2009.
7
3
4
Sidani S. Effects of patient-centered care on patient outcomes: An evaluation. Research And Theory For Nursing Practice: An International Journal 2008; 22(1): 24-37.
DiMatteo MR et al. Patient adherence and medical treatment: A meta-analysis. Med Care 2002; 40: 794 – 811. 8
The King’s Fund. Patient-Centred Leadership: Rediscovering Our purpose. 2013. 9
Stewart M et al. Patient-Centered Medicine: Transforming the Clinical Method. 2003. 10
Mead N & Bower P. Patient-centred consultations and outcomes in primary care: a review of the literature. Patient Education and Counselling 2002; 48: 51–56.
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Seeing the whole system Systems-thinking is an approach to improvement that sees challenges to quality as part of a wider, dynamic structure: looking for patterns of distributed risk rather than fragments or individual episodes.11 It involves more than a reaction to a particular outcome or event; it requires a deeper understanding of the distribution, linkages and relationships among the processes that characterize the entire system.12 As such, systems thinking is a:
“… mindset that views systems and their sub-components as intimately related and connected to each other, believing that mastering our understanding of how things work lies in interpreting interrelationships and interactions within and between systems.” 13
Standards for co-creation One way to ensure that the co-creation of person-cen-
The Global Healthcare Outlook examines and com-
tered care and systems-thinking are put into practice is
pares systems on a macro and regional level giving the
through accreditation. Accreditation provides a prac-
reader an immediate overview of the state of health-
tical, structured framework for addressing the quality
care around the world. In the Health Systems in Focus
improvement needs of healthcare. Trained external
chapter, we zoom in to the Chinese, American and Eu-
peer reviewers evaluate an organization’s compliance
ropean healthcare systems and examine the different
with pre-established performance standards that
quality components of a healthcare system, offering
can be applied to specific threats (such as managing
the reader a basis for further discussing what the
infection risk) or across services. Evidence shows that
systems have in common, what needs to be changed
healthcare providers “… that have either ISO certifica-
and what three seemingly different health systems can
tion or accreditation are safer and better than those
learn from each other.
that have neither” 14 and that “… accreditation programs should be supported as a tool to improve the quality of
Lastly, in the Roadmap to Changing Healthcare
healthcare services”.15
chapter, we continue to dig deeper, highlighting the solutions, organizations and people that constitute
Combining systems-thinking with the co-creation of
the disruptive elements in healthcare systems in low,
person-centered care plus frameworks such as accred-
middle and high income countries. These solutions
itation offers a powerful way to redesign healthcare.
address system failures with truly co-created efforts.
In this publication, we examine systems on different levels of action.
22
SYSTEMS-THINKING IN HEALTHCARE, AS WELL AS OTHER SAFETY CRITICAL AND COMPLEX ADAPTIVE SECTORS, FOCUSES ON:
Creating pre-emptive and mitigation controls to deliver safe and consistently reliable results
Establishing policies that set clear and explicit goals and directions regarding quality (including defining what quality means for an organization)
Identifying and assessing risks to human, technologiContinuously improving
cal and organizational safety
through the analysis of
and performance (including
performance and the
how these are distributed
adoption of necessary
within and across organiza-
process changes to
tions and who owns them)
achieve results Mapping processes and identifying indicators to monitor those processes (including Measuring process performance and
how they connect within and between organizations)
monitoring the efficacy of controls
Leyshon S & McAdam S. The importance of taking a systems approach to person-centred care. BMJ Spotlight Supplement on Patient Centred Care. 2015. 11
World Health Organization. Systems Thinking for Health Systems Strengthening. 2009. 12
Adam T. Advancing the application of systems thinking in health. Health Research Policy and Systems 2014; 12(50): 1-5. 13
Shaw C et al. Accreditation and ISO certification: do they explain differences in quality management in European hospitals? International Journal for Quality in Health Care 2010; 22(6): 445-451. 14
Alkhenizan A & Shaw C. Impact of accreditation on the quality of healthcare services: a systematic review of the literature. Ann Saudi Med 2011; 31(4): 407-416. 15
23
24
GLOBAL HEALTHCARE OUTLOOK AS THE PROVERB GOES, “A JOURNEY OF A THOUSAND MILES BEGINS WITH A SINGLE STEP.” ON THIS JOURNEY FROM HEALTHCARE CHALLENGES TO OPPORTUNITIES FOR IMPROVEMENT, THE GLOBAL HEALTHCARE OUTLOOK IS OUR FIRST STEP TOWARD CHANGE.
25
Global Healthcare Outlook In this chapter, we map out the state of healthcare throughout the world, using the six WHO regions as guides, in order to give a broad, global overview before diving into our three health systems in the next chapter. The Outlook includes key health-related financial indicators, such as total expenditure on health and out of pocket expenditures, but also figures on social elements of health, like the prevalence of non-communicable diseases and life expectancy. These numbers provide a general overview of healthcare in each region, but lack a local context. Therefore, each regional outlook also presents 10 illustrations of healthcare in particular countries, allowing the reader to zoom in and get a more complete look at the challenges, opportunities and complexities of healthcare in every region.
26
Algeria Angola
AFRICA
Benin Botswana Burkina Faso Burundi Cabo Verde Cameroon
Central African Republic Chad Comoros Congo Côte d’Ivoire Democratic Republic of the Congo
EUROPE
EASTERN MEDITERRANEAN
THE AMERICAS
Equatorial
Niger
South Sudan
Eritrea
Liberia
Nigeria
Swaziland
Ethiopia
Madagascar
Rwanda
Togo
Gabon
Malawi
Uganda
Gambia
Mali
Sao Tome and Principe
Ghana
Mauritania
Guinea
Mauritius
Guinea Bissau
Mozambique
Kenya
Namibia
Senegal Seychelles
Dominican Republic
Haiti
Peru
Honduras
Argentina
Chile
Ecuador
Jamaica
Saint Kitts and Nevis
Bahamas
Colombia
El Salvador
Mexico
Saint Lucia
Barbados
Costa Rica
Grenada
Nicaragua
Cuba
Guatemala
Panama
Bolivia
Dominica
Guyana
Saint Vincent and the Grenadines
Paraguay
Suriname
Afghanistan
Iran
Lebanon
Pakistan
Sudan
Bahrain
Iraq
Libya
Qatar
Djibouti
Jordan
Morocco
Saudi Arabia
Syrian Arab Republic
Egypt
Kuwait
Oman
Somalia
Tunisia
Albania
Croatia
Hungary
Malta
Andorra
Cyprus
Iceland
Monaco
Russian Federation
Armenia
Czech Republic
Ireland
Montenegro
Austria
Denmark
Israel
Netherlands
Azerbaijan Belarus
Estonia Finland France Georgia
Italy Kazakhstan Kyrgyzstan Latvia
Germany
Lithuania
Greece
Luxembourg
Bhutan
Democratic People’s Republic of Korea
Australia Brunei Darussalam
Bulgaria
Norway Poland Portugal Republic of Moldova
Zambia Zimbabwe
South Africa
Canada
Belize
Tanzania
Sierra Leone
Brazil
Bosnia and Herzegovina
SOUTH EAST ASIA
Lesotho
Antigua and Barbuda
Belgium
WESTERN PACIFIC
Guinea
Trinidad and Tobago United States of America Uruguay Venezuela
United Arab Emirates Yemen
San Marino
The former Yugoslav Republic of Macedonia
Serbia
Turkey
Slovakia
Turkmenistan
Slovenia
Ukraine
Spain
United Kingdom
Sweden
Uzbekistan
Switzerland
Romania
Tajikistan
India
Maldives
Nepal
Thailand
Indonesia
Myanmar
Sri Lanka
Timor-Leste
Fiji
Marshall Islands
Niue
Micronesia
Palau
Republic of Korea
Tuvalu
Japan Kiribati
Mongolia
Samoa
Vietnam
Cambodia
Lao PDR
Nauru
Papua New Guinea
China
Malaysia
New Zealand
Philippines
Solomon Islands
Bangladesh
Cook Islands
Vanuatu
Singapore Tonga
27
AFRICA 10 facts about healthcare in the region
The removal of user fees for children’s healthcare in 12 districts in Burkina Faso led to an average increase of 2,000 visits per year per center – a 110% spike. 3
In Ghana, 92% of caregivers of sick children sought treatment from community-based agents trained to manage pneumonia and malaria and most sought care for their children within 24 hours of the onset of fever. 5
eHealth Africa, WE CARE SOLAR
The introduction of results-based
and the McArthur Foundation
financing (RBF) in Burundi – the
worked together on the devel-
allocation of bonuses based on
opment, installation, monitoring,
performance and quality – result-
and maintenance of micro-solar
ed in visits per child increasing
installations in 28 health facilities
from 1.16 in 2009 to 1.6 in 2010,
in Nigeria. 6
and institutional deliveries increasing from 51% in 2009 to 62% in 2010.11
Studies on hospital-wide healthcare associated infections from African countries report high infection rates e.g. Mali 18.9%, the Tanzania 14.8% and Algeria 9.8%. 8
Pfizer. The Global Burden of Noncommunicable Diseases. 2011. 1
World Health Organization. The African Regional Health Report. 2014. 2, 3, 4, 5, 7, 8, 9, 10
eHealth Africa. Micro-Solar Systems for Maternal Health. Undated. 6
28
The World Bank. Results Based Financing at the World Bank: Burundi’s National Performance Based Financing (PBF) Program. 2011. 11
PHYSICIANS PER 10,000 PEOPLE (2006 – 2013)
2.6 0.1 – 12.1 Tanzania, Liberia – Algeria
Ethiopia’s community-based nutrition interventions have
HOSPITAL BEDS PER 10,000 PEOPLE (2000 – 2009)
increased primary healthcare coverage from 77% of communities in 2004 to 92% in 2010. This preventive care has also decreased
2 1 – 63 Mali – Ethiopia, Gabon
deaths per 1,000 live births in 2000 to 77 in 2011.7
Rwanda has mandatory health insurance (even for visitors staying less than 15 days). Currently 92% of the population is covered. 2
THE HEALTHCARE SYSTEM
under –five mortality from 139 PER CAPITA TOTAL EXPENDITURE ON HEALTH AT AVERAGE EXCHANGE RATE (US$) (2011)
TOTAL EXPENDITURE ON HEALTH AS % OF GDP (2011)
GENERAL GOVERNMENT EXPENDITURE OF TOTAL EXPENDITURE ON HEALTH (2011)
90% of births in the richest quintile in Madagascar were attended by skilled health personnel, while this was only the case in 22% of births in the poorest quintile. 4
OUT-OF-POCKET EXPENDITURE AS % OF PRIVATE EXPENDITURE ON HEALTH
A study in Zambia found that
$99
$12 – $1,051 Eritrea – Equatorial Guinea
6.2%
1.7% –16.3% South Sudan –Sierra Leone
48.3% 16.2% –94.8% Sierra Leone – Seychelles
56.6% 12.7% –100% Botswana – Comoros, Eritrea
68% of children with pneumonia received early and appropriate treatment from community health workers, and that overtreatment of malaria significantly declined. 9
58
Only five countries: Botswana, Madagascar, Rwanda, Togo and Zambia, have been able to achieve the target set in the Abuja Declaration – dedicating more than 15% of general government expenditure to healthcare.10
HEALTH IN SOCIETY
LIFE EXPECTANCY AT BIRTH IN YEARS (2012)
46 –74 Sierra Leone – Cape Verde, Seychelles, Mauritius
DEATHS CAUSED BY NCDS 1 (2008)
28%
20% – 85% Central African Republic – Mauritius
UNDER-FIVE MORTALITY RATE DEATHS PER 1,000 LIVE BIRTHS (2012)
95
13 – 182 Seychelles – Sierra Leone
29
THE AMERICAS 10 facts about healthcare in the region
By staggering start-times for surgery and standardizing surgical equipment, wait times dropped 75% and the number of surgeries completed increased by 136% in some Canadian hospitals. 9
An estimated 1.6 million chronic
Costa Rica has one of the most
patients could benefit from
effectively universalized health-
mHealth in Mexico, which would
care systems in Latin America. Its
result in per capita healthcare
health insurance coverage rate
spending reductions of 25%. 3
rose from 87.6% in 2006 to 91.9% in 2010. 8
30
While 97% of Colombians are
Ecuador has introduced price
covered by health insurance, only
controls for essential medicines,
40% of the country receives high
which account for more than 54%
quality care, typically at private
in the Ecuadorian pharmaceutical
hospitals. 60% of people rely
market, making access to these
on inadequate care at crowded,
drugs less expensive and more
public facilities. 2
equitable.10
Meticillin-resistant Staphylococcus aureus is the most common hospital acquired infection in Latin America, and the disease had a 51% infection rate in Argentine hospitals in 2006. 5
PHYSICIANS PER 10,000 PEOPLE (2006 – 2013)
2.1 – 67.2 Guyana – Cuba
The economic repercussions of low health literacy are estimated
HOSPITAL BEDS PER 10,000 PEOPLE (2006 – 2013)
to cost the United States economy between $106 billion and $236
pitals in Cuba found the overall prevalence rate of device-associated healthcare-associated infections (DA-HCA) to be 22.4%. 6
Partners in Health’s mobile clinics in Haiti have helped more than
THE HEALTHCARE SYSTEM
billion annually. 4
A 3-year study of two ICU hos-
20.8
33,000 patients since 2013, and
PER CAPITA TOTAL EXPENDITURE ON HEALTH AT AVERAGE EXCHANGE RATE (US$) (2011)
who tested HIV+ to receive further care.7
TOTAL EXPENDITURE ON HEALTH AS % OF GDP (2011)
OUT-OF-POCKET EXPENDITURE AS % OF PRIVATE EXPENDITURE ON HEALTH
In Brazil, it is estimated that 76% of towns dispose of medical and
6 – 62 Guatemala – Barbados
$3,482
$62 – $8,467 Haiti – USA
GENERAL GOVERNMENT EXPENDITURE OF TOTAL EXPENDITURE ON HEALTH (2011)
have referred over 450 people
23
municipal wastes together at the
14.1%
4.5% – 17.7% Venezuela – USA
49.5% 21.5% – 94.7% Haiti – Cuba
30.1%
3.5% – 100% Haiti– Barbados, Cuba, Saint Vincent and the Grenadines
municipal landfills.11
Webster P. “Health in Colombia: a system in crisis.” Canadian Medical Association Journal 2012; 184(6): 289-290. 2
in adult intensive care units of Cuban university hospitals: International Nosocomial Infection Control Consortium (INICC) findings.” International Journal of Infectious Diseases 2011; 15(5): 357-362. Skoll Foundation. Partners in Health. 2015. 7
PricewaterhouseCoopers. Socio-economic impact of mHealth. 2013. 3
Center for Health Care Strategies Inc. Health Literacy Implications of the Affordable Care Act. 2010. 4
Guzman-Blance M, et al. ”Epidemiology of meticillin-resistant Staphylococcus aureus (MRSA) in Latin America.” International Journal of Antimicrobial Agents 2009; 304-308. 5
Guanche-Garcell H, et al. “Device-associated infection rates 6
Pan American Health Organization. Costa Rica. 2012. 8
Canadian Health Coalition. Wait Times: Causes and Cures. 2009. 9
IHS Inc. Ecuadorian government introduces price controls for essential medicines. 2014 10
Health Care Without Harm. Medical Waste and Human Rights. 2011. 11
HEALTH IN SOCIETY
Pfizer. The Global Burden of Noncommunicable Diseases. 2011. 1
76
LIFE EXPECTANCY AT BIRTH IN YEARS (2012)
62 – 82 Haiti – Canada
79%
DEATHS CAUSED BY NCDS 1 (2008)
47% – 88% Guatemala – Canada, USA
UNDER-FIVE MORTALITY RATE DEATHS PER 1,000 LIVE BIRTHS (2012)
15 5 – 79 Canada – Haiti
31
EASTERN MEDITERRANEAN 10 facts about healthcare in the region
Palestine generates about 512.6 tons of medical waste every month.10
King Faisal Specialist Hospital & Research Center in Saudi Arabia Out-of-pocket health expendi-
is ranked in the top 5% of hospi-
tures account for 59% of total
tals worldwide for safety, quality
health financing in Egypt – the
of care and efficiency. 5
highest in the Region, and 4% in the Saudi Arabia, the Region’s In urban areas of Morocco, 100%
lowest. 9
of the population live less than 5 km from a healthcare facility,
The rate of antiretroviral
whereas in rural areas, this number is only 30%.
treatment (ART) coverage for
4
HIV-positive patients in Yemen has increased by 115% in three years (2010-2013). 8
Pfizer. The Global Burden of Noncommunicable Diseases. 2011. 1
Mobaraki A & Soderfeldt B. ”Gender inequity in Suadi Arabia and its role in public health.” Eastern Mediterranean Health Journal 2010; 16(1): 113-118. 2
32
WHO Regional Office for the Eastern Mediterranean. Demographic, Social and health Indicators for Countries of the4 Eastern Mediterranean. 2013. 3
Global Health Workforce Alliance. The Morocco Country Case Study: Positive Practice Environments. 2010. 4
HIMSS Analytics. Saudi hospital first in the Middle East to achieve global recognition for its healthcare IT. 2012. 5
6 Bossone A. “Sharing the pain: Improving healthcare in warzones.” Nature – Middle East. 2014.
Askarian M, Yadollahi M & Assadian O. “Point prevalence and risk factors of hospital acquired infections in a cluster of university-affiliated hospitals in Shiraz, Iran.” Journal of Infection and Public Health 2012; 5: 169-176. 7
Medecins Sans Frontieres. Yemen: Enrolment for antiretroviral treatment increasing in health facilities. 2014. 8
The World Bank. Who Pays?: Out-of-Pocket Health Spending and Equity Implications in the Middle East and North Africa. 2010. 9
PHYSICIANS PER 10,000 PEOPLE (2006 – 2013)
Due to instability caused by war,
HOSPITAL BEDS PER 10,000 PEOPLE (2006 – 2013)
between 50,000 and 100,000 Iraqis travel each year to countries in the region like Lebanon,
11.4 0.4–77.4 Somalia–Qatar
8 1– 37 Iran – Libya
Jordan, Iran and Turkey to receive
Pakistan’s government spent only $36 per person on health in 2011, the lowest in the region, while Qatar spent the most, at $1,738.
THE HEALTHCARE SYSTEM
healthcare. 6
A study of 4,350 patients at 8 7
OUT OF POCKET EXPENDITURE AS % OF PRIVATE EXPENDITURE ON HEALTH
For 55% of Qatari women, their husband decides whether contraception is used or not. 2
100% of the population in the
Al-Khatib I. “Medical waste management in healthcare centres in the occupied Palestinian territory.” Eastern Mediterranean Health Journal 2007; 113(3): 694-705.
HEALTH IN SOCIETY
to local health services, while this
10
$195
$36 – $1,738 Pakistan– Qatar
4.2%
1.9% – 8.8% Qatar – Jordan
51% 19% – 82.4% Afghanistan – Kuwait
88.9%
58.8% – 100 Saudi Arabia– Iraq, Libya, Syrian Arab Republic
68
LIFE EXPECTANCY AT BIRTH IN YEARS (2012)
United Arab Emirates has access figure is only 57% in Afghanistan. 3
TOTAL EXPENDITURE ON HEALTH AS % OF GDP (2011)
GENERAL GOVERNMENT EXPENDITURE OF TOTAL EXPENDITURE ON HEALTH (2011)
hospitals in Iran determined the HAI prevalence rate to be 9.4%.
PER CAPITA TOTAL EXPENDITURE ON HEALTH AT AVERAGE EXCHANGE RATE (US$) (2011)
53 – 80 Somalia –Lebanon
52%
DEATHS CAUSED BY NCDS 1 (2008)
19% – 85% Somalia – Lebanon
UNDER-FIVE MORTALITY RATE DEATHS PER 1,000 LIVE BIRTHS (2012)
57 7 – 147 Qatar – Somalia
33
EUROPE 10 facts about healthcare in the region
In 2011 administrative costs in Scotland accounted for 12% of total hospital expenditures while in the Netherlands this figure was 19.8%.7
Scotland, which has been a test bed for telehealth innovation since 2006, currently has approximately 180,000 people signed up to its telecare services, delivered through 32 local partnerships. 5
100,000 people waited over 12 months for an outpatient appointment at public hospitals in Ireland during April of 2013. 9
In the Netherlands, almost 70% of the population return their unused medicines to the pharmacy or a hazardous waste collection point. In Latvia only 6% do the same.11
The average waiting times for a hip replacement in 2012-13 was less than 40 days in the Netherlands, but around 150 days in Spain and Hungary.
Pfizer. The Global Burden of Noncommunicable Diseases. 2011. 1
WHO Regional Office for Europe. Better noncommunicable disease outcomes: challenges and opportunities for health systems. Country assessment: Turkey. 2014. 2
34
10
3
European Commission. Special Eurobarometer 411: Patient Safety and Quality of Care. 2014.
Management Systems Society. Integrated Health Innovations Conference: Press Release. 2013.
WHO European Observatory on Health Systems and Policies. Health Systems in Transition: Russian Federation. 2011.
6
4
5
Healthcare Information and
The cost of unnecessary Caesarean sections in Italy was $101 million in 2008 – the highest in Europe. This cost was lowest in Bulgaria, at $2.3 million. 6
WHO. The Global Numbers and Costs of Additionally Needed and Unnecessary Caesarean Sections Performed per Year: Overuse as a Barrier to Universal Coverage. 2010.
7
Himmelstein D, et al. “A Comparison of Hospital Administrative Costs in Eight Nations: US Costs Exceed All Others By Far.” Health Affairs 2014; 33(9): 1586-1594.
9
WHO Regional Office for Europe. Regional Pharmaceutical Situation Report. 2013.
10
8
WHO European Observatory on Health Systems and Policies. The impact of the financial crisis on the health system and health in Ireland. 2014. European Commission & OECD. Health at a Glance: Europe 2014. 2014.
PHYSICIANS PER 10,000 PEOPLE (2006 – 2013)
33.1
Only 7.7% of the healthcare 11.5 – 71.7 Albania – Monaco
facilities in Russia are capable of using electronic health histories or electronic medical records. Less
HOSPITAL BEDS PER 10,000 PEOPLE (2006 – 2013)
than 3% are equipped with the means to use telemedicine.
4
53
In Georgia, pharmacies and doctors are incentivized to dispense brand name drugs in preference to generics. By contrast, studies in Kyrgyzstan and Tajikistan show a high level of generic prescription, about 70% in both countries. 8
THE HEALTHCARE SYSTEM
25 – 138 Andorra, Turkey – Monaco
PER CAPITA TOTAL EXPENDITURE ON HEALTH AT AVERAGE EXCHANGE RATE (US$) (2011)
TOTAL EXPENDITURE ON HEALTH AS % OF GDP (2011)
GENERAL GOVERNMENT EXPENDITURE OF TOTAL EXPENDITURE ON HEALTH (2011)
Hospital in-patient medicines, all
OUT OF POCKET EXPENDITURE AS % OF PRIVATE EXPENDITURE ON HEALTH
cancer medicines, and medicines prescribed by family doctors are free of charge to patients in Turkey.
2
21%. 3
Health Care Without Harm. Unused Pharmaceuticals Where Do They End Up? A Snapshop of European Collection Schemes. Undated. 11
HEALTH IN SOCIETY
harmed by healthcare services Europe, and lowest is Austria at
$48 – $9,908 Tajikistan – Norway
9%
2.1% – 11.9% Turkmenistan – Netherlands
73.9% 18.1% – 88.6% Georgia – Monaco
68.8% 32.1% – 100% France – The former Yugoslav Republic of Macedonia, Turkmenistan
76
LIFE EXPECTANCY AT BIRTH IN YEARS (2012)
The perceived likelihood of being is 82% in Cyprus – the highest in
$2,370
63– 83 Turkmenistan – Andorra, Italy, San Marino, Switzerland
87%
DEATHS CAUSED BY NCDS 1 (2008)
62% – 95% Tajikistan – Serbia, The former Yugoslav Republic of Macedonia
UNDER-FIVE MORTALITY RATE DEATHS PER 1,000 LIVE BIRTHS (2012)
12 2– 58 Iceland, Luxembourg – 58 Tajikistan
35
SOUTHEAST ASIA 10 facts about healthcare in the region
A project at the cardiology outpatient department of a large university hospital in India was able to significantly reduce waiting times. In 2011, 64% of patients waited 3 hours or more for their consultation, while after the project’s completion, in 2013, this number had dropped to just 8%. 9
510 tons of medical waste is produced in the Maldives each year.11
67% of pregnant women and In 2010 Sri Lanka had a maternal mortality rate of only 39 deaths per 100,000 live births – an
In their first 1.5 years of operation, dedicated telemedicine centers in Bangladesh provided over 5,800 consultations. 4
exceptional achievement for a
WHO Regional Office for SouthEast Asia. Health in South-East Asia. 2013.
5
OECD. Structural Policy Country Notes: Thailand. 2013.
36
WHO Regional Office for SouthEast Asia. eHealth in South East Asia Region of WHO. 2013. 4
3
birth practices. 17% even forewent these payments. 2
1
2
funds to cover the cost of safe essential food in order to cover
developing country.7
Pfizer. The Global Burden of Noncommunicable Diseases. 2011.
new mothers in Myanmar had difficulties in raising necessary
Mobile Monday. Mobile Southeast Asia Report 2012: Crossroads of Innovation. 2012.
Peerapakorn S & Jayawickramarajah PT. “Role of Medical Education in patient safety.” South East Asian Journal of Medical Education 2008; 1(1). 6
Commonwealth Health Online. Health in Sri Lanka. Undated. 7
Amnesty International. The Crumbling State of Health Care in North Korea. 2010. 8
Dinesh TA, et al. “Reducing Waiting Time in Outpatient Services of Large University Teaching Hospital – a Six Sigma Approach.” Management in Health 2013; 1(17). 9
PHYSICIANS PER 10,000 PEOPLE (2006 – 2013)
5.9
0.7 – 14.2 Timor-Leste – Maldives
In 2010 North Korea spent less
HOSPITAL BEDS PER 10,000 PEOPLE (2006 – 2013)
than $1 per person on healthcare. This was less than any other coun-
29% of Indonesians have mobile internet access, making them prime candidates for mobile health apps. 5
THE HEALTHCARE SYSTEM
try in the world. 8
PER CAPITA TOTAL EXPENDITURE ON HEALTH AT AVERAGE EXCHANGE RATE (US$) (2011)
TOTAL EXPENDITURE ON HEALTH AS % OF GDP (2011)
GENERAL GOVERNMENT EXPENDITURE OF TOTAL EXPENDITURE ON HEALTH (2011)
About 10% of hospitalized patients in Indonesia suffer an adverse event and 5–10% acquire a healthcare associated infection. 6
OUT-OF-POCKET EXPENDITURE AS % OF PRIVATE EXPENDITURE ON HEALTH
10 6– 59 Bangladesh, Myanmar – Timor-Leste
$69
$19 – $525 Myanmar – Maldives
3.7%
1.8% – 8.1% Myanmar – Maldives
36.7% 15.9% – 83.9% Myanmar – Bhutan
84.3% 15.4% – 96.6% Timor-Leste – Bangladesh
While Bangkok has about 1 doctor per 1,000 people, the poorer northeast region of Thailand has only 1 doctor per 8,000 people. 3
Village Health Volunteers in Thailand provide essential basic healthcare services to 65 million Thai villagers, all free of charge.10
WHO Regional Office of South-East Asia. A Decade of Public Health Achievements in WHO’s South-East Asia Region. 2013. 10
The World Bank. Climate Change in the Maldives. 2010. 11
HEALTH IN SOCIETY
LIFE EXPECTANCY AT BIRTH IN YEARS (2012)
67
66 – 77 Myanmar, Timor-Leste – Maldives
55%
DEATHS CAUSED BY NCDS 1 (2008)
44% – 81% Timor-Leste – Maldives
UNDER-FIVE MORTALITY RATE DEATHS PER 1,000 LIVE BIRTHS (2012)
50
10 – 57 Sri-Lanka – Timor-Leste
37
WESTERN PACIFIC 10 facts about healthcare in the region
40% of the 7 million people killed by air pollution globally in 2012 lived in the Western Pacific Region. It is estimated that air pollution caused 350,000 to 400,000 premature deaths in China alone.11,12,13
Initiatives to address financial barriers to accessing care in Cambodia include Health Equity Funds which now cover 80% of the poorest people in the country. 3
77.2% of Singaporeans rated their overall satisfaction levels with public healthcare institutions as “excellent” or “good”. 6
The healthcare system in
50% of patients who had been
Singapore was ranked “most
placed on a public hospital
efficient in the world” by
elective surgery waiting list in
Bloomberg Rankings in 2014.
Australia waited 36 days or less.10
The city-state’s life expectancy is 82.1 years and healthcare costs account for just 4.5% of GDP. 9
1
Pfizer. The Global Burden of Noncommunicable Diseases. 2011.
3
WHO. Health System Financing Country Profile: Philippines. 2012.
4
2
38
WHO. Country Cooperation Strategy at a glance: Cambodia. 2014. WHO. Achieving the health-related Millennium Development Goals in the Western Pacific Region. 2012.
5
Institute for Health Systems Research. Adverse Events in MOH Non-Specialist Hospital. 2010.
7
Ministry of Health, Singapore. Patient Satisfaction Survey 2013. 2013.
8
6
Orlanes JE. “Health Check: The Cost of Medical Care in Japan.” Tokyo Weekender. 2014. WHO Regional Office for the Western Pacific. Antimicrobial Resistance. 2014.
Bloomberg. Most Efficient Health Care 2014: Countries. 2014. 9
Australian Institute of Health and Welfare. Survey in Australia’s hospitals. 2014. 10
PHYSICIANS PER 10,000 PEOPLE (2006 – 2013)
About 65% of Japanese patients with chronic conditions can be expected to secure same-day access
15.3 0.5 – 32.7 Papua New Guinea – Australia
to a healthcare provider.7 HOSPITAL BEDS PER 10,000 PEOPLE (2006 – 2013)
43
5 – 137 Philippines – Japan
spending for many countries in the Western Pacific are among the highest in the world. In the Philippines, household spending accounts for 58% of health spending. 2
Lower rates of hospital-acquired MRSA (methicillin-resistant Staphylococcus aureus )were reported in the Philippines
THE HEALTHCARE SYSTEM
The levels of out-of-pocket
(38.1%) compared to the Republic
PER CAPITA TOTAL EXPENDITURE ON HEALTH AT AVERAGE EXCHANGE RATE (US$) (2011)
TOTAL EXPENDITURE ON HEALTH AS % OF GDP (2011)
GENERAL GOVERNMENT EXPENDITURE OF TOTAL EXPENDITURE ON HEALTH (2011)
of Korea and Vietnam, which had very high prevalence rates of 77.6% and 74.1%, respectively. 8
OUT-OF-POCKET EXPENDITURE AS % OF PRIVATE EXPENDITURE ON HEALTH
6.3% of admissions into Ministry
$679
$35 – $5,991 Lao PDR – Australia
6.6%
2.2% – 17.6% Brunei – Tuvalu Darussalam
65%
22.6% – 99.9% Cambodia – Tuvalu
78.4% 0.5% – 100% Kiribati – Cook Islands, Niue, Tuvalu
of Health non-specialist hospitals in Malaysia had an adverse event (AE) and 78.8% of the AEs were due to errors. 5
76
A skilled birth attendant was present at only 37% of births in Lao PDR. The number is 100% for Fiji. 4
Chen C & Bennett S. “China Smog at Center of Air Pollution Deaths Cited by WHO.” Bloomberg Business. 2014. 11
WHO. Public health, environmental and social determinants of health (PHE). 2015. 12
Moore M. “China’s ‘airpocalypse’ kills 250,000 to 500,000 each year.” The Telegraph. 2014. 13
HEALTH IN SOCIETY
LIFE EXPECTANCY AT BIRTH IN YEARS (2012)
62 – 83 Papua New Guinea – Australia, Singapore
DEATHS CAUSED BY NCDS 1 (2008)
80%
42% – 91% Papua New Guinea – Australia
UNDER-FIVE MORTALITY RATE DEATHS PER 1,000 LIVE BIRTHS (2012)
16 3 – 72 Japan, Singapore – LAO PDR
39
AFRICA
THE AMERICAS
EASTERN MEDITERRANEAN
EUROPE
SOUTHEAST ASIA
WESTERN PACIFIC
2.6
20.8
11.4
33.1
5.9
15.3
2
23
8
53
10
43
$99
$3,482
$195
$2,370
$69
$679
6.2%
14.1%
4.2%
9%
3.7%
6.6%
GENERAL GOVERNMENT EXPENDITURE OF TOTAL EXPENDITURE ON HEALTH (2011)
48.3%
49.5%
51%
73.9%
36.7%
65%
OUT-OF-POCKET EXPENDITURE AS % OF PRIVATE EXPENDITURE ON HEALTH
56.6%
30.1%
88.9%
68.8%
84.3%
78.4%
PHYSICIANS PER 10,000 PEOPLE (2006 – 2013)
HOSPITAL BEDS PER 10,000 PEOPLE (2006 – 2013)
PER CAPITA TOTAL EXPENDITURE ON HEALTH AT AVERAGE EXCHANGE RATE (US$) (2011)
TOTAL EXPENDITURE ON HEALTH AS % OF GDP (2011)
40
AFRICA
THE AMERICAS
EASTERN MEDITERRANEAN
EUROPE
SOUTHEAST ASIA
WESTERN PACIFIC
58
76
68
76
67
76
28%
79%
52%
87%
55%
80%
95
15
57
12
50
16
377
20
5.5
20
22
6.8
29.7% 23.5%
24.5% 13%
23.1% 20.4%
3.7% 1.7%
6.8% 5.1%
LIFE EXPECTANCY AT BIRTH IN YEARS (2012)
DEATHS CAUSED BY NCDS 1 (2008)
UNDER-FIVE MORTALITY RATE DEATHS PER 1,000 LIVE BIRTHS (2012)
HIV MORTALITY RATE DEATHS PER 100,000 PEOPLE (2012)
OBESITY RATE AMONG ADULTS OVER 20 YEARS OLD (2008)
11.1%
women
ALCOHOL
USE AMONG ADULTS OVER 15 YEARS OLD (2011)
men
women
6
CONSUMPTION LITERS PER YEAR AMONG ADULTS OVER 15 YEARS OLD (2011)
TOBACCO
5.3%
men
women
8.4
men
0.7
women
men
women
10.9
men
women
3.5
men
6.8
7%
22%
16%
26%
4%
38%
19%
38%
4%
34%
3%
47%
women
men
women
men
women
men
women
men
women
men
women
men
41
42
HEALTH SYSTEMS IN FOCUS TAKING THE TEMPERATURE OF HEALTHCARE IN CHINA, EUROPE AND THE USA.
43
FROM EAST TO WEST From China over Europe to the United States of America, healthcare systems are under pressure to fulfill their task of delivering quality healthcare. This chapter gives three of the largest and most prominent healthcare systems in the world a check-up in order to describe some of the systemic challenges that are holding them back from becoming safer, smarter and more sustainable. By giving an objective diagnosis of the healthcare systems in China, Europe and the United States of America, we can begin to discuss the differences as well as the common healthcare denominators for the world today. The state of healthcare is uncovered by examining how the seven dimensions of quality in healthcare – adapted from the Institute of Medicine – measure up with the reality on the ground.
THE SEVEN DIMENSIONS OF HEALTHCARE QUALITY ARE: EQUITY
EFFECTIVENESS
SAFETY
TIMELINESS
PERSON-CENTERED CARE
ENVIRONMENTAL SUSTAINABILITY
COST-EFFICIENCY
The analysis is coupled with insights from the three roundtables conducted in the regions, where professionals, patients, policy makers and researchers discussed the future of healthcare and pointed us towards challenges and opportunities.
44
CHINA China faces some unique challenges in terms of sustainable healthcare provision in the coming decades. Its demographic and economic transitions have resulted in a massively expanding healthcare system, even outpacing the country’s economic growth. While government reforms in 2009 have acknowledged the need for a more personcentered healthcare system, the country is still struggling to institute such changes across the board. Drastic differences in access to quality healthcare between rural and urban populations is a major challenge, as are safety and hospital payment structures that incentivize over- and under-treatment of patients. Although the challenges China faces in relation to healthcare quality and sustainability are significant, certain bright spots, such as hospital coordination improvements and the Essential Drug List, could have the potential to help transform China’s healthcare system into one that is more equitable, person-centered and sustainable.
PAGES 46-65
EUROPE The healthcare systems of Europe are a microcosm of the region as a whole: constantly evolving and increasingly coherent, yet still fragmented in many respects. The Euro Debt Crisis and subsequent financial instability has put a serious strain on the region’s healthcare systems.
THE UNITED STATES OF AMERICA The healthcare system of the United States is under serious pressure due to high costs, the growing burden of NCDs, and the extreme variation in care quality. The country’s inefficient payment model has led to healthcare costs that far outpace any other industrialized nation.
Social factors such as aging populations and the growing burden of NCDs have only exacerbated these challenges. Despite national autonomy, the region’s countries are intertwined and deeply connected. Citizens have an increasing choice in where to live, work and seek healthcare.
Yet still, the care received by many Americans is of a markedly lower quality than many of their Western counterparts. Such inefficiencies are compounded by the increasing problem of NCDs and the growing divide between wealthy and poor citizens. Progress is being made1, as
Such interconnectedness has led the region
recent healthcare reforms have been designed
to adopt European-wide healthcare initiatives,
to address some of these disparities and
aimed at providing all of Europe with more
challenges. 2
equitable, safe and person-centered care in the years to come.
There remains, however, a long road ahead for the country in terms of equalizing access to care, lowering healthcare spending, and cultivating an all around more sustainable and efficient
PAGES 66-91
healthcare system.
PAGES 92-113
U.S. Department of Health and Human Services. The Affordable Care Act is Working. 2015. 1
Patient Protection and Affordable Care Act, 42 U.S.C. § 18001. 2010. 2
45
CHINA RECALIBRATING A SYSTEM FOR NEW DISEASE PATTERNS In 2009, the central government in China announced that a series of reforms would be implemented in an effort to provide safer, more convenient, and more affordable care to its population of 1.3 billion. The reforms affect nearly every aspect of healthcare, from insurance and primary care, to hospital management, medications, and public health. The reforms underline the fact that the health-
are more likely to live longer. In 2010, people
care sector has become an economic and
aged 60 and over accounted for 13% of the total
strategic priority for China. Healthcare spending
population and it is expected that this will further
in China is expected to near $890 billion a year
increase to 24% by 2030. 2
by 2017, growing by an average rate of 13.8% annually in local currency terms from 2013-2017.
As the country’s demographics and citizen
Total spending is forecast to reach the equivalent
lifestyles have changed, so have the diseases
of 5.9% of GDP by 2017, up from an estimated
which afflict them. The rate of non-communica-
5.3% in 2012.1
ble diseases (NCDs) has increased dramatically in China, and today more than 85% of the country’s
46
China has made impressive strides since the mid-
mortality is attributed to NCDs. While NCDs have
20th century in terms of healthcare. Notably, life
become the primary disease burden, communi-
expectancy at birth rose from 35 years before
cable diseases remain a problem in some western
1949 to 75 years in 2010. This increase has also
provinces, illustrating the often extreme divide
resulted in a rapidly aging population, as people
between urban and rural livelihoods in China. 3
While China has made remarkable progress in
There are also some positive developments, as
recent decades, serious challenges remain in
programs are seeking to help balance healthcare
the country’s approach to healthcare delivery.
resources between rural and urban populations6,
As explained in the analysis below, the divide
and new reforms like the redesign of the Essen-
between wealthier urban residents and poor-
tial Drug List have the potential to provide more
er rural citizens is apparent in their respective
equitable and safer access to pharmaceuticals.7
healthcare access. Corruption is a serious issue and person-centered care, while gaining traction,
remains almost entirely absent in some regions.4 Deloitte. Global healthcare outlook: Shared challenges, shared opportunities. 2014. 1
Due to major structural problems, safety for both patients and doctors alike is a concern. 5 The healthcare sector is growing at a rapid pace, consuming more economic resources, but the allocation and use of such funds is, at times, wasteful and inefficient.
WHO. Health sector reform in China. 2015. 2,3
Ministry of Health, China. “Counterpart Technical Support between Urban Tertiary Hospitals and Rural Hospitals in China.” WHO – Global Health Workforce Alliance. 2011. 6
IMS Consulting Group. New Game. New Opportunities. New Direction. 2013. 7
Yip W & Hsiao W. “The Chinese Health System At A Crossroads.” Health Affairs 2008; 460-468. 4
Hesketh T et al. “Violence against doctors in China.” BMJ 2012; 345. 5
47
CHINA
/ EQUITY
DIVIDED BY PHYSICAL AND SOCIAL INEQUALITIES While more Chinese citizens than ever now have health insurance, ensuring equal access to high quality care is still a major challenge for China’s healthcare system. The country’s physical and social divides continue to lead to inequality in terms of access to healthcare.
Stark differences between rural and urban China have cultivated a system in which urban dwellers have greater access to care than rural residents. As China’s Ministry of Health reports through the WHO, while 70% of China’s population is located in rural areas, only 20% of total health resources are allocated to the rural population. 8 Physically separated from care, and often with low incomes that restrict travel abilities, rural Chinese tend to receive lower quality care. 9,10 Large, well equipped Chinese hospitals are typically only located in large cities, meaning rural residents must travel great distances or utilize lower quality health centers.11
THE URBAN/RURAL CHASM While healthcare in China has improved dramatically in recent years, it has not improved equally across the entire country. Where a Chinese citizen lives, particularly whether it is in a city or the countryside, impacts that person’s access to care. According to the WHO, at the end of 2011, China had an average of 3.5 medical institution beds per thousand residents – with a total of 877,727 medical institutions. However, there is a striking difference between urban and rural areas, with 6.24 medical beds per thousand people in urban areas, but only 2.80 in rural areas.12 The divide is also evident in the types of hospi-
This section will focus on the division between urban and rural China and corruption as barriers for creating equitable healthcare.
tals that exist in a given region. Chinese hospitals are divided into three classification schemes depending on their size and capabilities, with first-level hospitals being the smallest and least well-equipped and third-level hospitals being the largest and best equipped.
8
Ministry of Health, China. “Counterpart Technical Support between Urban Tertiary Hospitals and Rural Hospitals in China.” WHO – Global Health Workforce Alliance. 2011.
11
Yip W & Hsiao W. “The Chinese Health System At A Crossroads.” Health Affairs 2008; 460-468.
12
9
Lua W. “Universal Rural healthcare in China? Not So Fast.” The Atlantic. 2013. 10
48
Chen Y, Zhou Y & Xie Q. “Suggestions to ameliorate the inequity in urban/rural allocation of healthcare resources in China.” International Journal for Equity in Health 2014; 13:34. WHO. Health sector reform in China. 2015.
WHO Western Pacific Region. Health Sector Reform in China. 2015. 13
The State Council of the People’s Republic of China. Guideline targets improving healthcare. 2015. 14
15
HIMA Research. Untitled.2013.
Swedish Agency for Growth Policy and Analysis. China’s Healthcare System – Overview and Quality Improvements. 2013. 16
Third-level hospitals are more likely to be in large
ruption has become extremely widespread in the
cities, while first- and second-level hospitals are
healthcare sector and exists at multiple levels. 20
more often located in local townships and smaller
Patients offer bribes, or as it is called in Chinese
cities.13 In 2011, China had 1,350 public third-level
hongbao, to doctors in the hopes of getting the
hospitals, 6,034 second-level hospitals and 2,908
best treatment possible. Drug companies and
first-level hospitals.14
medical manufacturers are also complicit in these schemes, as seen in the high profile case of Brit-
Rural China also has a drastically low supply of
ish pharmaceutical giant GlaxoSmithKline’s 2013
doctors, due in large part to their hospitals’ less
$488 million bribery fine for channeling nearly
technologically advanced equipment, physicians’
that same amount of money through conduits to
lower salaries, as well as lower prestige.15 As Law-
physicians and other medical staff to prescribe
ton Burns, a healthcare management professor at
their drugs at inflated prices. 21 Such practices
the Wharton Business School notes; “Why would
worsen an inequitable system as access to care
a doctor move from a class three urban hospital
becomes a matter of wealth rather than respond-
to the lower pay of a class one or two hospital in
ing to a clinical need.
a rural area? Doctors lose prestige and money by going outside the cities.” 16 Despite these challenges, rural hospitals have made substantial strides in providing better quality care in recent years. From 2005 to 2008,
5 KEY PRIORITIES OF THE CHINESE HEALTH REFORM OF 2009
as part of a WHO project, 10,000 physicians from well-respected urban third-level hospitals were assigned to work at rural county-level hospitals and township health centers. These doctors agreed to work in rural areas for one year, also providing training for healthcare workers in these communities, in exchange for higher wages and guarantees of future promotion.17 Additionally, a World Bank project in the rural Henan Province restructured hospital payment schemes and subsequently discouraged over-prescription, increased patient satisfaction, and increased physician salaries.18 To read more about alleviating healthcare treatment gaps in rural China, head to
The Chinese government’s 2009 reforms identified five priority areas and established a committee across ministries to coordinate their policy formulation and implementation. The five priorities are: • Accelerating the establishment of the basic medical security system • Establishing a national essential medicines system • Strengthening health services at grass roots level • Promoting the equalization of basic public health services • Promoting pilot projects for public hospital reform 22
page 148 of our Change Makers chapter to learn
Pilot project in practice: In June 2014,
about LifeSeeds.
China announced that 17 new pilot cities will fully implement hospital reforms, intended to strengthen policy interpretation, provide training for
CORRUPTION IS A FACTOR
relevant management personnel and
Given the sensitivity of the subject, little data
heads of pilot hospitals, and improve
exists concerning corruption in China’s healthcare
management. They will also work to
system. But according to Transparency International’s annual corruption perception index, China
publicize and communicate changes to the community. 23
ranks 117 out of 175 nations.19 By all accounts cor-
Wharton – University of Pennsylvania. Healthcare in China: Is There a Doctor in the House? 2013. 17, 18
19
WHO. Counterpart Technical Support between
Urban Tertiary Hospitals and Rural Hospitals in China. 2011.
21
World Bank. Hospital Reforms in Rural China Increased Patient Satisfaction. 2013.
22, 23
20
Transparency International. Corruption Perceptions Index 2014: Results. 2014. Beech H. “How Corruption Blights China’s Healthcare System.” Time. 2013.
49
CHINA
/ SAFETY
SAFETY AN ISSUE FOR PATIENTS AND PROFESSIONALS Safety is perhaps the most basic component of any healthcare system, but it is one in which China still struggles.
According to the limited information on the
EDUCATION AND TRAINING LEVEL OF
subject, the rate of hospital-acquired infections
DOCTORS VARIES
appears to be relatively low in China. The educa-
Having adequately educated and skilled care
tion and training of doctors, however, is a public
providers is one of the most vital components of
health concern, particularly for lower-income pa-
ensuring patient safety. China had about 2.3 mil-
tients in rural communities. 24,25 Additionally, a re-
lion doctors in 2010, 90% of whom are trained in
cent phenomenon of patient attacks on doctors
Western medicine. However, the level and quality
illuminates another side of the safety challenge
of training varies a great deal. Many doctors have
in China, as frustrations with poor and danger-
only a 3 year post-secondary certificate and the
ously inefficient treatment has been blamed for a
typical 8 year MD training of Western institutions
drastic increase in the number of incidents where
was, as of 2010, available only at two universi-
patients attack doctors. 26
ties. 27
Qualification of doctors and hospital acquired
Additionally, lacking a history of primary care,
infections are highlighted below as indicators
China has very few GPs. As such, most doctors
of the state of patient safety in Chinese health-
working at Community Health Centers (CHCs)
care. In addition, the aspect of physician safety
are not trained as GPs and are not necessarily
is presented as a unique propensity in Chinese
equipped to diagnose and treat common diseas-
healthcare.
es and chronic ailments experienced by patients at those facilities. 28,29
Tao X et al. “Hospital-acquired infection rate in a tertiary care teaching hospital in China: a cross-sectional survey involving 2434 inpatients.” International Journal of Infectious Diseases. 2014; 27: 7-9. 24
Q & Lu Y. “Medical Education Reforms in China.” Asia Pacific Biotech News 2014; 10(15): 805-808.
Wannian L & Chan D. “Community Healthcare Reform and General Practice Training in China – Lessons Learned.” Medical Education Online 2004; 9(10). 28
McKinsey & Company. China’s Healthcare Reforms. 2010. 29
25
Beam C. “Under the Knife.” The New Yorker. 2013. 26
McKinsey & Company. China’s Healthcare Reforms. 2010. 27
50
Tao L et al. “Device-associated infection rates in 398 intensive care units in Shanghai, China: International Nosocomial Infection Control Consortium (INICC) findings.” International Journal of Infectious Diseases 2011; 15(11): 774-780. 31
Tao X et al. “Hospital-acquired infection rate in a tertiary care teaching hospital in China: a cross-sectional survey involving 2434 inpatients.” International Journal of Infectious Diseases. 2014; 27: 7-9. 32
Hu B et al. “Device-associated infection rates, device use, length of stay, and mortality in intensive care units of 4 Chinese hospitals: International Nosocomial control Consortium findings.” American Journal of Infection Control 2013; 41(4): 301-306. 30
Beam C. “Under the Knife.” The New Yorker. 2013. 33
Burkitt L. “Violence Against Doctors on the Rise in China.” Wall Street Journal. 2013. 34
Hesketh T et al. “Violence against doctors in China.” BMJ 2012; 345. 35, 36
Beam C. “Under the Knife.” The New Yorker. 2013. 37
THE CASE OF LEE MEGNAN The case of Li Megnan, a 17-year old boy who attacked and killed hospital intern, Wang Hao, in 2012, drew national attention in China. Megnan’s story came to symbolize the collapse of doctor-patient and a fundamental dysfunction in China’s healthcare system, plagued by high costs, questionable diagnose, and poor care provision. Experiencing severe leg pain in his village, Megnan travelled 6 times over the course of 2 years to doctors in larger city hospitals, as those closer to home were unable to properly treat his condition. However, his care in Beijing and Harbin were hardly improvements. Faced with repeated bureaucratic hurdles, incorrect diagnoses, late detection of secondary ailments that necessitated pausing care for his leg pain and raising the cost of treatment through additional prescription drugs, Megnan reached a breaking point. While condemning his actions, many in China sympathized with Megnan’s utter frustrations. As the New Yorker reported in 2014, “Li Mengnan wasn’t a lunatic, nor did he have a history of violence. He was a man whom society had failed so completely that he was impelled to lash out.”
37
MORE DATA NEEDED ON HOSPITAL ACQUIRED
WHEN THE SYSTEM ATTACKS
INFECTIONS
When most of us think of safety in the healthcare
Generally speaking, little data exist on the issue
sector, we think primarily of patient safety. Yet,
of healthcare associated infections in China. 30
in China, safety and treatment of patients has
Therefore, knowledge on this burden comes from
become increasingly tied to the safety of doctors
small scale studies in various regions and cannot
and other healthcare providers. A survey by
be regarded as representative of the country as
the China Hospital Management Association
a whole. Still, the different studies can give the
found that violence against medical personnel
reader an idea of the state of HAI’s in China.
increased an average of 23% each year between 2002 and 2012. 33 By then, Chinese hospitals were
One such study surveyed nearly 400,000
reporting an average of 27 attacks a year, per
patients in 398 ICUs of 70 hospitals in Shanghai
hospital. 34
from September 2004 to December 2009 and determined that the rate of device-associated
The survey identifies four primary contributing
healthcare-associated infections was 5.3%. 31
factors to this phenomenon in China, name-
Another report from 2014 – a one-day point
ly a deteriorating doctor-patient relationship,
prevalence study of HAIs in the Yijishan Hospital
caused by the shortcomings of the health system;
of Wannan Medical College – found that the
seeking high level specialist care even for minor
prevalence rate of such infections was 3.53%
conditions, leading to unrealistic expectations;
among a survey of 2,434 patients. 32 While these
physician unhappiness and low morale; and inef-
studies act as examples of large and small
fective and inefficient legal channels for handling
scale surveillance of HAIs, the lack of a wider
malpractice disputes. 35 Solving this problem will
breadth of knowledge at a national scale results
take structural changes, such as improved insur-
in a significant knowledge gap. More extensive
ance coverage and lower out-of-pocket costs, a
studies on HAIs in China would therefore be
better system of legal redress, and an increase in
needed before firm conclusions about their
the use of primary care facilities. 36
prevalence and impact can be made.
51
CHINA
/ PERSON-CENTERED CARE
THE PATIENT IS A RESOURCE China’s approach to person-centered care has made significant strides in recent years. Yet, while some mindsets have changed, many structural practices have not. Person-centered care, therefore, remains a goal rather than an achievement. Person-centered care has been discussed in
to create patient organizations. According to
China’s healthcare system since at least 1997, and
the Stockholm Network’s report “Patient Power
has, since the 2009 blueprint for future health-
– what it takes for patient associations to help
care, been an official consideration of the govern-
shape public policy,” China is among the nations
ment. 38 The approach to person-centered care
least conducive to the inclusion of the patient
has been top down, with policy makers imposing
voice in health policy, when compared with seven
new rules on practitioners, such as to improve
other key emerging markets. There is no formal
communication with patients, respect privacy,
process of incorporating patients’ views.41
treat patients with dignity, and smile more. 39 Still, these reforms have yet to truly take hold. As
Although China’s constitution officially includes
Jingqing Yang of the Institute for International
freedom of speech and of assembly, there are
Studies at the University of Technology in Sydney
certain barriers preventing patients from exer-
and expert in Chinese healthcare, reports, the
cising their rights. According to the Stockholm
person-centered care reforms “provided some
Network’s report, the existing legislation on the
change in the way doctors and patients interact –
rights of patients still suffers from inconsistencies
and helped to create a culture that focuses more
and there are difficulties in organizing patient
on patients, but the Chinese healthcare sector is
associations. Some patient groups also suffer
not patient-centered through and through.”40
discrimination e.g. those that advocate for HIV/ AIDS awareness. As long as these structural
As described below, person-centered care is
barriers are in place, China will have tremendous
beginning to be seen in coordination efforts
difficulties in developing a truly patient-centered
at certain hospitals, but in other areas, such as
healthcare system.
patient involvement and eHealth, it still has some way to go. SMALL STEPS TOWARDS CONTINUOUS CARE Ensuring smooth transitions between different
52
NO TRADITION FOR INVOLVING PATIENTS
stages of care and providing patients with a
A strong indicator of patient engagement is the
seamless experience between nurses, doctors
opportunity for patients to be a part of health-
and hospitals is a central aspect of person-cen-
care policy development, as well as their ability
tered care. As it stands now, very little coordina-
tion exists in the Chinese hospital system. Appointment booking, for example, often includes bureaucratic hurdles, with patients typically unable to book consultations over the phone, instead needing to appear in person at their hospital of choice to wait in line in order to receive an appointment time.42 Some great strides are being made in this area though, as explained in the Journey Toward Opportunities chapter on p. 133. A small, qualitative 2014 study on the care of older adults with chronic illness from two general hospitals, two nursing homes, one community hospital and one clinic in the city of Tianjin found that nurses may lack an understanding of continuity of care for patients.43
E-HEALTH LANDSCAPE STILL FRAGMENTED eHealth and the use of electronic medical records contribute a great deal to person-centered care, as they make it easier for both patients and care providers to access and share health information. Both have been expanding in China since the early 2000s, but the systems have been afflicted by numerous problems preventing optimal use and coordination. These include insufficient funds to create a widespread and meaningful system; a lack of unification and coordination, resulting in the simultaneous creation of over 100 electronic record keeping systems in various regions and cities without interoperability; a lack of legislation and
Though limited, there are some indications of efforts to improve coordination at some large, busy hospitals. An initiative began in 2013, piloted in several major municipal hospitals, to break down barriers between hospital departments so that beds could be utilized in an integrated and coordinated manner, with greater efficiency and exploitation.44 Currently, some hospital departments are at full capacity while others, in the same building, have vacant beds, but due to restrictions they cannot share beds between divisions. This restructuring plan could potentially allow more patients to be admitted.
regulation; reluctance toward information sharing, particularly with large metropolitan hospitals not willing to share information with smaller Community Health Centers (CHCs), nor likely to recognize a diagnosis or test from such facilities due to concerns of personnel’s proficiency and the accuracy of their equipment.45 Additionally, access to eHealth material can be difficult for many Chinese – especially rural residents who are furthest from medical centers – due to low internet penetration throughout the country. While internet use has skyrocketed in recent years, from 10.5% in 2006 to 46% in 2014, over half of the country still remains without home- or mobile device-based access.46 See figure 1.
FIGURE 1.
50
INTERNET IS SPREADING RAPIDLY
40
Percentage of internet users in China over time
30
In the last decade the number of Internet users has exploded – paving the way for a more widespread implementation of eHealth.
20
10 Source: Internet Live Stats. China Internet Users. 2014.
0 2004
38
Yang J. The side-effects of China’s patient-centered healthcare reform. 2010.
42
Sustainia & DNV GL. Guide to Person-Centred Care. 2014.
43
39, 40
Stockholm Network. Patient Power – What it takes for patient associations to help shape public poilcy. 2013. 41
2006
2008
Huang E. “It Isn’t Getting Any Easier to Get a Doctor’s Appointment in China.” The Atlantic. 2013. Cheng S.L, Zhao JZ, Bai J & Zang XY. “Continuity of Care for Older Adults with Chronic Illness in China: An Exploratory Study.” Public Health Nursing 2014.
2010
2012
2014
Gao X, Xu J, Sorwar G & Croll P. “Implementation of E-Health Record Systems and E-Medical Record Systems in China.” The International Technology Management Review 2013; 3(2): 127-139. p131 45
46
Internet Live Stats. China Internet Users. 2014.
China-Japan Friendship Hospital. Municipal Hospitals to Pilot Internal Beds Coordination. 2013. 44
53
CHINA
/ COST-EFFICIENCY
THE ECONOMIC BURDEN OF NO GATE KEEPING Maintaining quality care while lowering costs is a difficult challenge for all healthcare systems. While China’s legacy of a lack of primary care exacerbates this burden, administrative problems are also to blame.
Keeping costs low while maintaining a high
A LACK OF GATE KEEPING LEADS TO
quality of treatment is a fundamental challenge
CROWDED CITY HOSPITALS
for healthcare systems across the world. In China, the concrete results of these efforts appear quite mixed. The country’s lack of gate keeping with use of primary care facilities places an enormous and unnecessary burden on hospitals, and thus overcrowding can lower the quality of care. Certain political reforms implemented in the last couple of years, such as the reform of the essential medicines system including the Essential Drug List, provide some hope that funds in the near future can and will be better managed from the top down. This section will hone in on the level of gate keeping in Chinese healthcare and the system’s administrative fragmentation.
In healthcare, a gate keeper is “a primary-care provider... who coordinates patient care and provides referrals to specialists, hospitals, laboratories, and other medical services.” 47 This role is helpful in addressing conditions early on and deferring non-serious ailments from emergency rooms so hospitals can treat those in most urgent need. The lack of gate keeping and utilization of community health centers contributes to overcrowded and inefficient care at hospitals in large cities.48 Patients travel long distances to these hospitals, unsatisfied with the care they would receive closer to home, or they are referred to these facilities by their local Community Health Centers (CHCs). While the CHCs were designed and implemented to act as gate keepers, treating common ailments that require less intensive care and procedures, the poor quality of care they offer has prevented them from relieving the burden of overcrowding at the better respected city hospitals.49
54
Without an effective primary care system in
ESSENTIAL DRUG LIST IS LOWERING COSTS AND IMPROVING ACCESS
place, and without well-functioning CHCs, China’s hospitals are likely to remain overcrowded, with resources spent on minor, easily treatable conditions rather than on patients in the most need.
The Essential Drug List (EDL) is a list of
FRAGMENTATION IS WASTING RESOURCES
drugs approved for use in China’s primary healthcare facilities and is one of 5 central
The 2013 report, “China’s Healthcare System –
components of the Chinese government’s
Overview and Quality Improvements,” conducted
2009 healthcare reforms. The goal of
by the Swedish Agency for Growth Policy Analy-
the EDL is to establish a “comprehensive
sis, found that China’s insurance system is deeply
system which facilitates access and ensures
fragmented, leading to inefficiencies and wasted
affordable care for all citizens by 2020.” 51
resources. While the insurance schemes designed
Hospitals are banned from applying their traditional 15% mark-ups on sales of EDL
to serve urban residents are managed by the
drugs to patients, ideally ensuring that low-
Ministry of Human Resources and Social Security,
income patients can gain affordable access
the plan meant for rural residents is operated by
to these basic medicines. 52
the Ministry of Health. Information on insured
While the initial 2009 EDL system was
individuals in the different systems is not shared
afflicted by inconsistencies and poor
between departments and some people take part
enforcement, the 2012 reincarnation shows
in both urban and rural schemes, which increases
great improvements. The number of
the burden on both the government and the indi-
Western drugs increased from 205 to 317 and coverage broadened to include more
vidual. A report by the Central Auditing Bureau in
treatments. 53 While the national list was
2011 showed that 5.47 million people take part in
expanded to include more drug options,
both resident medical insurance schemes, forcing
greater restrictions were placed on regional
the government to spend an additional nearly
supplementations, thereby ensuring greater
$150 million in subsidies. 50
consistency across geographic locations. 54 These new policies have the potential to improve both safety and cost-efficiency, by balancing expanded coverage with restricted supplementations.
The Free Dictionary by Farlex. Medical Dictionary. 2015. 47
WHO. Health insurance systems in China: A briefing note. 2010. 48
Swedish Agency for Growth Policy and Analysis. China’s Healthcare System – Overview and Quality Improvements. 2013. 50
IMS Consulting Group. New Game. New Opportunities. New Direction. 2013. 51
Yang H et al. “Determinants of Initial Utilization of Community Healthcare Services among Patients with Major Non-Communicable Chronic Diseases in South China.” PLOS One 2014: 9(12). 49
McKinsey & Company. An essential strategy for the essential drug list. 2013. 53
IMS Consulting Group. New Game. New Opportunities. New Direction. 2013. 54
McTiernan R. “China’s EDL release a positive for patients, pharma firms to face pricing pressure.” IHS Life Sciences Blog. 2013. 52
55
CHINA
/ EFFECTIVENESS
EFFECTIVENESS IS IMPROVING, BUT IS NOT INCENTIVIZED In many respects, China’s healthcare system has made immense strides in productivity and effectiveness in recent years, with reforms improving how healthcare operates and serves its citizens. Still, there exists a great deal of waste and poorly managed care, due in large part to distorted incentive structures.
In 2006, only 45% of the population had health insurance. Total health expenditures were $156 billion and per capita costs were $119. By 2011, these numbers had dramatically changed, with 95% of the population now covered under some form of health insurance, and total health expenditures more than doubling to $357 billion. Per capita expenditures also more than doubled, to $261. 55 Despite these improvements, out-of-pocket healthcare costs remain very high due to the fact that insurance often does not cover the full amount of many treatments. Additionally, due to poor incentive structures and systemic corruption many patients pay for tests and procedures they do not need, thus increasing their bill and wasting resources. 56,57,58 Conversely, under-treatment is also a problem, with patients unable to receive needed care due to cost, insurance status, or hospital constraints. The current magnitude of underinsurance and status of over- and under-treatment are indicators of the challenges that the Chinese healthcare system is faced with in terms of providing effective care.
56
UNDERINSURANCE IS WIDESPREAD The drastic increase in the number of insured citizens does not necessarily translate into better or less expensive care for patients. 59 Hospital bills are enormously high in China, and insurance rarely covers the full amount, meaning patients must pay a great deal out-of-pocket or forego care. Costs of care also vary a great deal depending on both the type of insurance someone has and where they live. Ultimately, China has one of the highest ratios of out-ofpocket payments to total health expenditure of any Asian country, and in 2012, 78% of all private expenditures on health came in the form of out-of-pocket payments.60 Additionally, over one-third of households have reduced their consumption or been impoverished by healthrelated expenditures.61 Such a high amount indicates that while a 95% insurance coverage rate is impressive, it may mask more systemic problems with the quality and depth of that coverage.
2%
FIGURE 2.
THE INCENTIVE TO OVERTREAT Hospital income structure in China 91% of hospital income comes from drug sales and medical treatments, thus incentivizing overtreatment and overprescription of medications. Sale of drugs
49%
42%
Government subsidy
Medical treatment income
Other
7%
Source: KPMG. “The changing face of healthcare in China”. 2010. Page 8.
POOR INCENTIVES PROMOTE INAPPROPRIATE
This combined with a fee system, in which
TREATMENT
hospitals are reimbursed by the government for
The double-edged challenge of over- and under-treatment contributes negatively to the effectiveness of healthcare in China. Since the liberalization of China’s economy in the 1970s and 80s, the central government has cut vast amounts of public money for hospitals. As such, these facilities have had to fund themselves, ultimately redirecting costs to patients. Another method of obtaining revenue is by increasing the cost of pharmaceuticals, and as such, hospitals can charge a 15% mark-up on the price non-EDL drugs, and sometimes higher, which often encourages physicians to prescribe more expensive medicines and more of them. For example, 75% of patients suffering from a common cold are prescribed antibiotics, as are 79% of hospital patients – over twice the international average of 30%.62 Given the extremely low salaries of Chinese doctors – officially about $7,500 a year – this incentive to over-prescribe is particularly great.63
McKinsey & Company. Healthcare in China: Entering ‘uncharted waters’. 2012. 55
Huang C. “Healthcare Is So Corrupt In China That Patients Have To Bribe Doctors For Proper Care.” Business Insider. 2014. 56
Beech H. “How Corruption Blights China’s Healthcare System.” Time. 2013. 57
Fan R. “Corrupt Practices in Chinese Medical Care: The Root in Public Policies and a Call for Confucian-Market Approach.” Kennedy Institute of Ethics Journal. 2007; 111-131. 58
McKinsey & Company. Healthcare in China: Entering ‘uncharted waters’. 2012.
services performed, regardless of necessity or quality of care, provides doctors an incentive to perform unnecessary tests, prescribe unnecessary medicine and recommend unnecessary treatments.64 See figure 2. Under-treatment is an equally serious problem in Chinese healthcare, as patients are rushed through the system in order for doctors to see as many people as possible. The Economist reported in 2013 that budget caps at certain hospitals caused doctors to keep the cost of treating each patient under a certain amount. Should that amount be exceeded, the remainder would be deducted from the physician’s own paycheck.65 This misguided tactic incentivizes rushed care and early discharges, and can be extremely dangerous for patients. While over- and under-treating patients may at first glance appear to be opposing problems, they in fact operate in tandem and signify numerous flaws in the healthcare system.
The World Bank. “Out-of-pocket health expenditure (% of private expenditure on health)”. Data. 2015. 60
The Economist. “Feeling your pain.” The Economist. 2013. 64, 65
Yip W & Hsiao W. “The Chinese Health System At A Crossroads.” Health Affairs 2008; 460-468. 61, 62
59
Woodhead M. “How much does the average Chinese doctor earn?” Chinese Medical News. 2014. 63
57
CHINA
/ TIMELINESS
WORTH THE WAIT? Long waiting times have been a wellknown aspect of the Chinese healthcare system. While many hospitals show no sign of change in this regard, others are taking strides to boost efficiency and cut waiting times in the process.
Crowded conditions in China’s largest and best
Since the 2009 healthcare reforms, though, wait-
hospitals – due in large to inadequate or per-
ing times are beginning to go down in a handful
ceived inadequate care at smaller, community
of hospitals. In 2012, Beijing Friendship Hospital,
hospitals – mean that long waiting times are a
for instance, was part of a pilot program de-
norm. Anecdotes abound of hours-long lines that
signed to improve the patient experience. As part
stretch outside just to receive a doctor’s appoint-
of the program, patients would pay more to see a
ment.66, 67, 68, 69 A 2010 PricewaterhouseCoopers
doctor, but drugs sold by that hospital would be
survey of Shanghai, Chengdu and Beijing found
much cheaper, lowering the total bill.71 This also
that while patients are generally satisfied with
resulted in shorter waiting times. Such a program
their choice of hospital, 75% of those dissatisfied
indicates how small changes in hospital income
with the service at their hospital of choice in
models (paying more for doctors rather than
Beijing indicated long waiting times as the pri-
drugs) can serve to improve the patient experi-
mary reason for dissatisfaction.70 This figure was
ence, lower costs, curtail corruption, disincentiv-
also high in Shanghai and Chengdu, at 64% and
ize over-prescription, and reduce long waits.
86.7%, respectively. See figure 3.
Huang E. “It Isn’t Getting Any Easier to Get a Doctor’s Appointment in China.” The Atlantic. 2013.
68
China Smack. “Waiting All Night Outside A Hospital Hoping to See A Doctor.” China Smack. 2009.
69
66
58
China Economic Review. “China’s healthcare reform needs to address hospital waiting times.” China Economic Review. 2009.
65
Lim L. “China’s Professional Queuers Paid to Stand Around.” NPR. 2011.
PricewaterhouseCoopers. Emerging Trends in Chinese Healthcare. 2010 70
Einhorn B & Loo D. “China Raises Doctor Fees, Lowers Drug Bills to Ease Anger.” Bloomberg Business. 2012. 71
FIGURE 3.
WAITING TIMES AND PATIENT DISSATISFACTION
Long wait time
Sources of dissatisfaction with hospital care in Beijing, Shanghai, and Chengdu hospitals
Poor personnel attitude
High price or overcharge Poor physical environment
Qualification of physicians Other
For patients in Beijing, Shanghai, and Chengdu that were dissatisfied with their hospital experience, long waiting times were the most common reason for this dissatisfaction. Source: PricewaterhouseCoopers. Emerging Trends in Chinese Healthcare. 2010.
BEIJING 7.3%
75.6%
SHANGHAI
43.9%
7.3% 32.6%
64%
46.3%
35.5%
9.8%
CHENGDU
54.1%
22.7% 86.7%
40%
11.6%
20%
20%
53.3%
59
CHINA
/ ENVIRONMENTAL SUSTAINABILITY
IN NEED OF A BREATH OF FRESH AIR The relationship between healthcare and environmental sustainability is an often-discussed issue in China. While the impact of the environment on healthcare is well documented and discussed, the healthcare industry’s impact on the environment is less so.
An increasingly important aspect of the health-
without compliance with national or international
care system in China is its environmental impact.
standards of pollution control.72 According to a
Medical waste is a serious concern in China,
recent study in the Shandong Province, a great
and as the world’s largest developing country it
deal of disparity exists between urban and rural
produces a lot of it. Another connection between
hospitals in terms of generation of medical waste.
healthcare and the environment in China is the
In second- and third-level hospitals, for example,
impact that pollution – of both air and water – has
the average waste generation rate was 0.74kg
on the health of Chinese citizens. This leads to a
and 0.56kg per bed per day, whereas in first-level
less healthy population with greater healthcare
rural community hospitals this rate rose to 1.53 kg
needs and higher healthcare costs.
per bed per day.73
In the following, medical waste, air and water pollution are presented as primary indicators of the
AIR POLLUTION IS OFF THE CHARTS
current status of sustainability and the environ-
Pollution is undoubtedly an enormous concern
mental challenges the Chinese healthcare sector
of China’s, and one that severely impacts both
is faced with today.
its health and environmental sustainability. Air pollution is particularly apparent, with stories of China’s dense, grey air making headlines around
MEDICAL WASTE IS PILING UP
the world. Typically, air pollution is measured by
While most of the discussion around sustainabil-
the concentration of particulates in the atmo-
ity in China’s healthcare sector revolves around
sphere, and WHO guidelines state that anything
environmental hazards that impact public health,
over 10 micrograms per cubic meter (PM2.5) of
another serious concern is the negative effect
these particulates is considered dangerous to
that the healthcare industry has on the environ-
human health. To put in perspective how bad Chi-
ment. As a rapidly growing developing country,
na’s pollution problem is, we can compare notori-
safe and efficient disposal of medical waste is
ously smog-filled Los Angeles, which averages an
of serious challenge in China. In 2007, the State
16.2 PM2.5, with the Chinese city of Xingtai, with
Environment Protection Administration reported
a population of over 7 million, which averages a
that China produces about 1,800 tons of med-
truly astounding 155.2 PM2.5.75 China has even
ical waste a day, much of which is disposed of
60
ADDRESSING THE WASTE CHALLENGE Some regions are attempting to address the
...NOT A DROP TO DRINK Air is not the only natural element in China being degraded by rapid industrial development. In
medical waste problem, such as Guangxi’s
2014, Chinese state media reported that 60%
Qinzhou City, which invested $3 million in a
of the country’s underground water was pol-
medical waste disposal center outside the city.
luted.79 It was also reported in 2013 that about
Results, however, are not meeting expectations,
one-third of China’s water resources are ground-
as particularly rural hospitals still choose to burn their hazardous waste rather than recycle
water-based, and that only 3% of the country’s
and process it properly.72 It remains to be seen
urban groundwater can be classified as “clean”. 80
whether these efforts can make an impact on the
Some regions are worse than others, with the
actions of hospitals and medical centers in terms
land ministry reporting that 70% of groundwa-
of their medical waste disposal protocols.
ter in the north China plain – an area that covers approximately 400,000 sq km and is some of the world’s most densely populated land is unfit for human touch, let alone consumption. 81 In 2007 The World Bank estimated that the health cost of
adapted its own air quality scale, relative to that
cancers and diarrhea associated with water pol-
of Europe and the United States. This reflects
lution reached approximately $8 billion in 2003 in
their inability to reach what is elsewhere consid-
rural areas of China. 82
ered safe and healthy pollution levels. One positive element of these reports is the Pollution has drastic consequences for China’s
source from which they are coming. The fact
healthcare system. The OECD reported that in
that Chinese state media are voluntarily produc-
2010 the health impact of air pollution in China
ing such alarming information about their own
was approximately $1.4 trillion.76 With data from
pollution habits appears to be a sign of increasing
a Global Burden of Disease study, the New York
transparency and accountability. Additionally, in
Times reports that air pollution contributed to 1.2
2013 the government announced plans to invest
million premature deaths in China in 2010, nearly
$277 billion to curb air pollution, aiming to reduce
40% of the global total that year. Nationally, this
air emissions by 25% by 2017 compared with 2012
means China lost 25 million healthy years of life
levels. 83 Such transparency and financial invest-
from the population.77 Beijing’s Center for Disease
ment are positive signs that the Chinese govern-
Control and Prevention recently reported that an
ment is serious about addressing its pollution
average 18 year old living in the city can expect
problems.
to spend as much as 40% of their remaining life in less than full health, suffering from cancer, cardiovascular disease, arthritis, and other ailments related to the city’s extremely poor environmental conditions.78
International Finance Corporation – World Bank Group. IFC Investment in Medical Waste Treatment Plants in China is Expected to Benefit 120 million people. 2007. 72
Gai R et al. “Hospital medical waste management in Shandong Province, China.” Waste Management & Research 2009; 27(4): 336-42.
China Daily. “China’s medical waste piles up.” China Daily. 2013.
Minter A. “Why Living in Beijing Could Ruin Your Life.” Bloomberg View. 2014.
Kan H. ”Environment and Health in China: Challenges and Opportunities.” Environmental Health Perspectives 2009; 117(2): 530-531.
74
78
82
Washington Post. “Worst air pollution in China and the U.S.” Washington Post. 2014.
79, 80
Kaiman J. “China says more than half of its groundwater is polluted.” The Guardian. 2014.
83
75
73
OECD. The Cost of Air Pollution. 2014. 76
Wong E. “Air Pollution Linked to 1.2 Million Premature Deaths in China.” New York Times. 2013. 77
China Water Risk. North China Plain Groundwater: >70% Unfit for Human Touch. 2013. 81
Reuters. “China to invest $227 billion to curb air pollution: state media.” Reuters. 2013.
61
SHANGHAI ROUNDTABLE The first of three roundtables on our global journey to co-create better healthcare systems took place in Shanghai, China. The discussions and active participation of stake holders from all parts of the Chinese healthcare system resulted in co-created outcomes in the form of identified challenges and opportunities for how we can change the system for the better. To spur discussions, Dr. Duan Tao, President of Shanghai First Maternity & Infant Hospital and Mr. Alex Lam, Vice Chairman of Hong Kong Alliance of Patients’ Organizations (profiled in an interview on page 64) gave inspirational presentations and summarized the conclusions of the day.
THREE GLOBAL ROUNDTABLES In late 2014 and early 2015, DNV GL and Monday Morning Sustainia traveled to Shanghai, Brussels, and Washington DC to gain insights for this publication and start a conversation on challenges and opportunities for improving the quality of care in the healthcare systems of China, the EU and the USA. The guiding question for the roundtables was: HOW DO WE IMPROVE THE QUALITY OF CARE?
62
CHALLENGES FOR HEALTHCARE IN CHINA
OPPORTUNITIES FOR CHANGE
There is a lack of financing and long-term
Involve patients in their treatment plan and establish feedback systems
planning to support the Chinese healthcare reform
Doctors are concentrated in urban areas,
limiting access to care for rural populations
Improve measurement of quality of care Establish incentives that improve quality of care for all
Incentives and hospital payment structures lead to over- and under-treatment of patients
Focus less on check-lists and more on the patient’s needs
Scandals in the healthcare system have resulted in a lack of trust between patients and
Establish trust throughout the system
healthcare professionals
The healthcare professionals are overworked, compromising safety and quality of care
The roundtables were in the format of one-day interactive workshops that gathered key stakeholders from across the healthcare system, including patients, professionals, providers, policy makers and researchers, with the aim of identifying possible trajectories for change by spurring dialogue and discussions based on the various perspectives from the different stakeholders.
63
CHINA
/ EXPERT INSIGHT
one example: there have been sever-
within healthcare. We have to see
al cases of patients or family mem-
the patient as the starting point of
bers hurting hospital professionals
healthcare and have their interests at
because they have not received
the center of all we do.
correct or timely treatment. There is no way of expressing anger or dissatisfaction within the
views and have a say in choice of
system as the formal channels for
treatment through dialogue before
complaints are not working.
and after treatment. Currently the approach of the Chinese healthcare
Mr. Alex Lam Vice Chairman of the Hong Kong Alliance of Patients Organizations Participant at the Shanghai roundtable
WHAT IS TO COME IN THE FUTURE FOR PATIENT ORGANIZATIONS IN CHINA?
portunities for patient organziations as they are seen by medical service
HOW DO YOU SEE THE
ROLE OF PATIENT ORGANIZATIONS IN CHINA? Currently patient organizations
with doctors telling patients what treatment they will be given without listening to patients’ needs.
providers like hospitals and doctors as working against the interest of the system. What could change the situation
WHAT ARE SOME TANGIBLE WAYS THAT CHINESE PATIENTS CAN BECOME MORE ACTIVELY INVOLVED IN THEIR HEALTHCARE? In Hong Kong we have a public complaint committee within the
is that Chinese people are becoming
Hospital Authority. The commit-
are small scale and not yet seen as
more aware of their rights. When
tee includes a representative from
important institutions in the Chinese
they pay their taxes, they also want
patient organizations, making the
healthcare system. It is very difficult
to receive high quality services in
committee more representative and
to form patient organizations be-
the healthcare system. This push
impartial in terms of considering
cause they are seen as challenging
may result in service providers within
complaints.
the system, and we do not have a
healthcare becoming more aware
strong history of service users ques-
of patients’ needs. In the future, I
established for patients to express
tioning the way in which healthcare
think the government may be more
their views and it is important to
is delivered or being involved in the
willing to accept the existence of
stress that these views will include
co-design of services. The result is
patient organization but they would
both complaints and appreciation.
probably still ask for a high degree
Patients are very grateful when they
of monitoring of activities.
receive the right treatment.
“Without patients, healthcare professionals don’t have a job to do.” that the patient voice is not as respected or recognized as it could be. The lack of focus on their inter-
I hope that more platforms will be
In Hong Kong, for instance, HOW CAN THE MINDSETS OF CHINESE HEALTH PROFESSIONALS BE CHANGED TO FOCUS MORE ON THE PATIENT AS AN ACTIVE PARTICIPANT OF THEIR OWN CARE?
64
professionals is more paternalistic,
Currently there are limited opto champion the voice of patients
The healthcare system needs to allow for patients to express their
Without patients, healthcare
the number of people expressing gratitude is four times higher than complaints. That is also why it is important to find a balance between the negative and positive feedback. We need to not only focus on complaints but also start to integrate approaches where patient appreciation
professionals don’t have a job to
is used actively to improve quality in
do. A mindset has to be devel-
the Chinese healthcare system.
ests has resulted in a lot of anger
oped where the patient’s interest is
and frustration from patients. Take
seen as pivotal for all professionals
WHAT IS THE BIGGEST
HOW CAN THE CHINESE HEALTH-
CHALLENGE FACING THE CHINESE
CARE SYSTEM OVERCOME THE
HEALTHCARE SYSTEM?
CHALLENGES OF AN AGEING
China’s large population is a big
POPULATION?
Patients should be willing to receive care outside of their home because it is in their own best interest, both socially and physically. In the future, when the Chinese
challenge but it is also an oppor-
Ageing is stressing the system
tunity, as fixing the problems that
and there is a need for a new mind-
care is provided in other parts of the
afflict the healthcare system has the
set from patients and their families.
world, I believe that we will see the
potential to improve the lives of a lot
In China, it is part of the culture that
needed mindset shift.
of people.
families take care of their elderly
Another challenge we are seeing
members. This is, in many instances,
is that the Chinese population is age-
not a good solution because the care
ing, which will change the healthcare
puts great strains on families and
system considerably in the future.
in some cases means that elderly
Today, we are already seeing more
patients do not receive the right
patients with diseases related to
treatment.
age, such as Alzheimer’s disease and dementia.
have become aware of how health-
HOW CAN PATIENT ORGANIZATIONS INFLUENCE THE POLITICAL DECISION-MAKING PROCESS IN CHINA? My organization has good access
My organization is working to
to the government, but we are not
change the mindset of families and
a large group and have problems in
patients to accept that nursing
regards to resources. We are trying
homes and other facilities that can
our best to push for a mindset where
deliver care to the elderly are op-
patients and families are at the
tions that benefit all parties involved.
center of care. We have suggested
The government will have to show
that the government sets up more
leadership and establish health-
healthcare facilities that can provide
care facilities that can provide care
the care that is needed for the
to elderly patients and treat their
elderly.
diseases.
This could also be done by establishing departments within hospitals
Professor Weiwei Zhang Board Member of the Beijing Association of Alzheimer’s Disease Participant at the Shanghai roundtable
HOW CAN PATIENTS AND FAMILIES BE INVOLVED IN THE TREAT-
that focus solely on providing care to Alzheimer’s and dementia patients.
MENT OF ALZHEIMER’S? Alzheimer’s patients are mostly elderly. The Government provides their medicine for free, but patients have to stay in their homes and be cared for by their families. There are no specialized nursing homes for patients with Alzheimer’s, which is a risk factor because their treatment and medicine are not managed by health professionals.
“Patients should be willing to receive care outside of their home because it is in their own best interest, both socially and physically.”
Alzheimer’s is on the rise in China. We must think of new ways of treating the disease, but it is very important that the patients and their families are involved in this process and that we respect their culture.
65
EUROPE SHARING A HEALTHCARE GOAL The 53 countries that make up the WHO European Region represent healthcare systems that are located within different social, economic, political and cultural contexts. Even though it is easy to view Europe as a fragmented region, 28 states are already coordinating health and healthcare policy through their participation in the European Union. Common challenges, such as ageing populations, increases in chronic diseases, and greater demand for healthcare for less money call for more coordination in the future – not less.
66
Recent years have been has characterized by
The healthcare challenges and solutions of tomor-
a growing body of common guidelines and
row are not staying within country borders but
cross-border healthcare initiatives in Europe.
demand transnational collaborations and knowledge sharing.
One concrete example is the “Communication on Effective, Accessible and Resilient Health Systems,�
Although the policies, organization, and delivery of
which came from the European Commission in
healthcare remain the responsibilities of individual
2014. It advocates the use of performance assess-
governments, the EU plays a role in helping to set
ment results, improved patient safety and develop-
new standards, promoting change, and exchanging
ment of integrated care.
best practice across borders.
Another cross border initiative is the European
Through the seven dimensions of quality in health-
health policy framework, Health2020, which was ini-
care, this chapter gives you an insight to the chal-
tiated by the WHO and adopted by the 53 member
lenges that the European healthcare systems face.
states of the Region in 2012. It urges governments to cooperate in fulfilling two strategic objectives: 1) improving health for all and reducing health inequalities, and 2) improving leadership and participatory governance for health.
67
EUROPE / EQUITY
PROTECTING UNIVERSAL CARE Despite the economic crisis, access to healthcare is still considered a fundamental right in European countries. This does not mean that all healthcare needs in the region are met – especially for low income groups.
Access to healthcare constitutes a basic right
UNMET CARE – PARTICULARLY FOR
according to the Charter of Fundamental Rights
THOSE MOST IN NEED
of the European Union.¹ This right, however, has been challenged by the recent economic crisis where health expenditures fell in half of the EU countries and growth significantly slowed in the other half. The crisis meant cuts in health workforce and salaries, reductions in fees paid to health providers, lower pharmaceutical prices, and increased patient co-payments.² These measures have had a negative effect on patients’ abilities to access the health system.³ Universal (or near universal) health coverage in most EU countries has remained the norm during and after the crisis.⁴ Still, The Euro Health Consumer Index from 2014 states that the financial crisis has resulted in a “slight but noticeable increase in inequity of healthcare services across Europe” and detects the biggest equity gap between wealthy and less wealthy European countries in the nine year history of the index.⁵ This section will hone in on coverage of healthcare costs, unmet care needs and doctor consultations examining the overall question: How equitable are the European healthcare systems?
In all European countries, the large majority of the population does not experience unmet care needs, according to the 2012 EU Statistics on Income and Living Conditions Survey.⁶ However, in Latvia, Poland, Romania and Bulgaria, for example, more than 10% of the respondents had unmet needs for a medical examination, and this burden fell unevenly on low income groups. On average across EU member states, more than twice as many people in low income groups reported unmet needs as did people in high income groups. The main reason for people in low income groups to report unmet healthcare needs was that care was too expensive. The proportion of people in low income groups reporting unmet needs for financial reasons is two times greater than that of the population as a whole and over four times greater than among people in high-income groups on average across EU countries.⁷
¹ European Parliament. Charter of Fundamental Rights of the European Union. 2000.
⁴ European Commission. Health at a Glance: Europe 2014 Executive Summary. 2014.
² European Commission. Health at a Glance: Europe 2014 Executive Summary. 2014.
⁵ Health Consumer Powerhouse. Euro Health Consumer Index. 2014.
³ Health Consumer Powerhouse. Euro Health Consumer Index. 2014.
68
According to sociological monitoring carried out in Russia for problems with the nations’ health systems,
ROMANIA IS STRUGGLING TO PROVIDE EQUAL ACCESS
high drug prices and out-of-pocket payments are two of the most crucial problems facing the country’s healthcare system, according to
In Romania, access to healthcare is a serious concern, especially for low income groups.
70% and 35% of respondents, respectively.
According to a review of the Romanian Health
Additionally, nearly half of the respondents men-
Sector by The World Bank from 2011, many poor
tioned that they would have to limit their food
individuals who are in need of healthcare do not
spending and purchase of staple goods to pay for
seek care.
medical services.12 High healthcare costs are there-
This is the case for almost 10% of the population. 8
fore having a significant impact on the quality of life
This gap is particularly large in the treatment
of many Russian citizens.
of chronic disease, as 42% of the poor with a chronic condition do not seek care, compared with 17% of the rich.
CRISIS CREATES VULNURABILITY IN
The true gap is likely even larger, as, according to the World Bank’s report, many low income
HEALTHCARE
individuals with chronic conditions are not aware
Most European countries have universal or near-uni-
9
of their need for care. Simulations that assume
versal coverage for a core set of healthcare services
that the need for care for chronic conditions
– exceptions are Bulgaria, Greece and Cyprus where
is similar between wealthy and poor people
a significant proportion of the population is unin-
estimate that a whopping 85% of the poor who need medical care are not getting it. In March 2014, the World Bank approved a loan to Romania of $338.8 million for the objective of improving access to, and quality and efficiency of public health services in Romania.10 The reforms include the streamlining of hospital services; enhancing primary care services,
sured. In Bulgaria, public insurance is not automatic for the unemployed and self-employed. Instead, they have the option to buy it. In Greece, coverage is reduced after 24 months of
particularly at the community level; and
unemployment. Both systems, and the people they
increasing sector governance and stewardship
serve, are very vulnerable to economic crises that
in order to improve management, strengthen
cause high unemployment rates.
departmental communication and better incentivize primary care. These reforms are expected to improve the performance of the health system as a whole and reduce existing inequities in terms of access to quality care amongst the population. The World Bank program will run until 2020.11
⁶ European University Institute. EU Statistics on Income and Living Conditions. 2015. ⁷ OECD & European Commission. Health at a Glance: Europe 2014. 2014. ⁸ The World Bank Europe and Central Asia Region. Romania Functional Overview – Health Sector. 2011.
The World Bank. Romania – Health Sector Reform – Improving Health System Quality and Efficiency Project. 2015. 10
The World Bank. Project appraisal document on a proposed Loan in the amount of Euro 250 million to Romania for a health sector reform – improving health system quality and efficiency project. 2014. 11
European Observatory on Health Systems and Policies. Health Systems in Transition – Russian Federation: Health system review. 2011. 12
The World Bank Europe and Central Asia Region. Romania Functional Overview – Health Sector. 2011. Page ix. 9
69
FIGURE 4.
COUNTRIES INTRODUCING COSTS FOR ACCESS TO HEALTHCARE
Greece
In 2011 copayments increased from approximately $3 to $5 for outpatient hospital care and health centers.
Ireland
Portugal
In 2008, it cost about $65 to access emergency care and $65 per day for hospital care, capped at 10 days per year ($650). By 2013, this was increased to over $100 to access emergency care and $80 per day for hospital care, capped at 10 days per year ($800). These fees are waived for people with a medical card (40% of the population in 2013).
The 2014 Eurofund report, “Access to healthcare in times of crisis,” which explores the impacts of the financial crisis on access to public healthcare services, also found that economic crises are contributing to the emergence of new types of vulnerable groups which have difficulties accessing healthcare.13 Job loss – and the loss of work-associated health insurance – is creating new groups of Europeans that struggle to access quality healthcare. At the same time, though, several countries have recently introduced measures that increase the cost of healthcare or restrict access to it. Spain, for instance, passed a measure in 2012 denying universal healthcare entitlements to nearly
From 2007 to 2013, copayments for both inpatient and outpatient care were raised, with the largest increase occurring in 2012. Exemptions for chronically ill patients were restricted to consultations/ treatments for their specific condition.
Source: European Foundation for the Improvement of Living and Working Conditions. Access to healthcare in times of crisis. 2014.
UNEQUAL USE OF HEALTHCARE SERVICES Throughout the region, there are income-related differences in the use of healthcare services. According to the OECD report, “Health at a Glance” from 2012, there is evidence of inequity in terms of doctor consultations by income group in European counties. The probability of a generalist visit is equal in most countries and lower income individuals actually consult a GP more frequently. In regard to specialist visits, however, a different story emerges. In nearly all countries, high income individuals are more likely to see a specialist than those with low incomes and also do so more frequently.15
900,000 non-registered residents and introduced copayments for drugs on the grounds of austerity.14 These simultaneous phenomena are placing a double burden on vulnerable Europeans seeking healthcare. Figure 4 shows three examples.
European Foundation for the Improvement of Living and Working Conditions. Access to healthcare in times of crisis. 2014. 13
14 Legido-Quigley H. Erosion of universal health coverage in Spain. The Lancet 2013; 382(9909): 1977.
70
15 OECD & European Commission. Health at a Glance: Europe 2012. 2012.
EUROPE / SAFETY
CREATING A CULTURE OF PATIENT SAFETY Over the last decades patient safety has moved far up the political agenda in Europe. But despite a line of common guidelines aimed at improving patient safety, fragmentation still rules. Some countries have made patient safety a top priority while others remain reluctant to take on the challenge.
Looking at the EU in general, patient safety remains an unresolved issue in healthcare. An estimated 8-12% of patients admitted to hospitals in the EU suffer from adverse events while receiving healthcare. 25% of these adverse events are healthcare-associated infections (HAIs), but adverse events also include medication-related errors, surgical errors, medical device failures, errors in diagnosis, or
The overall recommendations include: • The establishment and development of national policies and programs on patient safety • Making patients part of the process • Education and training of healthcare workers
failure to act on the results of tests.16
• Sharing knowledge, experience and best practice at community level
In 2009, the European Council put forward 13
• Prevention of healthcare associated infections
recommendations for patient safety measures, including the prevention and control of
Variation in the implementation of the EU
HAIs, and invited the Commission to report
recommendations, the state of HAIs, and a
on progress and further action.
lack of healthcare professionals are discussed below as indicators of the development of patient safety in the Europe.
16 European Commission. Special Eurobarometer 411: Patient Safety and Quality of Care. 2014.
71
FIGURE 5.
WHAT IS STANDING IN THE WAY OF PATIENT SAFETY RECOMMENDATIONS? Economic strain, technology and fragmentation are among the main reasons for the lack of implementing patient safety recommendations among the EU countries Source: European Commission. Report on the Public Consultation on Patient Safety and Quality of Care. Undated.
ECONOMIC CRISIS AND RESULTING CONFLICTING PRIORITIES
FRAGMENTATION OF PROVISIONS AND ORGANIZATION
LACK OF POLITICAL WILL
BARRIERS DOMINATING “BLAME CULTURE”
LACK OF PATIENT SAFETY CULTURE
PUSHING SHARED PATIENT SAFETY GUIDELINES FORWARD The report from the European Commission from
Over the last couple of years, some progress has
2012, which analyzes Member countries’ imple-
been made in regards to the 13 recommenda-
mentation of the 13 recommendations, indicates
tions.
that while some countries focus intently on patient rights, patient safety strategies, and patient
An evaluation from 2014 shows that most
inclusion policies, others take a more passive
countries have implemented at least half of the
stance and place the burden on individual hospi-
Council’s 13 measures. Ireland, with 12 out of 13
tals to introduce patient safety measures.
actions in place, is near completion, followed closely by the UK and Germany, each with 10
Similarly, some EU member states have instituted
actions implemented. On the other end of the
official legislation on these strategies, while oth-
scale, Romania and Slovenia only have 3 out of 13
ers rely on less formal networks and platforms.17
actions implemented.19
From 2013-2014 the European Commission conducted an online survey on patient safety in the EU, particularly in order to highlight the barriers to implementing the 13 Council Recommendations for patient safety measures. Economic strain, lack of political will, limited technology and fragmentation were among the primary barriers.18 See figure 5.
72
HARMED BY HEALTHCARE Every year an estimated 4.1 million patients acquire
There is still room to improve information provided
a HAI in the EU, and at least 37,000 die as a result.
to patients and their involvement in HAI prevention.
The financial cost of HAIs in Europe is approximately
According to the Eurobarometer survey on patient
$6.2 billion annually.20
safety and quality of care from 2014, only 39% of the respondents that had been hospitalized or admitted
Although HAIs are a challenge, the solutions are
to a long term facility in the past 12 months report-
within reach. It is thus estimated that 20-30% of
ed that they had received information on the risk of
HAIs can be prevented by intensive hygiene and
HAI – the majority of those who did came from the
control programs.21
western and northern areas of the EU.23 The Eurobarometer report also notes that there has been an
According to a report from the European Com-
increase in how many adverse events are reported,
mission based on member states’ reports on the
from 28% in 2009 to 46% in 2014. At the national
implementation of the Council Recommendation on
level there have been even more dramatic changes,
patient safety, about two out of three EU countries
for instance in France (+61% points), Spain (+40) and
had defined a national strategy and/or action plan
Luxembourg (+32).
for the prevention and control of HAIs in 2011: Sadly, 37% of the respondents report that the most • More than 80% of national action plans included
likely outcome of reporting an adverse event was
hospital implementation of: infection prevention
that nothing happened. 20% received an apology
and control programs; appropriate organizational
from the professional and only 17% received an ex-
governance arrangements and qualified infection
planation for the error.
control staff; surveillance of targeted HAIs; surveillance of particular events for timely detection of
During the past few years, the EU has funded further
alert microorganisms or HAIs; and high quality mi-
projects aimed at improving the state of HAIs, such
crobiological documentation and patient records.
as the Third Health Programme 2014-20, which aims to improve patient safety and reduce HAIs in Euro-
• 14 out of 17 countries with an action plan at the na-
pean countries.24 This program focuses specifically
tional level had set up mechanisms to encourage
on the control of healthcare-associated infections
its implementation.
through exchanging good practices on quality assurance systems, developing guidelines and tools
• 15 countries had considered nursing homes and
to promote quality and patient safety, increasing
healthcare institutions other than acute care hos-
the availability of information to patients on safety
pitals when designing their action plans.22
and quality, and improving feedback and interaction between health providers and patients.25
Despite this development, the latest evaluation from EU “Patient safety and Health-Associated Infections” from 2014 concludes that HAIs continue to be a problem in Europe.
17 European Commission. Detailed analysis of countries’ reports on the implementation of the Council Recommendation (2009/C 151/01) on patient safety, including the prevention and control of healthcare associated infections. 2012. 18 European Commission. Report on the Public Consultation on Patient Safety and Quality of Care. Undated.
19 European Commission. Patient Safety and Healthcare-Associated Infections. 2014. 20 Cilag GmbH International. Healthcare Associated Infections – Fact & figures. 2015.
European Center for Disease Prevention and Control. Healthcare-associated infections. 2015. 22 European Commission. Detailed analysis of countries’ reports on the implementation of the Council Recommendation (2009/C 151/01) on patient safety, including the prevention and control of healthcare associated infections. 2012. 21
24 European Commission. Patient Safety and Healthcare-Associated Infections. 2014. 25 Official Journal of the European Union. Regulation (EU) No 282/2014 of the European Parliament and of the Council. 2014.
23 European Commission. Special Eurobarometer 411: Patient Safety and Quality of Care. 2014.
73
DOCTORS WITHOUT BORDERS All across Europe, the shortage of healthcare professionals is a reality. In 2012, on average across EU countries, one in three doctors was over 55 years of age, up from one in six in 2000. This aging workforce, combined with other factors,
SHORTAGE OF HEALTHCARE PROFESSIONALS IN FINLAND In Finland, the demand for healthcare services is increasing, while there are not enough applicants
will likely cause an estimated shortage of 1 million
for the vacant positions. The primary reason for
health workers in Europe by 2020.26
this shortage is not a lack of sufficient training at educational institutions, but rather that a
The healthcare sector is clearly affected by these shortages and the 2014 Care Quality Commission
significant proportion of the qualified labor works in sectors other than healthcare. For example, there are 20,000 qualified practical
report assessing the UK’s National Health Service
nurses working outside the healthcare sector,
(NHS) and social care services stated that short-
meaning that their skills and training are not
ages of doctors and nurses posed safety risks for
being properly utilized. Partly to blame for this
patients.27
is the fact that salaries in the healthcare sector are fairly low, the work physically and mentally demanding and the working conditions often
The 2014 European Commission report, “Map-
unfavorable.31 Reconciling this challenge will
ping and Analysing Bottleneck Vacancies in
be critical if Finland is to fulfill its demand for
EU Labour Markets,” examines the occupations
healthcare workers in the coming years.
where there is evidence of recruitment difficulties. In total, 21 of 29 European countries reported vacancies in their healthcare workforce. The findings show different reasons for the shortage of healthcare professionals. For instance, in most EU1528 countries not enough people are
Projects and organizations are being developed
training as health professionals, whereas the
in an effort to alleviate the problems caused by
challenge in newer EU states is that healthcare
cross border migration of professionals. The
professionals seek employment in other coun-
European Joint Action on Health Workforce
tries, where the salary and the working condi-
Planning and Forecasting, for instance, gathers
tions are better.
experiences and best practices in planning and assessing health workforce needs. Their work
Furthermore, mitigation strategies used by
seeks to uncover sustainable solutions to the
some countries to actively fill the gaps in their
challenge of the growing demand for healthcare
recruitment of healthcare professionals can have
workers throughout Europe.30
a detrimental impact on other countries in the region. For example, Norway is attracting labor from neighboring countries, which consequently further depletes the supply of labor in those nations.29 26Joint Action Health Workforce Planning and Forecasting. Leaflet. Undated.
74
27 Campbell D. “NHS staff shortages pose risk to patients, warns watchdog.” The Guardian. 2014.
28 Austria, Belgium, Denmark, Finland, France, Germany, Greece, Ireland, Italy, Luxembourg, the Netherlands, Portugal, Spain, Sweden and the United Kingdom
29 European Commission. Mapping and Analysing Bottleneck Vacancies in EU Labour Markets. 2014.
30 Joint Action Health Workforce Planning and Forecasting. Welcome page. Undated.
EUROPE / PERSON-CENTERED CARE
TOWARDS CO-CREATION AT DIFFERENT SPEEDS The idea of putting the patient in the center of healthcare is gaining momentum – and becoming an integrated part of care delivery in European countries. Still, a shared understanding of the term is missing. The focus on and interpretation of personcentered care varies within the region of Europe. According to the Euro Health Consumer Index
study also identified different levels of
patient rights legislation and involvement in
person-centered care in what they define as
policy-making became standard in Europe
Eastern and Western Europe.
by 2013, and only 2 countries have not yet introduced healthcare legislation based on
In Russia, patient rights, as outlined in the
patient rights.32
WHO’s “Declaration of Patients’ Rights in Europe,” have not been actively implemented
Despite the positive development, Europe
and patients typically lack the information
still faces challenges in terms of delivering
needed to fully understand their illness or
person-centered care. The “Eurobarometer
potential treatment options. Without such
qualitative study” conducted for the Europe-
information, it is hard for patients to make
an Commission in 2012, which was based on
informed choices about their medical care.
interviews in 15 EU member states33, revealed that the meaning of the term “patient involve-
In the following dimension, we examine the
ment” was not clearly understood by either
state of integrated care, eHealth and health
practitioners or patients.34
literacy as three indicators of person-centered care in Europe, as they help to gauge
In fact, it was often perceived by both groups
how well patients understand their involve-
“as medical compliance and following doc-
ment in their own health and healthcare
tors’ orders,” which is quite the opposite of
system.
the co-creation approach that person-centered care is meant to evoke.35 The same
31 European Commission. Mapping and Analysing Bottleneck Vacancies in EU Labour Markets. 2014. 32 Health Consumer Powerhouse. Euro Health Consumer Index. 2014. 33 Austria (AT), Belgium (BE), Czech Republic (CZ), Finland (FI), France (FR),
Germany (DE), Greece (EL), Hungary (HU), Italy (IT), Latvia (LV), Poland (PL), Romania (RO), Spain (ES), Slovakia (SK) and the United Kingdom (UK).
36 WHO Regional Office for Europe. Roadmap: Strengthening people-centred health systems in the WHO European Region. 2013.
European Commission. Eurobarometer Qualitative Study – Patient Involvement. 2012.
37,38
34,35
Center for Strategy and Evaluation Services & Oxford Research. Final Evaluation of the Lead Market Initiative. 2011.
75
FIGURE 6.
DIFFERENT APPROACHES TOWARDS MORE INTEGRATED CARE From E-health records in Estonia to integrated HIV treatments programs in Ukraine, integrated care is unfolding in different settings
AIM
OUTCOMES
ESTONIA
GERMANY
UKRAINE
To fully integrate communication through National Electronic Health Records, hosting over 3,000 e-services and health insurance systems for claims, reimbursement and prescriptions.
To implement integrated care pathways for selected treatments through an integrated contracting model designed to improve coordination between managers, doctors, psychiatrists and psychotherapists.
To develop integrated services for people with a history of injection drug use through innovations including pharmacy-based needle exchanges, overdose prevention services and improved case management services.
Efficiency gains via the direct communication between institutions and providers.
Patients treated through integrated networks able to return to work 72 days earlier than those treated via conventional care pathways.
Improved HIV treatment outcomes, as well as reduced drug use through improved adherence to treatment and retention in care.
More patient empowerment via personal health records, virtual medical centers and mobile patient applications.
Improved user satisfaction.
Source: WHO Regional Office for Europe. Roadmap: Strengthening people-centred health systems in the WHO European Region. 2013.
A EUROPEAN VISION FOR INTEGRATED CARE
To help address some of these barriers, WHO
In the common policy framework – Health 2020 –
launched “Framework for Action towards Coor-
that the 53 member states in the WHO European
dinated/Integrated Health Services Delivery" in
Region have agreed on, people-centered health
2013, which supports countries with policy options
systems are defined as a shared goal. Figure 6
and recommendations that target key areas for
shows a selection of different nations’ integration
strengthening the coordination/integration of
initiatives. While they are very different cases, they
health services.
do illustrate that steps towards more integrated health systems are being taken.
The framework focuses on ensuring the participation of partners, including a network of focal points
One of the barriers standing in the way of further
in member states, external experts and leading
expanding people-centered initiatives is that ad-
organizations in the field, such as the International
vocating coordination and integration of services
Foundation for Integrated Care.
takes a backseat to other political priorities in times of economic crisis.36
76
FIGURE 7.
HEALTH LITERACY IS STILL A GREAT CHALLENGE Percentage distributions of general health literacy for each country and the 7,795 respondents
Inadequate health literacy
Problematic health literacy
Sufficient health literacy
Excellent health literacy
AUSTRIA BULGARIA GERMANY GREECE
Across countries in Europe, health literacy continues to pose a great challenge in healthcare. The results vary significantly between countries. For example, inadequate health literacy was present in 2% of the population of the Netherlands, but 27% in Bulgaria.
SPAIN IRELAND NETHERLANDS POLAND TOTAL
Source: European Health Literacy Project. Final Report – Executive summary (D17) – The European Health Literacy Project (HLS-EU). 2012.
0
10
20
30
40
50
60
70
80
90 100
TREMENDOUS POTENTIAL FOR EHEALTH In 2007, the European Commission selected eHealth
Aside from a promising economic potential, eHealth
as one of six promising lead markets, meaning that
can empower patients through greater transparen-
it is innovative, responds to customers’ needs, has a
cy, access to services and information, and the use
strong technological and industrial base in Europe
of social media for health.39 Furthermore, patient
and depends on public policy actions to create
empowerment is mentioned as part of the vision in
favorable framework conditions.
the eHealth Action Plan 2012-2020, put forward by the European Commission.
The European Commission was proven right in their prediction, since the market potential of eHealth has
However, eHealth is still not a common standard
remained strong, despite the economic crisis.
in the region. The study, “Overview of the national laws on electronic health records in the EU member
The global telemedicine market, for example, has
states and their interaction with the provision of
grown from $9.8 billion in 2010 to $11.6 billion in
cross-border eHealth services,” from 2013 concludes
2011, and is expected to continue to expand to $27.3
that, “there are major disparities between countries
billion in 2016.38 This increase indicates a growing
on the deployment of EHRs40 [as] part of an interop-
potential for the use of eHealth measures through-
erable infrastructure that allows different healthcare
out the world, including Europe.
providers to access and update health data in order to ensure the continuity of care of the patient”.41
77
Another disconcerting finding from the study is
Unfortunately, according to WHO’s Health Litera-
the fact that EHR systems use very different ter-
cy Survey, nearly half of all Europeans have inad-
minology and coding methods depending on the
equate and problematic health literacy skills, and
country in which they operate, and this semantic
as such have difficulties in accessing, understand-
diversity is considered one of the main barriers
ing, appraising and applying information to make
to the transfer of health data making it difficult to
healthcare decisions.43 See figure 7. This poses
ensure continuity in care.
a threat to the future of person-centered care in Europe, as low health literacy makes it difficult for
LOST IN TRANSLATION
patients to take their health in their own hands,
Health literacy is a key dimension of Health 2020
thereby leaving professionals as the only experts
– the European health policy framework adopted
in health.
by member states in 2012 – and it remains a challenge in the region. According to WHO, low health literacy is strongly associated with more hospitalization and less self-management. An individual’s level of literacy directly affects his or her ability to access health information, learn about disease prevention and health promotion, follow healthcare regimens and communicate about health messages with other people.42
39 Center for Strategy and Evaluation Services & Oxford Research. Final Evaluation of the Lead Market Initiative. 2011. 40 Electronic Health Records 41 Health Programme of the European Union. Overview of the national laws on electronic health records in the EU member states and their interaction with the provision of cross-border eHealth services – Final report and recommendations. 2014. Page 7.
78
42 WHO. Working document for discussion at the 7th Global Conference on Health Promotion, “Promoting Health and Development: Closing the Implementation Gap”, Nairobi, Kenya, 26-30 October 2009.
43 European Health Literacy Project. Final Report – Executive summary (D17) – The European Health Literacy Project (HLS-EU). 2012.
EUROPE / COST-EFFICIENCY
GROWING DEMAND AND SHRINKING BUDGETS Economic strain is the reality and the future for healthcare systems throughout the European region. These constraints will hopefully pave the way for a delivery of healthcare where cost-efficiency is named king – not through reductions in healthcare, but through new models, new priorities and new incentives.
The healthcare sector accounts for 8% of the total EU workforce and 10% of the GDP. According to the 2013 report, “Investing in Health,” from the European Commission, the high healthcare costs in the EU pose the question of “cost efficiency and the financial sustainability of the region’s healthcare systems.”44 The pressure for finding a sustainable healthcare model is rising. On one hand, the economic crisis caused enormous reductions in public health spending. In Iceland, Ireland and Greece public expenditure on health was reduced by 9.3%, 9.9% and 10.8%, respectively, between 2009 and 2010. On the other hand,
PRESCRIBING PREVENTION Focusing on disease prevention can reduce high long-term treatment costs and improve health outcomes by avoiding tens of thousands of premature deaths.46 However, little relative importance is currently given to health promotion in budgetary terms. Between 70% and 80% of healthcare budgets across the EU is currently spent on treating chronic diseases, and 97% is spent on treating patients with both acute and chronic conditions. But only 3% is spent on prevention, with chronic diseases being among the most preventable illnesses.47 See figure 8.
ageing populations and the prevalence of chronic diseases are also stressing the need for better quality care for less money.45 In the following, healthcare promotion and costs of pharmaceuticals will serve as measurements of cost efficiency within European healthcare.
European Commission. Investing in Health. 2013. 44,45,46
47 Spongenberg H. “Chronic diseases: forcing change in EU healthcare management.” EU Observer. 2014.
48 Friends of Europe. Healthcare in Times of Austerity: Boosting Cost-Effective Prevention. 2013.
79
FIGURE 8.
PREVENTION IS NOT TOP PRIORITY Current health expenditure by function, 2012 (or nearest year)
In-patient care
Outpatient care
Medical goods
Prevention and adminstration
Long-term care
100 90 80 70 60 50 40 30
Prevention efforts are taking
20 10
One example of the benefits of prevention is
EFFORTS TO CUT
the flu vaccine. According to the WHO, season-
PHARMACEUTICAL SPENDING
al influenza can cost $6.5 million per 100,000 residents each year in countries like France and Germany. If vaccination rates in Europe went up to 75%, 1.7 million more cases of flu could be prevented. In addition, achieving this target would reduce the number of visits to GPs by approximately 770,000 annually.48
Between 2000 and 2009, pharmaceutical expenditure grew by 3.2% annually in EU member states, an increase that exceeded GDP growth.49 As the economic crises hit Europe, this picture changed and the pharmaceutical sector was targeted by governments seeking to cut costs without harming patient outcomes. A range of measures has been introduced across the EU member countries, including price cuts, centralized public procurement of pharmaceuticals, promoting the use of generics, reduction of package sizes,
49 Deloitte Center for Health Solutions. Impact of austerity on European pharmaceutical policy and pricing: Staying competitive in a challenging environment. 2013. 50 OECD & European Commission. Health at a Glance: Europe 2014. 2014. 51 Deloitte Center for Health Solutions. Impact of austerity on European pharmaceutical policy and pricing: Staying competitive in a challenging environment. 2013.52 OECD & European Commission. Health at a Glance: Europe 2014. 2014.
80
53 European Federation of Pharmaceutical Industries and Associations. Annual Review of 2011 and Outlook for 2012. Undated.
reduction in coverage, and increases in co-payments by households.50 In terms of the increasing use of generics, Germany has introduced systems to benchmark prices and started to link reimbursements to the lowest available price of the drug as a way to reduce public spending.51 The result of these initiatives has been falling annual growth rates of spending on pharmaceuticals of 2.7% in 2011-2012 across EU member states.52,53
ICELAND
SWITZERLAND
NORWAY
SPAIN
SLOVAK REPUBLIC
HUNGARY
PORTUGAL
SWEDEN
LUXEMBOURG
DENMARK
LATVIA
CROATIA
GERMANY
ESTONIA
FINLAND
SLOVENIA
NETHERLANDS
EU23
CZECH REPUBLIC
CYPRUS
LITHUANIA
POLAND
Source: OECD & European Commission. Health at a Glance: Europe 2014. 2014.
AUSTRIA
0 GREECE
Region.
ROMANIA
spending across the European
FRANCE
up a small part of the overall
EUROPE / EFFECTIVENESS
EU GUIDES THE WAY TO MORE EFFECTIVE CARE Policy recommendations from the EU are trying to promote effectiveness in healthcare in the region. In recent years, a line of improvements has taken place, but there are still shared challenges and great variations when it comes to effectiveness between established EU countries and new additions to the Union.
In 2014, the European Commission issued the “Communication on Effective, Accessible and Resilient Health Systems” which addresses the effectiveness of EU healthcare systems by calling for member states to apply performance assessment results, improve patient safety and develop integration of care.54 The Communication also acknowledges that assessing the effectiveness of health systems is a complex process and states that, “healthcare measures may only show their effects after a long period, and comparability and reliability of data is a challenge.”55
STATE OF AMENABLE MORTALITY From 2000 to 2010 virtually all EU member states have succeeded in reducing the rate of ‘amenable mortality. However, the distribution of the rate of amenable mortality across the EU member countries shows a clear divide between the ‘old’ Western member countries and the ‘new’ Eastern member countries and highlights a trend towards large variations in the effectiveness of healthcare systems in the EU28. See figure 9.
While it can take many years to collect the data needed to assess a healthcare system’s effectiveness, this section examines two indicators that offer more immediate feedback on a system’s effectiveness, namely the rate of premature deaths (deaths that should not have occurred if timely and effective healthcare was provided) and the underuse and overuse of healthcare.56, 57 These indicators give insight into how well a healthcare system is performing its primary job: properly and safely treating those in need.
54 European Commission. On effective, accessible and resilient health systems. 2014. 55 European Commission. On effective, accessible and resilient health systems. 2014. Page 7. 56 European Commission. On effective, accessible and resilient health systems. 2014. 57 Amenable mortality combines the standardized mortality rates for a selected set of diseases on which healthcare is estimated to have a direct impact.
58 Measuring the effectiveness of EU healthcare systems is challenged by the lack comparable data across the 28 member countries of the union. 59 EU Health & Consumer Protection Directorate-General. European guidelines for quality assurance in breast cancer screening and diagnosis. 2006. 60 European Commission. European guidelines for quality assurance in breast cancer screening and diagnosis. 2006.
81
Amenable mortality, standardized death rates per 100,000 inhabitants, 2010
FIGURE 9.
BIG DIFFERENCES IN AMENABLE MORTALITY
Despite improvements in all EU countries, there are still great differences in the amenable mortality in the region. France and the Netherlands are at the top, while Latvia and Lithuania are at the bottom. Data for Greece not available.
600
Female
Source: Eurostat (2010)
Males
500 400 300 200 100 0
FR NL
IT
ES LU BE DK SE PT
FI
CY DE MT AT
IE
SI
UK PL CZ HR BG EE SK HU RO LT
LV
CHALLENGE: ENSURING APPROPRIATE CARE Overall figures for comparing under- and overuse
Antibiotic use is an ideal indicator of medication
of treatments and medicines across the European
overuse, as the volume of antibiotics prescribed
Union are hard to come by, and instead breast
at a community level and prevalence of resistant
cancer screenings and the use of antibiotics will
bacterial strains are linked. Infections caused by
serve as examples of under- and overuse re-
resistant microorganisms often fail to respond to
spectively. All though not drawing the complete
conventional treatment, resulting in prolonged
picture, these two cases will serve as inspiration
illness, greater risk of death, and higher costs.62
for further comparisons.
Hence, it is essential that antibiotics are prescribed based on evidence-based needs and not
In the case of breast cancer screening, a num-
for viral conditions like a mild throat infection.63
ber of European countries are underusing certain treatments and thus not living up to
The volume of antibiotic use varies substantially
EU guidelines.58, 59 The European Commission
across EU member countries with the Nether-
has established the “European guidelines for
lands and Estonia reporting the lowest volumes
quality assurance in breast cancer screening and
and Greece, Cyprus and Belgium reporting
diagnosis”, which promotes a desirable breast
volumes around 1.5 times the European Union
cancer screening target of at least 75% of eligible
average.64 According to “Health at a Glance”,
women in European member states.60 Despite all
reducing antibiotic use is a pressing, yet complex
countries having uniformly established programs
problem in the European Union. Improvement
according to the guidelines, only six countries
of this issue should involve multiple coordinated
had reached the target of 75% in 2010.
initiatives that include surveillance, regulation and education of professionals and patients.65
Participation in the programs also varied considerably across EU member countries, ranging from 8% in Romania and 16% in the Slovak Republic, to over 80% in Finland, Denmark, Austria and the Netherlands.61
82
61 OECD & European Commission. Health at a Glance: Europe 2014. 2014.
EU GUIDELINES FOR THE FUTURE ACTION ON HEALTH SYSTEMS ACCORDING TO MARIA IGLESIA GOMEZ FROM DG SANTE In April 2014, the Commission adopted the “Communication
ACCESSIBILITY
on effective, accessible and resilient health systems,” which
“Access to healthcare is a multidimensional phenomenon; we
presents some overall guidelines for the future action on
can identify at least four dimensions of it: share of the popu-
health systems. Ms. Maria Iglesia-Gomez from DG Sante
lation that is covered, the basket of care, the affordability of
explains key elements of the recommendations:
care and the availability of care. Measuring access to health-
EFFECTIVENESS “Health systems should improve the health of the population. The challenge is to measure improvements in the health status that are due to the health system, and not for instance to better nutritional habits, or safer roads and cars. The Commission is currently supporting member states with using health system performance assessment, through an expert group that started in the framework of the reflection process on modern, responsive and sustainable health systems, initiated by the Council in 2011. The goal of this process is to improve the coordination on health systems performance assessment at EU level.”
care encompasses significant difficulties. Available indicators allow for the measurement of self-perception of unmet needs for care but not for objective measurement of access; indicators for coverage, waiting times and affordability are either non-existent or inadequate." RESILIENCE “Resilience is the ability to adapt effectively to changing environments, tackling significant challenges with limited resources. member states’ future ability to provide high quality care to all will depend on making health systems more resilient, more capable of coping with the challenges that lie ahead. And they must achieve this while remaining cost-effective and fiscally sustainable. Clearly, innovation in health must be cost-effective; we give a great importance to increasing co-operation on Health Technology Assessment.”
AVOIDING HOSPITALIZATION THROUGH EFFECTIVE PRIMARY CARE Healthcare systems can avoid unnecessary hospitaliza-
However, variations across countries are prevalent.
tion through an effective primary care system. Looking
Asthma-related admissions in the Slovak Republic and
at chronic diseases such as asthma, chronic obstruc-
Latvia were more than double the EU average, where-
tive pulmonary disease (COPD), and diabetes, a high
as Italy, Portugal, Germany, Sweden and Luxembourg
performing primary care system could, to a significant
report rates that were less than half the EU average.
extent, avoid acute deterioration for people living with
Hospital admission rates for uncontrolled diabetes
these diseases and prevent admission to hospital.66
vary 8-fold across the EU member countries with Italy, United Kingdom and Spain showing the lowest rates,
These are all conditions that affect EU healthcare
and Austria and Hungary reporting rates that are near-
systems substantially with e.g. COPD accounting for
ly double the OECD average.69
approximately 3% of total deaths in the European Union and diabetes resulting in an estimated 10% of total adult deaths in Europe.67, 68 EU member countries have reported a reduction in admission rates for each of the three aforementioned conditions over recent years.
62 OECD & European Commission. Health at a Glance: Europe 2014. 2014.
68 International Diabetes Federation. IDF Diabetes Atlas, Sixth Edition.2013.
63 Cochrane Collaboration. The Cochrane Acute Respiratory Infections Group.2013.
69 OECD & European Commission. Health at a Glance: Europe2014. 2014.
OECD & European Commission. Health at a Glance: Europe 2014. 2014. 64,65,66
67 World Health Organization. Background Paper 6.13: Chronic Obstructive Pulmonary Disease (COPD). 2013.
83
EUROPE / TIMELINESS
TIMING IS EVERYTHING Bringing down waiting lists has been a main target in European countries in recent years. But there are still challenges when it comes improving the timeliness of healthcare in Europe, and with strains on the healthcare budgets they do not seem to be overcome just yet.
In the survey Eurobarometer “Patient Safety and Quality of Care” from 2013, one in five of the respondents point to the waiting time to be seen and treated as crucial in their evaluation of a hospital.70
LOST IN THE CROWD Overcrowded hospitals are an important hindrance to the provision of timely and high quality care. An array of issues are identified as reasons for crowding: increased patient
Improving the timeliness of care – reducing waiting times, avoiding crowding and ensuring the right treatment in due time – demands resources, but it also calls for great changes in areas such as hospital processes, culture, technology use. In the following, hospital crowding and wait times for elective procedures are presented as indicators for the state of timeliness in European healthcare.
acuity, hospital bed shortage, increasing ED volume, radiology delays, insufficient ED space, laboratory delays, consultation delays, nursing shortage, physician shortage, and managed care issues. International studies have also shown that delays caused by overcrowded EDs can lead to adverse effects on patient care.71 A Danish study from 2014 found that high bed occupancy rates were associated with a significant 9% increase in rates of in-hospital mortality and thirty-day mortality, compared to low bed occupancy rates.72
70 European Commission. Special Eurobarometer 411: Patient Safety and Quality of Care. 2014. 71 Jayaprakash N, et al. “Crowding and Delivery of Healthcare in Emergency Departments: The European Perspective.” Western Journal of Emergency Medicine 2009; 10(4): 233-239.
84
72 Madsen F, Ladelund S & Linneberg A. “High Levels of Bed Occupancy Associated With Increased Inpatient And Thirty-Day Hospital Mortality In Denmark.” Health Affairs 2014; 33(7): 1236-1244. 73 OECD & European Commission. Health at a Glance: Europe 2014. 2014.
74 The NHS defines major incidents as any occurrence that presents serious threat to the health of the community, disruption to the service or causes (or is likely to cause) such numbers or types of casualties as to require special arrangements to be implemented by hospitals, ambulance trusts or other acute or community provider organizations”.
75 The Guardian. Eight more hospitals declare critical incidents as demand surges. 2015. 76 The Independent. NHS in critical condition as A & E waiting times are worst in a decade. 2015. 77 Jayaprakash N, et al. “Crowding and Delivery of Healthcare in Emergency Departments: The
An efficient way to measure crowdedness is through the number of hospital beds per citizen. If the demand for care outpaces the resources to handle patients, long wait times can ensue. Over the past 10 years, the number of hospital beds per population has decreased in all European countries except Greece. On average across EU member states, the number fell by close to 2% per year, coming down from 6.5 beds per 1,000 people in 2000 to 5.2 beds in 2012.73 Although the reduction in beds could signify that more patients are seeking care at primary care facilities rather than hospitals, it can also be a safety hazard if the number of patients seeking care in hospitals does not decline alongside the number of beds. Illustrating the latter, in December 2014, 15 hospitals in England declared major incidents74 because of pressures on A&E department bed capacity.75, 76
PUTTING A PRICE ON TIME Elective – but often very necessary – procedures are also prone to long wait times, and these vary a great deal between European countries. For example, in 2012-13, the average waiting time for cataract surgery was just over 30 days in the Netherlands, but about three-times longer (100 days) in Spain and Finland.78 Over the past decade, waiting time guarantees have become the most common policy tool to tackle long waiting times in several European countries. This has been the case in Finland, for example, where a National Healthcare Guarantee was introduced in 2005 and led to a reduction in waiting times for elective surgery. In Denmark, a key policy is the “free choice” of hospital provider for patients. If a hospital can foresee that the maximum time cannot be
Long wait times can also discourage people from utilizing hospital services, as a 2007 study in Ireland reported that out of 45,000 surveyed
fulfilled, the patient can choose another public or private hospital, either within or outside Denmark – and the money follows the patient.79
ED patients, 35% said that the prospect of a prolonged stay affected their willingness to come to the ED or to return.77
European Perspective.” Western Journal of Emergency Medicine 2009; 10(4): 233-239.
health care waiting times in EOCD countries.” Health Policy 2014; 118(3): 292-303.
78 OECD & European Commission. Health at a Glance: Europe 2014. 2014. 79 Siciliani L, Moran V & Borowitz M. “Measuring and comparing
85
EUROPE / ENVIRONMENTAL SUSTAINABILITY
A HEALTHY ENVIRONMENT Sustainability is moving up the agenda in all European countries – not only as an economic phrase, but also in terms of the effects of climate change on the region’s healthcare sector and vice versa.
In the coming years the European healthcare sector will be forced to reduce its own negative effect on the environment and also be prepared for meeting and coping with a new pathological picture created by climate change. Within the EU, sustainability in the healthcare sector is becoming a focus area and an important element of the region’s ambitious green targets for the coming years. One example is the EU Green Public Procurement Policy aimed at making public authorities go green and push the market towards a more sustainable production, in which a main focus area is green procurement of medical devices – currently one of the top five of most energy intensive products in Europe.80
HEALTHCARE IS HEATING UP The healthcare sector is a contributing factor to the climate change experienced in Europe. The healthcare sector is a major energy user, as European hospitals consume on average 300 Kw of thermal and over 100 Kw of electrical energy per square meter per hour. Considering that there are approximately 15,000 hospitals in Europe, this represents an expense of 10% of the GDP and accounts for 5% of CO2 emissions.81 The NHS Sustainable Development Unit in the UK has calculated its carbon footprint at more than 18 million tons of CO2 each year — 25% of total public spending.82
Despite initiatives like this, there is still a long way for a common green goal within healthcare in the European region. Great challenges remain, and the healthcare sector in general continues to be a ‘black industry’. Energy use and the effect of climate change on healthcare are outlined as primary challenges when it comes to sustainability and climate change in regard to the healthcare sector in Europe. 80 Swedish Competition Authority. The EU GPP criteria for medical devices. 2014. Healthcare Without Harm. Climate change and Health. Undated. 81,82
86
83 European Commission. Commission Staff Working Document – Accompanying document to the White Paper: “Adapting to climate change: Towards a European framework for action.” 2009.
DIAGNOSIS: CLIMATE CHANGE
INNOVATIVE THINKING CAN SAVE ENERGY
Not only does the healthcare sector affect the environment, but the reverse is also true. Climate change has an enormous impact on health and
At the Royal Free Hospital in the UK, the
healthcare in Europe, in terms of public health,
implementation of a Combined Heat and Power
safety, and the associated healthcare costs
plant and the installation of three new boilers –
of both. It affects human health both directly
plus a number of smaller adjustments such as low
through extreme heat and damage to health
voltage distribution boards and lighting updates
service delivery infrastructure in times of envi-
– resulted in annual energy savings of $1.9 million. The project provided a return on investment after
ronmental disaster and indirectly through forced
just seven years and allowed the site to increase
migration, flooding, and lifestyle changes.83
its energy security and meet its sustainability targets.
Additionally, temperature-sensitive infectious diseases, such as food borne infections are likely to grow. Recent studies show that the disease burden caused by climate change in Europe could be significant, with 20,000 potential extra cases of
The European Commission has outlined that the
food borne diseases per year by the 2030s, and
greatest concern in terms of climate change and
25,000 to 40,000 extra cases per year by the
its effect on health is heat-related mortality and
2080s.84
morbidity due to increases in annual temperature. In EU countries, it is estimated that mortality increases by 1–4% for each one-degree rise in temperature, meaning that heat related mortality could rise by 30,000 deaths per year by the 2030s and by 50,000 to 110,000 deaths per year by the 2080s.85
84 European Commission. Commission Staff Working Document – Accompanying document to the White Paper: “Adapting to climate change: Towards a European framework for action.” 2009.
85 European Commission. Commission Staff Working Document – Accompanying document to the White Paper: “Adapting to climate change: Towards a European framework for action.” 2009.
86 KPMG International. Improving energy and resource efficiency. 2012.
87
BRUSSELS ROUNDTABLE The roundtable discussion in the European Parliament in Brussels marked the second stop on our journey to co-create better healthcare systems worldwide. The roundtable participants represented a broad range of European healthcare stakeholders and provided their insights concerning the common challenges and opportunities across the healthcare systems in the 28 member countries of the EU. To inspire the discussion, the Danish Member of the European Parliament, Ms. Christel Schaldemose (profiled in an interview on page 90), presented her perspective on what the political priorities for healthcare in the EU should be; Dr. Francesco De Lorenzo, President of the European Cancer Patient Coalition (profiled in an interview on page 91), provided a status update on the European healthcare systems from a patient perspective with a special emphasis on the role of accreditation and Ms. Maria Iglesia Gomez, Head of the Strategy and Analysis Unit in DG SANTE (profiled on page 83), outlined the European Commission’s priorities and policy initiatives for healthcare.
THREE GLOBAL ROUNDTABLES In late 2014 and early 2015, DNV GL and Monday Morning Sustainia traveled to Shanghai, Brussels, and Washington DC to gain insights for this publication and start a conversation on challenges and opportunities for improving the quality of care in the healthcare systems of China, the EU and the USA. The guiding question for the roundtables was: HOW DO WE IMPROVE THE QUALITY OF CARE?
88
CHALLENGES FOR HEALTHCARE IN EUROPE
OPPORTUNITIES FOR CHANGE
There is much variation in the quality of healthcare services and access to treatment
Change the mindset of health professionals to see themselves as guests in patients’ lives, not the hosts
Increased demand for healthcare services and strained budgets are stretching healthcare
systems at both ends
Demographic change with an ageing population
Make organizational data public in order
in most EU countries is increasing the need for
to increase learning across the member
integrated long-term care
countries
There is an inability to properly manage long term
and chronic illnesses
Enhance coordination and incentivize collaboration on all levels
Improve quality of care for chronic diseases Empower patients to self-care and harvest the
There is a lack of focus on how to manage the
benefits of a more efficient use of healthcare
“mobile patient” that is moving across the open
professionals’ time
EU borders
The roundtables were in the format of one-day interactive workshops that gathered key stakeholders from across the healthcare system, including patients, professionals, providers, policy makers and researchers, with the aim of identifying possible trajectories for change by spurring dialogue and discussions based on the various perspectives from the different stakeholders.
89
EUROPE / EXPERT INSIGHT
though a lot of work is still needed
tunities for patients to take greater
to reach the full potential of better
control of their own health is a bar-
prevention.
rier to greater patient involvement.
HOW DO YOU SEE THE ROLE OF THE EUROPEAN UNION IN OVERCOMING THE CHALLENGES FACED BY ITS COUNTRIES’ HEALTHCARE SYSTEMS?
Ms. Christel Schaldemose Member of the European Parliament Participant at the Brussels roundtable
I sincerely hope that the new Commission is serious about taking responsibility for the healthcare agenda instead of just leaving it to the member states alone. Obviously, it is the responsibility of the individual countries to design their own healthcare systems, but I
WHAT CHALLENGES DO
YOU SEE FOR HEALTHCARE SYSTEMS IN THE EU?
tions and the economic crisis. These issues have resulted in countries not being willing to invest a larger share
more on patient involvement both in terms of changing organizations and introducing new technologies.
HOW SHOULD HEALTHCARE ORGANIZATIONS ENGAGE WITH OTHER SECTORS TO IMPROVE THE DELIVERY OF SAFER, SMARTER AND MORE PERSON-CENTERED CARE? Civil society and local communities can play a crucial part in keeping
edge sharing within the EU holds
citizens healthy and these kinds of
great promise in terms of addressing
efforts need to be scaled up. But
some of the similar challenges we
just as with patient engagement,
are all facing.
it is essential that we don’t frame community involvement as a way to
HOW CAN PATIENTS TAKE PART IN ENHANCING THE QUALITY OF CARE IN THE EU?
simply cut budgets or as a last resort to save ailing healthcare systems. Companies also have an important role to play. By encouraging and fa-
of GDP in healthcare. This is certain-
I think patients are going to have
ly a challenge but it could also be an
to contribute more and be more ac-
lives, companies can also benefit
opportunity.
tive in the healthcare system of the
financially with greater employee
future. This could include measuring
satisfaction and fewer sick days.
HOW IS THE ECONOMIC CRISIS AN OPPORTUNITY FOR HEALTHCARE IN THE EU? The efforts to lower healthcare
greater personal responsibility by living healthier lifestyles with better diets and more physical activity. The EU countries will essentially have
spending in all EU countries will
to develop healthcare systems that
hopefully help drive the develop-
empower patients to take control
ment of better treatments and
of their own health. This would also
increase the focus on prevention.
serve to involve patients more in the
This is a positive development
consequences of their own choices.
on how to enhance the quality of life
cilitating employees to live healthier
their own blood pressure or taking
because the result is a clear focus
90
for EU healthcare systems to focus
believe that collaboration and knowl-
Across the EU countries, I see two overall challenges: aging popula-
Moreover, it is a great challenge
EU healthcare systems will have
for patients. By improving efforts
to become more focused on keeping
to prevent rather than treat illness,
patients out of the hospital, as this
Europeans will live better and longer.
benefits both patients and strained
The economic crisis could therefore
national budgets. Unfortunately, the
be seen as an advantage for patients
fact that these changes are framed
and healthcare systems alike, even
as service cuts rather than oppor-
“I believe that collaboration and knowledge sharing within the EU holds great promise in terms of addressing some of the similar challenges we are all facing”
“it is unacceptable not to grant access to the best care available to all European citizens”
problems, but I believe patients shall
prevention means avoiding the
be formally involved in the very pro-
recurrence of cancer or preventing
cess of implementing the Directive,
other chronic diseases. Effective
hence ensuring a more concrete
screening is also the only reliable
application of the European norm.
instrument we have to effectively
WHAT ARE SOME TANGIBLE WAYS
HOW DO YOU SEE THE
THAT PATIENTS CAN BECOME
ROLE OF THE PATIENT IN THE EU
MORE ACTIVELY INVOLVED IN
TODAY?
THEIR HEALTHCARE?
Nowadays, patients are crucial
I strongly believe in the power
reduce the incidence of cancer and therefore help our health systems saving billions of euros.
WHAT IS THE GREATEST OPPORTUNITY FOR IMPROVING HEALTH-
partners not only in the implemen-
of patient’s advocacy. ECPC’s
tation and evaluation of healthcare
advocacy efforts are based on real
policies, but also in their design.
needs and true experience. From
Within a Europe Union with 28 mem-
this standpoint it is very difficult for
cancer patients face are related to
ber states and growing harmonised
policymakers not to take our voice
the sharp decrease of resources al-
institutions, patients need strong,
into consideration. The European
located to healthcare. ECPC believes
specialised and professional advo-
Parliament demonstrated to be a
that a sustainable solution would be
cates to push on the crucial common
formidable partner in advocating pa-
to better integrate the promising
problems faced by all patients and
tients’ rights. The European Cancer
eHealth and mHealth technologies
raise awareness on the unbearable
Patient’s Bill of Rights, ECPC Call to
into European citizens’ lives, hence
national and local situations existing.
Action and several other advocacy
lowering the costs of several tradi-
efforts are finally bearing practical
tional care services. We are actively
fruit. The European Commission has
working to demonstrate this through
demonstrated a high level of sensi-
eSMART, an EU funded project
tivity towards patients’ perspective,
investigating the use of mobiles to
establishing the Expert Group on
monitor cancer treatment.
WHAT IS THE BIGGEST CHALLENGE FACING PATIENTS IN THE EU TODAY? There are still unbearable inequal-
CARE IN THE EU? Many of the problems European
Cancer Control and including pa-
ities in the way EU’s 500 million
tients’ representatives in the CanCon
citizens access healthcare. Inequal-
Joint Action.
ities in access to healthcare have different and varied faces: drugs are not evenly priced in all member states, and in several countries essential drugs are not available at all.
WHAT ROLE DOES PREVENTATIVE CARE PLAY IN AN EFFECTIVE HEALTHCARE SYSTEM?
Patients’ freedom to seek healthcare
The European Union has been
outside their country is declared by
very vocal on the role of prevention,
EU law, but cross-border health-
particularly through the promotion
care remains complex, bureaucratic
of healthy lifestyles. This is laudable
to obtain and in several cases too
and ECPC strongly encourages
expensive for the patient. Consid-
equilibrate nutrition, physical activity
ering the overall high standards
and screenings. However, preven-
and effectiveness in curing cancer
tion has many faces. In many cases,
in Europe, it is unacceptable not to
early diagnosis represents the most
grant access to the best care avail-
reliable weapon a cancer patient
able to all European citizens. The
has to successfully beat his/her
Cross Border Healthcare Directive
disease. For a cancer patient, either
can provide a partial solution to the
in remission or facing the treatment,
Dr. Francesco De Lorenzo President of The Italian Federation of Cancer Patients Organizations (FAVO) Participant at the Brussels roundtable
91
THE UNITED STATES OF AMERICA BALANCING THE SCALES The United States’ healthcare system has been under increasing stress in recent years. High spending costs, combined with the growing burden of chronic and non-communicable diseases has created a fractured and unsustainable healthcare model. In 2013, the USA spent $2.9 trillion on healthcare,
capita spent on healthcare.2 The costs are caused
amounting to $9,255 per person and 17.4% of the
by multiple factors: insurance, specialist visits,
GDP.1 The country outspends all others when
numerous expensive treatments, and overpriced
it comes to healthcare and by a considerable
pharmaceutical drugs.
margin – the second highest-spending country is the Netherlands with 12% of GDP and $4,710 per
92
Seven of the top ten causes of death in 2010 were
but some progress has already been made –
chronic diseases, and by 2012 nearly half of all
namely in terms of lowering the uninsured rate
American adults – 117 million people – had one
through the implementation of the Affordable
or more chronic health conditions. This growth
Care Act. By the end of 2014, the uninsured rate
in chronic illnesses affects not only the country’s
among American adults was down to 12.9% –
health, but also its pocketbook, as these diseas-
compared to 17.1% just one year earlier.4
es cost individuals and the government a great deal. In 2009, for example, 84% of all healthcare
This chapter offers a look at the American health-
spending went toward the treatment and man-
care system today, through the lens of the seven
agement of chronic conditions.3
dimensions of quality of care. By understanding the challenges that exist in terms of equitable ac-
The structure of the American healthcare system,
cess, patient safety, appropriate use of treatment
particularly its fee for service model, is also
and medicine, and cost-efficient service, we can
important to consider when discussing how
develop solutions to address these weaknesses
healthcare delivery in the country can improve.
and create a more sustainable, person-centered
As it stands now, the country is unable to provide
system for the entire country.
low cost, high quality care for all its citizens, even those unable or unwilling to purchase private insurance. Reaching this goal is a daunting task, 1 Centers for Medicaid and Medicare Services. National Health Expenditures 2013 Highlights. 2014. 2 OECD. StatExtracts – Health expenditure and financing, main indicators. 2013.
3 Robert Wood Johnson Foundation & Johns Hopkins Bloomberg School of Public Health. Chronic Care: Making the Case for Ongoing Care. 2010. 4 Joszt L. Uninsured Rate Fell to 12.9% by the End of 2014. American Journal of Managed Care. 2015.
93
USA
/
EQUITY
WATCH THE ACCESS GAP Equitable access to healthcare regardless of income, race and ethnicity, gender, education, or geographic location is an area in which the USA still struggles.
In the report “Mirror mirror on the Wall: How the U.S. Healthcare System Compares Internationally,” from 2014, the private foundation, The Commonwealth Fund, found that the USA came in last in terms of providing equitable care, when compared with 10 other developed countries.5 Setting it apart from some of the other care dimensions, the issue of inequality permeates all sectors of American society, and healthcare is just one of the areas it touches. It is therefore difficult to separate inequality in healthcare from inequality in every other aspect of life. With that in mind, rather than discussing the larger issue of socio-
QUALITY BY ZIP CODE... An American’s place of residence plays an integral role in the equity of access and quality of care they receive, as state by state disparities are quite large. In fact, low income populations in certain states, such as Minnesota, receive better care than higher income populations in other states, like Louisiana.6 In Massachusetts, 9% of adults went without care last year because of cost, while further south in Mississippi that portion skyrocketed to 22%.7 This disparity exists throughout the country and is often caused by historic patterns of racial and ethnic discrimination.
economic disparity, this section will focus more narrowly on how entrenched inequality manifests
…AND BY PAYCHECK
in the healthcare system, particularly in terms of
37% of Americans went without care in 2013
location, income, and insurance coverage.
because of cost, meaning that they did not visit a physician when sick, did not get a prescription filled, or did not get a recommended test or treatment. See figure 10. Adults with lower socioeconomic status are more likely to experience high blood pressure, obesity, heart disease,
5 Commonwealth Fund. Mirror, Mirror on the Wall: How the Performance of the U.S. Health Care System Compares Internationally. 2014.
94
9 Kaiser Family Foundation. Medicaid and the Uninsured. 2009.
infectious diseases and mental illness.8 Due to the incredibly high cost of care, access is often determined by whether or not someone is insured,
6 Commonwealth Fund. Healthcare in the Two Americas. 2013.
10 Commonwealth Fund. America’s Underinsured: A State-by-State Look at Health Insurance Affordability Prior to the New Coverage Expansions. 2014.
7 Commonwealth Fund. Aiming Higher: Results from a Scorecard on State Health System Performance. 2014.
11 Kaiser Family Foundation. A Guide to the Supreme Court’s Decision on the ACA’s Medicaid Expansion. 2012.
er-income individuals, leading to income-based
8 Weir K. “Closing the healthwealth gap.” American Psychological Association. 2013; 44(9): 36.
12 Kaiser Family Foundation. Number of Uninsured Eligible for Medicaid Under the ACA. 2015.
and it has been well-established that low income adults are more likely to be uninsured than highinequalities.9 In addition, when low-income people do have insurance, they are more likely to be “underinsured” with coverage that fails to provide
FIGURE 10.
RANKING SCORES (FROM 1-11 )
COSTS ARE KEEPING PEOPLE AWAY FROM HEALTHCARE
AUS
CAN
FRA
GER
NETH
NZ
NOR
SWE
SWIZ
UK
7
1
US
COST-RELATED ACCESS PROBLEMS
9
5
10
4
8
6
3
1
11
Access Measures DID NOT FILL A PRESCRIPTION
More than one-third of the Americans went
Skipped recommended medical test, treatment, or follow-up; or had a medical problem but did not visit doctor or clinic in the past year because of cost
without healthcare because of costs in 2014. This puts the USA in the bottom in terms
7
4
8
6
10
9
3
2
4
1
11
9
1
11
cost-related access problems. Source: Commonwealth Fund. Mirror, Mirror on the Wall: How the Performance of the U.S. Health Care System Compares Internationally. 2014. Page 21.
Patient’s insurance denied payment for medical care or did not pay as much as expected 8
6
10
6
5
4
1
1
financial protection from out-of-pocket healthcare
not expand coverage, however, only an average of
costs, putting them at risk of delaying or forgoing
31% of adults are Medicaid eligible, meaning huge
needed care and contributing to the disparity of
numbers of residents remain uninsured and with
healthcare access. As a nation, over 50% of people
little access to quality care.12 In these states, many
with low incomes and 20% of those with middle
now fall into what is known as a “coverage gap” in
incomes were either underinsured or uninsured in
which they earn too high an income to be eligible
2012.10
for Medicaid, but not high enough to qualify for tax credits which would have made other insurance plans affordable.13 In some states, such as Texas,
TRYING TO BRIDGE THE GAP
this gap is enormous, leaving about one million low
WITH MEDICAID AND MEDICARE
income people who could otherwise be covered,
Medicaid and Medicare are two government
uninsured.14 Thus, while some states move toward
funded insurance programs designed to provide
greater equity under this provision, others are
healthcare for low-income and elderly Americans,
widening the access gap between the haves and
respectively. Both are intended to ensure that
the have-nots.
vulnerable populations still receive quality medical care. Medicare is operated at the national level, and Medicaid is a state-run program. Both have been affected by recent healthcare reforms, but the changes to Medicaid coverage, in particular, have an enormous impact on equitable care distribution in the United States.
LEARNING FROM THE BEST While the American healthcare system’s inequitable access is truly astounding on an international
On June 28, 2012, the USA Supreme Court issued a ruling that states can decide whether or not to expand Medicaid to cover individuals with incomes
scale a great deal can be done to alleviate some of these disparities, and many solutions can be found without leaving the country. As the Commonwealth Fund reports, if all states could
up to 138% of the poverty line.11 This ruling has had
meet the benchmarks of the highest performing
a mixed effect on the alleviation of inequality of
American states, massive strides could be made
access to care for low-income individuals. At the
across the board. Over 30 million more low-in-
positive end, in states that chose to expand coverage, an average of 77% of uninsured adults are now eligible for Medicaid insurance. In states that did
come adults and children would have health insurance – reducing the number of uninsured by more than half. Additionally, an estimated 86,000 fewer people would die prematurely and about 21 million fewer low-income adults would go without needed care because of cost.15
Kaiser Family Foundation. The Coverage Gap: Uninsured Poor Adults in States that Do Not Expand Medicaid – An Update. 2014. 13, 14
15 Commonwealth Fund. Healthcare in the Two Americas. 2013.
95
USA
/
  SAFETY
THE FIGHT TO IMPROVE PATIENT SAFETY The USA has made some notable progress in recent years in regard to ensuring safer environments and safer treatment for all patients, but is still lagging behind when compared internationally. A study released in 2013 by the Journal of Patient
the American healthcare system: diagnostic er-
Safety estimates that up to 400,000 people die
rors, healthcare acquired infections, and prevent-
each year due to preventable medical errors.16
able drug events.
The study places preventable medical errors as the third leading cause of death in America, behind heart disease and cancer. In 2008, medical
DIAGNOSTIC ERRORS POSE A SERIOUS
errors cost the United States $19.5 billion.17
THREAT A correct diagnosis is a key element in increasing
Patient safety in the USA has improved in the
patient safety. Each year in the USA, approx-
last couple of years. According to the Agency for
imately 12 million adults who seek outpatient
Healthcare Research and Quality, hospital-ac-
medical care are misdiagnosed. This figure
quired conditions (HACs) in the USA have de-
amounts to 1 out of 20 adult patients, and in half
creased from 2010 to 2013 with 1.3 million fewer
of those cases, the diagnostic error has the po-
patient harms. As a result 50,000 fewer patients
tential to result in severe harm.19
died in the hospital and approximately $12 billion in healthcare costs were saved.18 See figure 11.
Misdiagnosis also strains budgets with diagnostic errors accounting for the largest fraction of
In the following section, we will look at some of
malpractice claim payouts, totaling $38.8 billion
the challenges that compromise patient safety in
between 1986 and 2010.20
FIGURE 11.
HACS ARE DECREASING SIGNIFICANTLY
20
Annual and cumulative decrease in HACs, 2010-2013
12
16 17%
8
The national HAC rate declined by 9% from 2012 to 2013 and was 17% lower in 2013 than in 2010 Source: AHRQ. Interim Update on 2013 Annual Hospital-Acquired Condition Rate and Estimates of Cost Savings and Deaths Averted from 2010 to 2013.
96
9% 7%
4 0
2% Change in HACs, 2010 to 2011
Change in HACs, 2011 to 2012
Change in HACs, 2012 to 2013
Change in HACs, 2010 to 2013
HOSPITAL ACQUIRED INFECTIONS ARE DECREASING There is currently no system in place that can estimate the extent of all types of hospital acquired infections (HAIs) – but a prevalence study from the Center for Disease Control provides an estimate of the overall challenge of HAIs in American hospitals. The latest survey found that on any given day, about 1 in 25 hospital patients has at least one HAI.21 There were an estimated 722,000 HAIs in American acute care hospitals in 2011
In August 2014, the first national action plan for ADE prevention – “The ADE Action Plan“ – was released by the Department of Health and Human Services Office of Disease Prevention and Health Promotion. The four pillars in the ADE Action Plan are surveillance, prevention, incentives and oversight, and research: 1) Surveillance—Coordinate existing Federal surveillance resources and data to assess the health burden
and approximately 75,000 hospital patients with HAIs
and rates of ADEs.
died during their hospitalizations.22, 23 In addition to costing human lives, HAIs also put a strain on healthcare budgets. HAIs alone are responsible for $28 billion to
2) Prevention—Share existing evidence-based prevention tools across Federal Agencies and with
$33 billion in potentially preventable healthcare expen-
non-Federal healthcare providers and patients.
ditures annually.24 In 2009 the USA Department of Health and Human
3) I ncentives and Oversight—Explore opportunities, including financial incentives and oversight authori-
Services set out the “National Action Plan to Prevent
ties, to promote ADE prevention.
HAIs: Road Map to Elimination” and each year the progress towards this goal is measured and captured in “The HAI Progress Report”. The Report shows that
4) Research—Identify current knowledge gaps and future research needs (unanswered questions) for ADE
significant reductions were reported in 2012 for nearly
prevention.
all infections. A main driver in this progress is, in part, the Medicare rule that took effect October 2008, which prevents hospitals from receiving payment for the costs of treating certain HAIs.25, 26 A study reporting results of a survey of 317 infection-control professionals published in The American Journal of Infection Control in May 2012 shows that
The ambition for the ADE Action Plan is that it will document the same measurable results as the “National Action Plan to Prevent HAIs”, which was released in 2009 and showed measurable reductions by 2012.30 Results are not yet available for the ADE Action Plan.
more than 80% of the respondents believe the Centers for Medicare and Medicaid Services policy has led to greater focus on the healthcare-associated infections targeted under the Medicare rule.27
PREVENTABLE MEDICATION ERRORS COST LIVES AND MONEY Each year in the USA, serious preventable medication errors occur in 3.8 million inpatient admissions and 3.3 million outpatient visits. Inpatient and outpatient preventable medication errors cost approximately $21 billion annually.28 Medication errors typically occur because of prescription error, fragmentation of care, and lack of information technology infrastructure, such as Electronic Medical Records and electronic prescribing. Studies show that improved communication among physicians, pharmacists and nurses prevented 85% of serious medication errors and that including a pharmacist on routine medical rounds led to a 78% reduction in medication errors.29
16 James J. “A New, Evidence-Based Estimate of Patient Harms Associated with Hospital Care.” Journal of Patient Safety. 2113; 9(3): 122-128. 17 Andel C, Davidow SL, Hollander M & Moreno DA. “The economics of health care quality and medical errors.” Journal of Health Care Finance 2012; 39(1): 39-50. 18 AHRQ. Interim Update on 2013 Annual Hospital-Acquired Condition Rate and Estimates of Cost Savings and Deaths Averted from 2010 to 2013. 2013. 19 Singh H, Meyer A & Thomas E. “The frequency of diagnostic errors in outpatient care: estimations from three large observational studies involving US adult populations.” BMJ Quality and Safety 2014; 23(9). 20 Johns Hopkins Medicine. Diagnostic Errors More Common, Costly And Harmful Than Treatment Mistakes. 2013. Centers for Disease Control and Prevention. Health-associated Infections (HAIs) – Data and Statistics. 2015.
24 Office of Disease Prevention and Health Promotion. National Action Plan to Prevent Health Care-Associated Infections: Road Map to Elimination. 2013. 25 US Department of Health and Human Services. Testimony on U.S. Efforts to Reduce Healthcare-Associated Infections. 2013. 26 Centers for Medicare & Medicaid Services. Hospital-Acquired Conditions. 2014. 27 Lee G et al. “Perceived impact of the Medicare policy to adjust payment for health care-associated infections.” American Journal of Infection Control 2012; 40(4): 314-319. 28,29 New England Health Institute. Preventing Medication Errors: A $21 Billion Opportunity. 2010. 30 American Society of Health-System Pharmacists. Federal Plan Aims to Reduce Adverse Drug Events. 2014.
21,22
23 Magill S et al. ”Multistate Point-Prevalence Survey of Health Care-Associated Infections.” New England Journal of Medicine. 2014; 370: 1198-1208.
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PERSON-CENTERED CARE
TOWARDS HEALTHCARE OF, BY AND FOR THE PEOPLE Putting the patient at the center of care is not a new ambition in the USA. Since the early 2000s the Institute of Medicine and the Physician Charter have both defined person-centeredness as an essential component of high-quality healthcare. While the concept is well-known, its adoption into the overall healthcare system remains less widespread.
In its Declaration on Patient-Centred Healthcare
these issues are the Accountable Care Organi-
from 2006, The International Alliance of Patients'
zations (ACO) for Medicare recipients, health
Organizations states that the essence of per-
homes for Medicaid recipients and a reward sys-
son-centered healthcare is that the “healthcare
tem for person-centered care in hospitals.32 See
system is designed and delivered to address the
textbox on page 99.
healthcare needs and preferences of patients so that healthcare is appropriate and cost-effective.”
The following section discusses three elements of
The Declaration sets out five principles of per-
person-centered care in order to point to some of
son-centered healthcare: respect; choice and em-
the challenges standing in the way of the scaling
powerment; patient involvement in health policy;
of person-centered care in the USA. These ele-
access and support; and information.31
ments are continuity of care, health information technology, and health literacy,
American frontrunners such as Planetree, The Institute of Medicine and Kaiser Permanente have focused on promoting and implementing person-centered care, but still there is a long way to go for person-centered care to become common practice in the USA. The Patient Protection and Affordable Care Act (ACA) repeatedly refers to patient centeredness, patient satisfaction, patient experience of care, patient engagement, and shared decision-making in its provisions. Three initiatives that address
98
31 International Alliance of Patients’ Organizations. Declaration on Patient-Centred Healthcare. 2006.
34 Families USA. The Promise of Care Coordination: Transforming Health Care Delivery. 2013.
32 Center for Health Care Strategies, Inc. Health Literacy Implications of the Affordable Care Act. 2010.
35 Centers for Medicaid and Medicare Services. Medicaid Health Homes: An Overview. 2014.
33 Centers for Medicaid and Medicare Services. Medicare ACOs continue to succeed in improving care, lowering cost growth. 2014.
36,37 Families USA. The Promise of Care Coordination: Transforming Health Care Delivery. 2013. 38 AHRQ. Care Coordination. 2014.
IMPROVING PERSONCENTERED CARE THROUGH POLITICAL INITIATIVES •A n Accountable Care Organization is an entity
CONTINUITY OF CARE IS A PROBLEM Poor continuity of care increases the risk of medication errors, unnecessary tests and emergency room visits, and preventable hospital admissions, all of which lead to costly and lower quality of
that consists of healthcare providers across
care.36 In 2011, the economic burden of inade-
the continuum of care (including acute care,
quate care coordination in the United States was
long-term care, and behavioral and mental
estimated to be between $25 billion and $45
healthcare) that agrees to be held accountable
billion.37
for improving the health of patients receiving Medicare. If patients’ healthcare costs end up being less than would otherwise be expected
According to The Agency for Healthcare Re-
while healthcare quality is maintained or
search and Quality (AHRQ) poor communica-
improved, the providers get to keep a share of
tion exchange between primary care physicians
that savings. Since passage of the Affordable
and specialists and information lost in referral
Care Act, more than 360 Medicare ACOs have been established, serving over 5.6 million Americans with Medicare.33 •A health home is a provider or group of providers who coordinate care for all the
processes are two of the most crucial areas of coordination to improve.38 These findings are mirrored in the 2011 “Survey of Public Views of the U.S. Health System” from the Commonwealth
medical and non-medical needs of Medicaid
Fund, where 47% of the respondents reported at
patients with two or more chronic conditions.
least one failure of care coordination.39
The Affordable Care Act created this option as a way to allow states to use Medicaid funding to better coordinate care for high-need, high-risk populations.34 As of June 2014, 15 states have opened health homes and more
HEALTH INFORMATION TECHNOLOGY IS MOVING FORWARD
than one million Medicaid beneficiaries have
Health information technology has become a key
been enrolled. Nearly a dozen other states are
element of person-centered care as it encom-
planning health home models.35
passes a wide range of products and services
•T he reward system for hospitals focuses on
designed to collect, store, and exchange patient
quality of care, and maintenance of high levels
data throughout the healthcare experience. The
of patient satisfaction. To measure how satisfied
core feature of health IT is electronic patient
patients are with the care they experienced, patients are surveyed randomly and asked
records. The USA federal government has put
about various aspects of their experience. In
forth legislation to make electronic health records
October 2012, Medicare began rewarding the
a national goal.40 This could explain why the
best performing hospitals with bonuses based
proportion of hospitals having electronic records
on the evaluations.
has tripled since 2010 and why 38% of physicians report having adopted basic digitization in 2012. Although the numbers point towards an increase in the adoption of electronic records overall, there is still room for improvement. A study from
39 Commonwealth Fund. A Call for Change: The 2011 Commonwealth Fund Survey of Public Views of the U.S. Health System. 2011. 40 Centers for Disease Control and Prevention. Meaningful Use. 2012. 41 American Medical Association. Quality of Patient Care Drives Physician Satisfaction; Doctors Have Concerns About Electronic Health Records, Study Finds. 2013.
42 George Washington University. Low Health Literacy: Implications for National Health Policy. 2007.
2013 found that digital recordkeeping negatively affected physicians’ satisfaction. Those surveyed expressed concern that current electronic health record technology interferes with face-to-face discussions with patients, requires too much clerical work, and degrades the accuracy of medical records by encouraging template-generated notes.41
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THE NATION SUFFERS FROM POOR
• GOAL 2: Promote changes in the healthcare
HEALTH LITERACY
delivery system that improve health informa-
When the health literacy of the American people
tion, communication, informed decision-mak-
was reviewed by the National Assessment of
ing, and access to health services
Adult Literacy, it showed that a mere 12% had proficient health literacy. At the other end of the
• GOAL 3: Incorporate accurate, stan-
spectrum, 14% had below basic health literacy,
dards-based, and developmentally appropriate
and would not, for example, be able to recognize
health and science information and curricula in
a medical appointment on a hospital appoint-
child care and education through the university
ment form.42
level
Low health literacy is associated with reduced use
• GOAL 4: Support and expand local efforts
of preventive services and management of chron-
to provide adult education, English language
ic conditions, and higher mortality. Furthermore,
instruction, and culturally and linguistically
it also results in medication errors, misdiagnosis
appropriate health information services in the
due to poor communication between providers
community
and patients, low rates of treatment compliance, hospital readmissions, unnecessary emergency room visits, longer hospital stays, and poor re-
• GOAL 5: Build partnerships, develop guidance, and change policies
sponsiveness to public health emergencies. • GOAL 6: Increase basic research and the deThe economic repercussions of low health liter-
velopment, implementation, and evaluation of
acy have been estimated to cost the American
practices and interventions to improve health
economy between $106 billion and $236 billion
literacy
annually.43 • GOAL 7: Increase the dissemination and use of Several provisions in the Affordable Care Act
evidence-based health literacy practices and
directly acknowledge the need for greater atten-
interventions
tion to health literacy, and many others imply it. Moreover, the Plain Writing Act of 2010, requires Furthermore, the Department of Health and Hu-
all new publications, forms, and publicly distrib-
man Services developed the National Action Plan
uted documents from the federal government
to Improve Health Literacy in 2010. The National
to be written in a “clear, concise, well-organized”
Action Plan provides a framework for consistent
manner.44
action to address health literacy and proposes coordinated societal action across seven different
The provisions in the ACA, in the national action
areas to improve systems, information communi-
plan to improve health literacy and the Plain
cation and education.
Writing Act all point towards a positive focus on empowering the patients to become a more ac-
The seven goals in the plan are listed below:
tive part of their care. Whether they have helped produce positive results is too soon to tell.
• GOAL 1: Develop and disseminate health and safety information that is accurate, accessible, and actionable
43 Center for Health Care Strategies. Health Literacy Implications of the Affordable Care Act. 2010. 44 Plain Writing Act. 5 U.S.C. 301. 2010.
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COST-EFFICIENCY
GETTING YOUR MONEY'S WORTH? Given the ever increasing cost of healthcare throughout the world, maximizing efficiency is of the utmost importance for every country. Unfortunately in the USA, more expensive healthcare does not translate to better quality.
Since 1980, the USA has increased its healthcare spending from around 9% of its GDP to 17.7% in 2012.45 From 2007-2012, a period that encompassed the Great Recession, healthcare spending rose $491 billion, reaching $2.8 trillion nationally according to government estimates.46 Spending increased in all states on both a per capita basis and as a share of total state income. And still, the Commonwealth Fund’s 2014 “Scorecard on State Health Performance” points to deteriorating access to care for adults, stagnant or worsening performance on other key measures such as preventive care for adults, and widespread disparities in peoples’ healthcare experience across and within states.47, 48, 49
COSTLY PAYMENT MODEL With the fee-for-service (FFS) model, physicians are reimbursed for all services they provide and pay is not necessarily linked to outcomes.50 In 2008, 78% of employer-sponsored health insurance used this model.51 This means that there is little or no incentive to discourage the delivery of unnecessary services in this system.52 According to the American think-tank, Center for American Progress, the FFS model has multiple disadvantages: it encourages wasteful use, especially of high cost items and services, and it does not align financial incentives between different providers.53
The American healthcare system therefore provides the lowest quality of care at the highest price tag – the definition of cost-inefficiency. Hence, gearing the system towards providing better quality care for less money is one of the great challenges that this region is up against. While the others sectors explored the quality of the American healthcare system, this section will look at some of the features that makes this system so expensive.
45 Commonwealth Fund. Mirror, Mirror on the Wall: How the Performance of the U.S. Health Care System Compares Internationally. 2014. 46 Commonwealth Fund. Aiming Higher: Results from a Scorecard on State Health System Performance. 2014. 47 Center for Medicaid and Medicare Services. National Health Expenditures – Table 1. Undated. 48 Center for Medicaid and Medicare Services. Total All Payers State Estimates by State of Residence. 2011.
49 Commonwealth Fund. Aiming Higher: Results from a Scorecard on State Health System Performance. 2014. 50 National Commission on Physician Payment Reform. Report on The National Commission on Physician Payment Reform. 2013. 51 Center for American Progress. Alternatives to Fee-for-Service Payments in Health Care. 2012. 52 Barnes J. “Moving Away from Fee-for Service.” The Atlantic. 2012.
101
Furthermore, FFS does not encourage preven-
Administrative costs account for 25% of hospital
tive care and patient education, which results in
spending in the USA, and the 2014 Common-
conditions that could have been managed with
wealth Fund report, “A Comparison of Hospital
better preventive disease management being
Administrative Costs in Eight Nations,” found that
managed in acute care instead.54
there is no link between higher administrative costs and better quality care.57 The study attri-
However, the need for alternative payment mod-
butes the high administrative costs in the USA to
els is well recognized and small shifts in payment
two factors:
models are emerging. In September 2013, the National Commission on Physician Payment Reform
1) The complexity of billing a multiplicity of
issued its recommendations on how to reform the
insurers with varying payment rates, rules and
physician payment system. The first recommen-
documentation requirements;
dation reads: “Over time, payers should largely eliminate stand-alone fee-for-service payment to
2) The imperative for hospitals to generate profits
medical practices because of its inherent ineffi-
or, for nonprofit hospitals, surpluses. The re-
ciencies and problematic financial incentives.”55
searchers found that within the USA, administrative costs were highest (27.2% of spending)
Other alternative payment models were intro-
at for-profit hospitals.
duced with the Affordable Care Act with the aim of paying for quality instead of quantity of
Reducing USA per capita spending on hospital
care. These payment models include bundled
administration to Scottish or Canadian levels
payments, patient-centered medical homes and
would have saved more than $150 billion in 2011.58
accountable care organizations. See text box. DOCTORS ON THE DEFENSIVE SKY HIGH ADMINISTRATIVE COSTS
In a 2009 national survey of physicians, 75% of
The money spent on healthcare administration
doctors said that they order more tests, proce-
is more than twice the total spending on heart
dures and medicines than are medically nec-
disease and three times the spending on cancer.56
essary in an attempt to avoid lawsuits.59 About $650 billion are spent annually on defensive medicine, which, aside from the high cost also results in other consequences:
NEW PAYMENT MODELS TO PROMOTE QUALITY CARE
1) Limiting access to care for high-risk patients 2) Over- and under-treating patients with life-threatening illnesses
•B undled payments, which are fixed amounts paid to healthcare providers for a bundle of services or all the care a patient is expected to need during a period of time
3) F ostering distrust among patients and their physicians, which has resulted in lowered
•P atient-centered medical homes, which are redesigned primary care practices that focus more on preventive care, patient education, and care coordination between different healthcare providers •A ccountable care organizations, which are groups of healthcare providers who agree to share responsibility for coordinating lower-cost, higher-quality care for a group of patients
physician morale and manpower 53 Center for American Progress. Alternatives to Fee-for-Service Payments in Health Care. 2012.
and Improving the Health Care System.” New England Journal of Medicine 2012; 367: 1875-1878.
54 Gillies S & Gretch S. “Coping with Medicare Advantage fee-for-service plans.” American Academy of Orthopaedic Surgeons. 2008.
57,58
55 National Commission on Physician Payment Reform. Report on The National Commission on Physician Payment Reform. 2013. 56 Cutler D, Wikler E & Basch P. “Reducing Administrative Costs
102
Himmelstein D et al. ”A Comparison Of Hospital Administrative Costs In Eight Nations: US Costs Exceed All Others By Far.” Health Affairs 2014; 33(9): 1586-1594. Page 1586 59 Jackson Healthcare. Quantifying the Cost of Defensive Medicine. 2010.
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EFFECTIVENESS
TOO MUCH AND NOT ENOUGH The dual problem of over- and under-use use of healthcare services is a significant concern in the USA. Overuse of medications and tests puts a severe financial burden on the system. However, underuse of certain services is still a great challenge, especially for low-income groups.
Applying the appropriate measures based
This section will provide a status on the devel-
on science, and thus ensuring the effective-
opment of underuse and overuse of treat-
ness of the healthcare system, has proven a
ment in the American healthcare system and
difficult task.60 Appropriate measures refer
highlight key developments within promoting
to the avoidance of both underuse – like not
the use of evidence based medicine.
receiving a vaccine despite its proven effectiveness – and overuse, e.g. treating a child’s simple ear infection with antibiotics.61 Overuse and underuse of treatment are both far too common in the USA. Overuse has been named one of the main contributors to the skyrocketing healthcare expenses, and underuse remains a challenge feeding into the ‘healthcare for all’ discussion. A trend away from employing evidence based medicine also contributes to improper and ineffective treatment.
60 Institute for Healthcare Improvement. Across the Chasm: Six Aims for Changing the Health Care System. 2015. 61 Commonwealth Fund. Mirror, Mirror on the Wall: How the Performance of the U.S. Health Care System Compares Internationally. 2014.
103
STATUS QUO OF OVERUSE
UNDERUSE STEMS FROM INEQUALITY
Overuse in America’s healthcare system is a sub-
A 2007 study by the National Committee for
stantial problem that may account for as much as
Quality Assurance reports that 91,000 Americans
30% of healthcare spending.62 Antibiotic overuse
die each year because they don’t receive the
is perhaps the most well-known issue, and it is
right evidence-based care for chronic conditions
particularly apparent in the USA. For instance,
like high blood pressure, diabetes and heart
60-90% of patients with acute bronchitis who
disease.69
seek care are given antibiotics, despite the fact that they will recover without them.63, 64, 65 Some
An important indicator of effectiveness in terms
positive news on this front has emerged recently,
of underuse is the degree to which a healthcare
though; the NCQA's 2014 “State of Healthcare
system manages the care of patients with chronic
Quality Report” found that avoidance of antibi-
illnesses and prevents future illnesses through
otic treatment in adults with acute bronchitis had
targeted interventions.70 The 2014 “Mirror Mirror
its first gain in the measure's seven-year history.
on the Wall” report from the Commonwealth Fund
This is a substantial development, since aside
places the USA in third place on effective care
from being harmful to individual and communal
overall – performing relatively well on prevention
health, antibiotic-resistant bacteria costs ap-
but average in comparison to other Western coun-
proximately $55 billion in health services and lost
tries on quality of chronic care management.71
productivity.66 Underuse in the American healthcare system The overuse of tests and procedures is also a
has traditionally been linked to equity with many
problem. The NCQA's 2014 State of Healthcare
patients not getting the care they need due to
Quality Report concludes that the USA is either
lack of insurance or ability to pay out of pocket.
stagnant in or overusing a range of medical
By expanding access to insurance, the Affordable
procedures. More than a quarter of all wasteful
Care Act has the potential to address underuse
spending in healthcare— $210 billion out of the
due to lack of insurance and ensure that more
estimated $765 billion in wasteful spending in
Americans get the appropriate treatment.72
2009—is attributed to overuse of services.67 This is due, in large part, to the fact healthcare providers are paid in a way that rewards doing more, rather than being efficient. Alternative payment models exist, such as prior authorization for approval to run certain tests; episode-based payments; and value-based benefit design. These alternatives, however, present three respective challenges, namely increasing excessive bureaucratic steps, incentivizing numerous doctors’ visits, and the fact that most services are not uniformly appropriate or inappropriate.68 Therefore, more research must be conducted to identify the best possible way to structure payments that reduce the incentive to overuse medical services.
104
62 Overuse Accounts for Up to 30% of Healthcare Spending. Medscape. 2012.
66 Smith R & Coast J. “The True Cost of Antimicrobial Resistance.” BMJ 2013; 346.
63 WebMD. Acute Bronchitis—Topic Overview. 2015.
67,68
64 Kroening-Roche JC, Soroudi A, Castillo EM, Vilke GM. “Antibiotic and bronchodilator prescribing for acute bronchitis in the emergency department.” The Journal of Emergency Medicine 2012; 43:221. 65 Evertsen J, Baumgardner DJ, Regnery A, Banerjee I. “Diagnosis and management of pneumonia and bronchitis in outpatient primary care practices.” Primary Care Respiratory Journal 2010; 19:237.
Robert Wood Johnson Foundation. Doing Better by Doing Less: Approaches to Tackle Overuse of Services. 2013. 69 National Committee for Quality Assurance. The Essential Guide to Healthcare Quality. 2007. 1 Commonwealth Fund. Mirror, Mirror on the Wall: How the Performance of the U.S. Health Care System Compares Internationally. 2014. 70,7
72 Patient Protection and Affordable Care Act, 42 U.S.C. § 18001. 2010.
EVIDENCE VS. EXPERIENCE In the USA, the lack of integration of evidence
This is in part due to evidence-based med-
based medicine (EMB) into the healthcare
icine being derived from averaged global
system has had severe impacts with as many
evidence gathered from exogenous popu-
as 57,000 Americans dying each year due to
lations, which may not be relevant to local
care not being based on the best available
circumstances. As Trish Greenhalgh explains,
evidence.73 Thus the USA will, in the coming
there are some additional crises in the EMB
years, be forced to reflect on how to better
movement, namely:
integrate EBM as a way to develop more scientifically valid and smart ways to care for patients.
• The evidence based “quality mark” has been misappropriated by vested interests
Not surprisingly, a lack of EBM – and health-
• The volume of evidence, especially clinical
care professionals’ reliance on tradition and
guidelines, has become unmanageable
anecdotal personal experience when making decisions – contributes to the aforementioned problems of inappropriately- and over-used
• Statistically significant benefits may be marginal in clinical practice
medical services.74 It has been estimated that about half of all physicians rely on clinical ex-
• Inflexible rules and technology driv-
perience rather than evidence to make deci-
en prompts may produce care that is
sions. This happens despite physicians rarely
management driven rather than patient
seeing enough cases of the same conditions
centered
to draw scientifically valid conclusions about treatment.75
• Evidence based guidelines often map poorly to complex multimobidity77
On the flip side, though, the evidence based medicine movement is struggling to narrow the gap between EBM and physician clinical
Greenhalgh continues that these problems
practice.76
don’t signify the end of EBM, but rather point toward a need to return to “real” evidence based medicine, that values individual patient care and sound, supported judgment rather than strict rules.78
73 National Committee of Quality Assurance. The State of Healthcare Quality: 2003. 2003. 74 Institute for Healthcare Improvement. Across the Chasm Aim #2: Health Care Must Be Effective. 2015.
Hay MC et al. ”Harnessing experience: exploring the gap between evidence-based medicine and clinical practice.” Journal of Evaluation in Clinical Practice 2008; 14(5): 707-713. 75, 76
Greenhalgh T. “Evidence based medicine: a movement in crisis?” BMJ 2014; 348. 77,78
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TIMELINESS
HEALTHCARE ON TIME... SOMETIMES The timeliness of healthcare delivery in the USA is highly dependent on the type of care being sought. While specialist visits are typically quick and easy to schedule, primary care visits tend to come with long waiting times.
It has been shown that a lack of timely
GREAT VARIATION IN TIMELINESS
treatment may result in emotional dis-
FOR PRIMARY CARE AND SPECIALISTS
tress, physical harm, frustration for service users and professionals alike and higher treatment costs.79, 80 If all American states improved their performance to the level of the best-performing state in terms of timely care delivery, the benefits would mean a reduction in premature deaths by as much as 84,777 per year from causes that are potentially treatable or preventable.81 Additionally, timely outpatient care has the potential to reduce admissions for pediatric asthma, which costs $1.25 billion in hospitalization charges annually.82, 83
When compared internationally, the USA performs poorly on waiting times for primary care, as the Commonwealth Fund’s “Mirror Mirror on the Wall” survey from 2014 ranks the USA 8th of 11 high-income nations.84 This picture changes when examining how the USA performs on specialist and elective surgery waiting times. Here the country ranks 3rd and 6th, respectively, on questions regarding waiting. The results correspond with the fact that the healthcare system in the USA puts less
In the following, waiting times for primary care, specialists and emergency wards are discussed as primary indicators for the state
emphasis than most countries on primary care and has a greater proportion of specialists than general physicians.85
of timeliness in the American healthcare sector.
79 Boudreau RM et al. “Improving the timeliness of written patient notification of mammography results by mammography centers.” The Breast Journal 2004;10(1):10-9. 80 Institute for Healthcare Improvement. Across the Chasm: Six Aims for changing the Health Care System. 2015.
106
81 Commonwealth Fund. Aiming Higher: Results from a Scorecard on State Health System Performance. 2014. 82 Schatz M, Rachelefsky G, Krishnan JA. “Follow-up after acute asthma episodes: what improves future outcomes?” Proceedings of the American Thoracic Society 2009;6: 386-93.
83 Agency for Healthcare Research and Quality. Calculated from Healthcare Cost and Utilization Project. Kids’ Inpatient Database. Undated. 84 Commonwealth Fund. Mirror, Mirror on the Wall: How the Performance of the U.S. Health Care System Compares Internationally. 2014.
INCREASINGLY CROWDED EMERGENCY ROOMS Waiting times in emergency departments are often used as central indicators of timeliness in healthcare systems. In 2003, American patients arriving at emergency departments had to wait for an average of 46 minutes before receiving
A SOLUTION: OPEN ACCESS SCHEDULING One way to better manage waiting times in healthcare is through smarter appointment scheduling. In an open access schedule – also
treatment. Six years later, this increased by 25%
known as advanced access and same-day
to almost an hour.86 This development is due,
schedule – almost all patients are seen on the
in part, to the fact that there has been a 32%
day they call for an appointment regardless of
increase in visits to emergency departments from 1999 to 2009.87
the reason for their visit. Instead of booking a physician’s time weeks in advance, this model leaves a specific number of appointments kept open in each clinic session. Open access
The overuse of EDs for conditions that could be
scheduling has proven able to eliminate
seen in a non-emergency setting is one of several
backlogs of appointments in many healthcare
contributors to ED overcrowding and delays in care and is often caused by a lack of primary care
organizations – covering primary care facilities, medical centers and specialists clinics. At the Kaiser Permanente facility in Roseville, California,
utilization. For instance, the WHO’s European Ob-
where the open access strategy originated,
servatory on Health Systems and Policies found
average waiting times for routine appointments
that in 2008, a regular doctor could have handled
were lowered from 55 days to one day in less
19% of ED visits, had one been available.88
than a year. Other examples of successful implementation of open access scheduling include e.g. The Mayo Clinic’s Primary Care
A survey of emergency department users in Cal-
Pediatric and Adolescent Medicine Team and The
ifornia shows that 46% of the users themselves
Alaska Native Medical Center.90,91
indicated that their problem could have been handled by a primary care physician. See figure 12.
1%
FIGURE 12.
IS THIS AN EMERGENCY?
27%
Urgency of emergency room visits Recent ED users’ responses to whether their problem could have been handled by a primary care physician Yes
No
N/A (Visit Was Prearranged)
Not Sure
46% 25%
Source: California Health Care Foundation. Overuse of Emergency Departments Among Insured Californians. 2006.
85 WHO European Observatory of Health Systems and Policies. Health Systems in Transition: United States. 2013.
88 WHO European Observatory of Health Systems and Policies. Health Systems in Transition: United States. 2013.
90 Murray M and Tantau C. “Must patients wait?” Joint Commission Journal on Quality Improvement 1998; 24(8): 423-5.
Centers for Disease Control and Prevention. Wait Time for Treatment in Hospital Emergency Departments: 2009. 2012.
89 California Health Care Foundation. Overuse of Emergency Departments Among Insured Californians. 2006.
91 Agency for Healthcare Research and Quality. Open Access Scheduling for Routine and Urgent Appointments. Undated.
86,87
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ENVIRONMENTAL SUSTAINABILITY
GREENING THE HEALTHCARE AGENDA In December 2014, the Obama administration declared climate change a public health hazard, highlighting the shared challenges of healthcare and environmental sustainability. These challenges are framing the ‘green’ healthcare agenda in the coming years.
One month after hurricane Sandy hit New York City, four hospitals – together receiving 1.5 million patient visits per year – were still partially closed. Adapting healthcare practices and infrastructure to new conditions caused by climatic and environmental changes is a key element in a sustainable healthcare system. But sustainable healthcare should also reflect the environmental footprint of healthcare providers. In relation to environmental footprint, the substantial amounts of waste generated in the healthcare system is a major challenge. The following sheds light on the two main agendas within sustainability affecting the healthcare sector in the coming years: how climate change affects healthcare and how the healthcare sector in general responds to the fact that they have to work towards becoming more sustainable.
A WASTE OF ENERGY... Energy consumption is another environmental and economic challenge for American healthcare systems. Currently, American healthcare facilities spend $8.8 billion per year on energy. In 2013, USA Department of Energy's "Advanced Energy Retrofit Guide for Healthcare Facilities" outlined the opportunities of retrofitting healthcare facilities in order to improve energy efficiency. Along with reduced energy consumption, retrofitting also yields other benefits, ranging from improved equipment longevity to decreased patient recovery times to a more attractive brand. An example of the benefits of energy retrofitting is Connecticut's Greenwich Hospital. On the American government's 1-100 rating scale for Energy Star, Greenwich Hospital scored only 47, falling far short of the 75 required to garner an Energy Star designation. The hospital implemented a deep energy retrofit, saving more than 1.7 million kWh and $303,000 of electricity per year. The hospital also doubled its Energy Star rating by 2010 to 88 in only six months, and reduced its overall energy consumption by 35% with a lessthan-six-month payback on the effort.92
108
...AND RESOURCES The majority of the materials procured by a hospital ultimately become waste, resulting in nearly 7,000 tons of waste every day and $10 billion annually in disposal costs across the healthcare industry.93 Most of that waste—as much as 8085%—consists of materials that typically end up in ordinary landfills: paper files, cardboard packing materials, glass, plastics, and other types
GREEN FRONTRUNNERS ARE LEADING THE WAY
of commercial trash.94 The potential for reducing materials used and handling waste smarter could improve the environmental footprint of health-
Kaiser Permanente has become widely
care in the USA substantially.
recognized as an environmental leader in the healthcare sector and over the past decade
But healthcare waste is complex not only be-
they have initiated a line of green initiatives.
cause of its sheer volume, but also because a
Among other implementations, they have
small but significant amount of that waste, about
created an Environmental Preference Program
15–20%, must be regulated by multiple agencies,
and a Sustainability Scorecard for medical products, which helps the company evaluate
including U.S. Environmental Protection Agency,
and select products without harmful chemicals.
Occupational Safety and Health Administration,
This Scorecard was the first of its kind in the
Drug Enforcement Administration, and others.95
healthcare sector, and it helps encourage its
The ever-growing healthcare industry in the USA
suppliers to provide more sustainable products.
means that the medical waste industry is also
These dual benefits are estimated to save the company $26 million annually.
growing rapidly, expected to reach $3.2 billion by 2017.96
EXTREME WEATHER WREAKS HAVOC ON HEALTHCARE Extreme weather events are associated with a
The growing focus on how extreme weather
range of health impacts, from immediate injuries
impacts healthcare is a response to the USA
and deaths, to chronic depression and post-trau-
experiencing as much or more severe weather
matic stress disorders seen in weather-related
than any other country on Earth.99 Each year,
disaster survivors.97
nearly 12,000 people are hospitalized as a result of extreme temperature conditions.100 This calls
In the 2014 report "Primary Protection: Enhancing
for adapting the healthcare infrastructure in the
Healthcare Resilience for a Changing Climate," the
country to mitigate new risk factors and enable
Obama administration provides a guide and tool
healthcare providers to tackle events such as hurri-
kit that is designed to help healthcare providers
canes, heat waves, droughts and floods.
ensure quality care before, during and after extreme weather events.98
92 Connecticut Energy Efficiency Fund. Energy Efficiency At Work – Case Study: Greenwich Hospital. 93 Sustainability Roadmap for Hospitals. Waste. 2015. 94 Ganju N & Walsh M. “Sustainable Computing: How Digital Healthcare can Help the Environment, Reduce Costs, and Improve Patient Service.” TechNet Magazine. 2009.
95 Sustainability Roadmap for Hospitals. Waste. 2015. 96 BCC Research. U.S. Market For Medical Waste Treatment, Containment, Management, and Disposal To Reach Nearly $3.2 Billion In 2017. 2012.
U.S. Department of Health and Human Services. Primary Protection: Enhancing Health Care Resilience for a Changing Climate. 2014. 97,98
American Meteorological Society Policy Program. Under The Weather: Environmental Extremes and Health Care Delivery. 2010. 99,100
109
WASHINGTON DC ROUNDTABLE The Washington DC roundtable was the final destination on our global journey to co-create better healthcare systems. The keynote speaker, Ms. Susan Sheridan (profiled in an interview on page 144), became a passionate patient engagement advocate after her family suffered from no less than two major healthcare system failures. She is now Director of Patient Engagement at the Patient-Centered Outcomes Research Institute, fighting for the creation of a safer healthcare system. Her story greatly influenced discussions at the roundtable with all participants engaging actively in developing new ways to overcome the known challenges of the healthcare system in the USA and identify the opportunities at hand.
THREE GLOBAL ROUNDTABLES In late 2014 and early 2015, DNV GL and Monday Morning Sustainia traveled to Shanghai, Brussels, and Washington DC to gain insights for this publication and start a conversation on challenges and opportunities for improving the quality of care in the healthcare systems of China, the EU and the USA. The guiding question for the roundtables was: HOW DO WE IMPROVE THE QUALITY OF CARE?
110
CHALLENGES FOR HEALTHCARE IN THE USA
OPPORTUNITIES FOR CHANGE
The quality of care varies greatly across the system
Introduce a patient safety liaison outside the care team who can interact with patients and address concerns
The current payment model is not cost-efficient
There is a lack of involvement of patients and recognition of patient expertise as a valuable resource in treatment
Use open health records to bring down waiting times
Communication between professionals and patients is challenged by overly complex healthcare information
Create strong, courageous leadership that can lay out common goals to change the healthcare culture
Education and training of health professionals does not have a sufficient focus on patient engagement
Break the “10 minute rule� to give physicians time for more meaningful conversations with patients
Include patient centeredness in the training of healthcare professionals
The roundtables were in the format of one-day interactive workshops that gathered key stakeholders from across the healthcare system, including patients, professionals, providers, policy makers and researchers, with the aim of identifying possible trajectories for change by spurring dialogue and discussions based on the various perspectives from the different stakeholders.
111
USA
/
EXPERT INSIGHT
The idea was that psychiatry will
to someone discovering a drug that
take care of the mental health prob-
cures 50% of people with depres-
lems but it never worked because
sion. The inventor of such a drug
there have never been enough psy-
would win the Nobel Prize, for sure.
chiatrists. Mental health issues are
Training for patient-centeredness
the most common problem a doctor
would be the equivalent of five or
will see in their clinic every day.
ten Nobel prizes in terms of the im-
Therefore, doctors need to know
pact it would have on mental health.
more about mental health.
Robert Smith Professor of Medicine and Psychiatry at Michigan State University Participant at Washington DC roundtable
WHAT MAIN CHALLENG-
ES DO YOU SEE FOR HEALTHCARE SYSTEMS IN THE USA? The biggest challenge is to take care of the most common, most
WHAT ARE SOME TANGIBLE WAYS WHAT’S THE BIGGEST OPPORTU-
OF IMPROVING PATIENT-CEN-
NITY FOR IMPROVING THE QUALI-
TERED CARE IN THE USA?
TY OF CARE IN THE USA? In short: teaching health profes-
Doctors need to realize that treatments are not prescribed, they
sionals a generic, patient-centered
are negotiated. When faced with the
approach that includes a greater fo-
difficult decisions regarding their
cus on mental healthcare. Students
healthcare, patients need assistance
and residents need to be trained
in understanding what is happening
intensively in the psychological and
to them. This is a negotiated process
social dimensions of medicine as
that is, in essence, bilateral between
well as basic principles of doctor-pa-
the healthcare professional and the
tient relationships where the patient
patient.
leads the way in their own treatment. Getting that done is the key
However, patients can also learn to take a more active part in their
disabling and most ignored problem,
task in solving the biggest problem
treatment. In one study, patients in
which is mental healthcare. It is more
facing healthcare in the US. We have
clinic waiting rooms were coached
common than cancer and heart
estimated that training students in
on several factors in relation to com-
disease combined. Psychiatrists see
every medical school and residency
municating with the doctor before
only 15% of the mentally ill, which
in mental healthcare will cost some-
they went in to their consultation.
means that the remaining 85% are
thing in the range of $300 million
This was a randomized, controlled
seen entirely by medical doctors.
over 10 years. That sounds like a lot
trial and it was quite effective in
Care is very poor because medical
of money but we are losing more
improving the dialogue between
doctors are not sufficiently trained in
than that every year due to poor
patients and doctors.
mental health. It is such an obvious
mental healthcare.
problem but nothing is being done about it.
The impact of teaching with a greater focus on patient-centeredness would be dramatic. It would
WHY DO YOU THINK THAT IS?
take twenty years to train everyone but the impact would be comparable
Medical education focuses almost entirely on physical disease and omits anything to do with psychological or social factors. Medicine education has not changed for well over a hundred years in the US.
112
“Doctors need to realize that treatments are not prescribed, they are negotiated.”
“We really have the opportunity to change the way the US healthcare system is run.”
WHAT MAIN CHALLENG-
ES DO YOU SEE FOR HEALTHCARE SYSTEM IN THE USA? As a whole for the US healthcare
by the year 2025 – due to graduate medical education funding. The US government has capped graduate medical education funding since 1997, but the number of medical
system, the fact that not every per-
schools has grown since that time.
son has access to quality healthcare
The consequence is that we are
is a great challenge. In the US we
facing a bottleneck shortage. Today
have a healthcare system that is
we have around 26,000 residency
reactionary instead of preventative
positions available for first year
– where we focus on treating people
trainees and that will not be enough
instead of preventing people from
to provide training for the students
getting sick. We do not focus on
graduating from medical schools as
primary care, but on the myriad of
early as 2016.
Britani Kessler National President of the American Medical Student Association Participant at Washington DC roundtable
sub-specialties. We usually try to shuffle patients off to those instead of allowing ourselves to really focus on the patient and their needs.
HOW IS THE MINDSET OF THE FUTURE GENERATION OF DOCTORS DIFFERENT FROM THE CURRENT GENERATION?
WHAT’S THE BIGGEST OPPORTUNITY FOR IMPROVING THE QUALITY OF CARE IN THE USA? We are currently in a tremendous
take part in the delivery of healthcare. For them, providing healthcare is a dialogue with the patient and not just one way communication from the professional to the patient.
We have a generation of young physicians that really want to be active and to make things better in the healthcare system. They won’t settle
WHAT ARE SOME OF THE OBSTACLES PREVENTING CARE FROM BEING MORE PATIENT CENTERED?
time of change in the US healthcare
for the status quo, but want to be a
system. Politically the healthcare
strong voice in improving the state
We are fighting the status quo
system is up for debate and political
of the healthcare system. They are
at the moment. We have a history
initiatives such as the Affordable
focused on patients, patient safety
where care has been very paternal-
Care Act are changing the health-
and on improving the quality of the
istic. A majority of the older gen-
care system. For the new generation
healthcare system – both at hospitals
eration are used to a culture where
of professionals, but also for the
but also at a political level.
the doctor has the final say. This
patients, there is currently a realization that this time of change gives them the opportunity to make things better. We really have the opportunity to change the way the US healthcare system is run.
means that moving towards a more DO YOU SEE THE MINDSET OF THE FUTURE GENERATION OF DOCTORS AS MORE ACCEPTING OF PATIENT-CENTERED CARE? The new generation is more
WHAT IS THE BIGGEST CONCERN FOR MEDICAL STUDENTS AND RESIDENTS IN THE USA? We are facing a physician shortage of more than 130,000 physicians
patient centered healthcare system will demand a cultural change. This is not something that is done overnight. Also there are currently no real incentives for professionals to include patients. On the contrary, we
patient centered. They are taught to
are faced with great time constraints
listen to patients and to make sure
and pressure for fast delivery of
that the patient is involved through-
diagnoses, plans and treatments,
out their training at medical schools.
which makes it difficult to provide
They learn that patients have an
care that is truly patient centered.
active voice and expect patients to
113
114
ROADMAP TO CHANGING
HEALTHCARE ON OUR JOURNEY THROUGH THIS PUBLICATION, WE HAVE NOW REACHED THE DESTINATION OF CHANGE. WHILE OUR PREVIOUS CHAPTERS HAVE DEALT WITH THE CHALLENGES THAT HEALTHCARE SYSTEMS AROUND THE WORLD ARE FORCED TO DEAL WITH, WE NOW WISH TO UNFOLD THE OPPORTUNITIES THAT EXIST AS DISRUPTIVE ELEMENTS IN OTHERWISE STATIC HEALTHCARE SYSTEMS.
115
A JOURNEY TOWARDS OPPORTUNITIES
LEARN ABOUT... ...PATIENT ENGAGEMENT PROGRAMS IN THE USA Formalized patient in-
From improving timeliness in China to value-based healthcare at the Schön Klinik in Germany to patients leading the way in improving patient safety in the USA – examples of new opportunities, new ways of thinking, and new models of healthcare are flourishing as tangible responses to the growing challenges that the healthcare sector faces.
volvement and creating a culture where tapping into patients’ thoughts, worries and experiences is the ‘new normal’ opens the door to effective improvements in patient safety.
Page 122
Seven opportunities – each paired with a case that highlights how to move from idea to action – serve as examples of how to improve the quality of healthcare in practice. They are framed around each of the seven dimensions of healthcare quality: equity, safety, person-centered care, cost-efficiency, effectiveness, timeliness, and environmental sustainability and act as a roadmap for others who wish to effect change in healthcare from small to large-scale. These inspiring examples are not yet the new normal, but they tell the story that the current healthcare challenges can be turned into
sector does not have to wait until tomorrow – it can and it does, in fact,
...SUSTAINABLE HOSPITAL PRACTICES IN THE USA
happen today.
The power of role
opportunities – with the right mind-set. They are leading the way and can inspire us to see that changing and improving the healthcare
model clusters and specific guides on how to achieve change can spearhead new agendas and promote behavioral shifts throughout the healthcare sector.
116
Page 137
QU AN
Y
IT Y
...MEASURING HEALTHCARE’S TRUE VALUE IN GERMANY
...KNOWLEDGE SHARING IN THE UK
Knowing what we do, why we do it, at what price and with
Measuring the impact of healthcare and learning
TIT
AL QU
what specific outcome is vital Page 131
from the best are vital in
information that can help reduce the costs – and not the
ensuring long-lasting and
Page 128
quality – of healthcare.
profound improvements to the effectiveness of healthcare delivery.
...DIGITAL APPOINTMENT SCHEDULING IN CHINA Technology targeted at improving the communication ‘gap’ can help bridge some of the main obstacles standing in the way of quality, timely healthcare. These innovations lay the groundwork for a more convenient, quicker and more person-centered interaction between patients and the healthcare sector.
Page 134
Page 125
...MOBIL HEALTH APP IN KENYA
...HEALTHCARE ALLIANCES IN NEW ZEELAND
Convenient, accessible and user-friendly technology
A clear and binding con-
can pave the way for more
tract committing healthcare
equitable and high quality healthcare – not just for the few, but for the masses.
Page 119
providers to work towards a common goal – instead of working on the basis of individual interests – is crucial in creating a healthcare system that is person-centered.
117
FROM OPPORTUNITY...
Mobile health apps open the door to universal healthcare Healthcare is online and provided increasingly
Additionally the new technologies have also prov-
through technological platforms opening the
en to be a vehicle for reducing healthcare costs,
door to new possibilities and new solutions in
optimizing asset utilization and efficiency, deliver-
healthcare provision.
ing higher quality care, and improving the patient experience.
This changing tide is not a small wave, but a tsunami of new communication platforms transforming healthcare systems today and in the coming years. In terms of revenue, the mobile health market is expected to grow to $21.5 billion by 2018 with a compound annual growth rate of 54.9%, according to a report from the market research company, BCC Research.1 The growth and innovation of new mobile healthcare technologies is a positive addition to the world of healthcare – as these innovations can lead to new services and higher quality of care. The application of mobile technologies, also called mHealth, has already sparked a revolution in the way healthcare is delivered – especially in developing regions such as Africa. It is currently becoming a key factor in democratizing healthcare, opening up the possibility to gain access to healthcare services on the individual level – and thus helping to break down barriers of income, race, ethnicity, geographic location and education.
BCC Research. Wireless Electronic Health Records: Technologies and Global Markets. 2014. 1
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A doctor to the masses ... TO ACTION IN KENYA
The challenge: 40 million people, but only 7,000 doctors. The solution: the mHealth app, MedAfrica. In a country where doctors are in high demand, healthcare services are fragmented and the vast majority of healthcare consumers are poor. Additionally, access to healthcare is far from universal and there is a widespread need for services that can help bridge the gap between the supply of and demand for healthcare services. This is where the mHealth app, MedAfrica, steps in. MedAfrica was launched in 2011 by the Kenyan based mobile design and development company, Shimba Technologies. It is a free app that allows healthcare consumers to access relevant medical information and find reputable doctors and hospitals in their local area. 2 MedAfrica takes advantage of the fact that 25 million Kenyans have mobile phone subscriptions and makes it possible for all Kenyans with a mobile phone get access to healthcare and health information. 3 This allows for a whole new type of healthcare – one that is much more accessible for everyone. It helps dissolve the barriers between the rich and poor, well educated and uneducated, and rural and urban – and thus helps achieve a more equitable Kenya. The Kenyan healthcare system consists of a large number of fragmented and also fraudulent healthcare services, making it very difficult for consumers to access and identify quality care.
EQUITY
MEDAFRICA MHEALTH APP IN KENYA INITIATOR
PRIMARY DRIVER
Private company with support from leading
Mobile technology
healthcare institutions SCALE INVOLVED ACTORS
Kenya
Primarily potential and current healthcare users,
2
but also involves professionals and healthcare
TYPE OF CHANGE
institutions
Increased access to healthcare
Shimba Mobile. Medafrica. 2014.
World Wide Web Foundation. Problem: 7,000 Doctors Serve a Nation of 40 Million People. Solution: MedAfrica. 2012. 3
119
The country struggles not only with scarce resources and insufficient
4
healthcare professionals, but also with providing safe and quality-
5
based healthcare. The MedAfrica app tries to respond to exactly this challenge by providing detailed contact information for 7,200 qualified doctors and 8,076 quality assured health facilities - all freely accessible for the app’s users.
Medafrica. 2012.
Pivot25 is an mlab initiative to bring focus on the Mobile developer and entrepreneur community in East Africa. mlab East Africa is a consortium of four organizations aiming to be a leader in identifying, nurturing and helping to build sustainable enterprises in the knowledge economy. Ericsson. Health care and painting apps win top prizes in 2012 Ericsson Application Awards. 2012. 6
The development and structure of the app are based on the idea of involving the individual patient as an active consumer of healthcare. Besides allowing the user to locate qualified healthcare providers, MedAfrica also provides a diagnostic tool to identify the potential cause of illness and then link patients to specialists who can treat them.4 Furthermore, it offers information on recommended drugs and diets for specific medical conditions. By providing this kind of information, the app is taking a great step towards closing the gap between the supply of professionals and demand of the Kenyan people. It helps remove some of the pressure on the healthcare system by serving as a first point of entry to the healthcare sector – helping to focus and guide healthcare consumers in the right direction. The app was developed in partnership between Samsung, Nokia, the Kenya Open Data Initiative, and others. The app is not publicly funded, but is rather a product based on a clear underlying business model. Thus, Shimba Technologies receive revenues for the free app through targeted ads and extended subscription services. Since its launch in 2011, MedAfrica has been growing quickly. Today the app has more than 200,000 downloads, about 60% of which are active users and the app is currently one of the top 10 apps in Kenya. These numbers clearly indicate that the app is an accessible and necessary tool for the average Kenyan; it’s a spot-on solution for meeting the country’s healthcare demands. The company behind the app is now focused on scaling and extending its reach. They are currently working on cross-border partnerships that will open the door for spreading the app to other countries. At the same time they are adding more user services, and listing more doctors by collaborating with one of the country’s doctors organizations. They are also developing a Ministry of Health feed with real-time information on disease outbreaks. The potential for this app is substantial
TAKE AWAY
because it offers a solution to a great healthcare problem – not only in
Convenient, accessible and user-friendly technology can pave the way for more equitable and high quality healthcare – not just for the few, but for the masses.
Kenya, but in many developing countries: safe and quality healthcare is not a commodity for all, but still reserved the few. The success of and future potential for the app has been widely recognized. In its short history, the app has won the Pivot25 award5 and the Ericsson Award, the latter “for the potential to bring important information to many people and give them the power and knowledge to take better care of their communities.”6
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FROM OPPORTUNITY...
The patient as the expert Since the 2000 Institute of Medicine report, “To
The patient role in improving patient safety is
err is human – building a safer health system,” pa-
widely recognized by the WHO.
tient safety has gained an increasingly prominent place on the international health policy agenda.7
A main part of their “Patient Safety Program” and
Fifteen years on, the quest continues to find new
work for promoting patient safety throughout the
models and new systems that can help improve
world is initiatives that include and incorporate
patient safety in healthcare. 8
patients as active players in this process. 9 One example from the WHO is the “Patients for Safety” initiative that was launched in 2004. The initiative aims to build a global network that champions patients as key change makers when it comes to improving safety in the healthcare sector. Through the initiative, the WHO works actively for “a world in which patients are treated as partners in efforts to prevent all avoidable harm in healthcare.” 10 Looking to the future, patient involvement and engagement as a means of improving the culture of safety are recognized as key components of creating much safer healthcare systems. 11,12
WHO. Exploring patient participation in reducing health-care-related safety risks. 2013. 7, 8, 9
WHO. Patients for Patient Safety. 2015. 10
AHRQ. The Role of Patients in Safety. 2015. 11
The bmj spotlight. Patient Centred Care. 2015. 12
121
Bringing the patient voice to the world of patient safety Patient safety improvements do not happen to patients – but with them. Partnerships with patients and families are thus an essential
SAFTEY
... TO ACTION IN THE USA
aspect of improving patient safety and healthcare quality. But patients and their families are not always engaged, and they do not automatically take on an active role in ensuring their own safety. They need to learn and become equipped to take on this role. At the Dana-Farber Cancer Institute in Boston, USA, this is a primary DANA-FARBER CANCER INSTITUTE IN THE USA
goal. Dana-Farber/Harvard Cancer Center is the largest cancer center in the world and is funded by the National Cancer Institute, USA. The institute has incorporated patient-centered care as a key element of
INITIATOR
their healthcare services – and has used this approach to create a
Healthcare provider
stronger culture of patient safety. They focus on collaboration, comINVOLVED ACTORS
munication, and engagement with the patients and their families in
Management, patients,
a range of aspects in order to improve the quality and safety of their
professionals
care.13
PRIMARY DRIVER
Patient Involvement
Their work began in 1994 due to a heartbreaking incident. Betsy Lehman, a 39 year-old Boston Globe health reporter suffering from
SCALE
breast cancer died at the Dana-Farber Cancer Institute because of
Dana-Farber Cancer Institute
four overdoses of chemotherapy. Doctors apparently refused to hear her warnings that something was drastically wrong and ignored the
TYPE OF CHANGE
results of tests indicating heart damage.14,15 This incident prompted the
Improving patient safety by
hospital to engage in self-examination of the state of patient safety at
involving patients
the Institute. Setting out on this journey, the patients were given a pivotal role. In the Institute’s mission statement they state that patients and their families have “experience; expertise; insights; and perspectives that can be invaluable to bringing about transformational change in healthcare and enhancing quality and safety.” 16 To walk the talk, the Institute has named patients and their family members “experts in quality improvement” and, as such, they are regarded as equals with hospitals management, doctors and nurses in terms of improving the safety of every patient. One of the specific tools used by the Dana-Farber Cancer Institute is education of patients on their role as key players on the healthcare team. Patients are encouraged to check their medication, ask providers to disinfect their hands and notify clinicians of last minute changes in their treatment.
122
Institute for Patient- and Family-Centered Care. Partnering with Patients and Families to Design a Patient and Family-Centered Health Care System. 2008. 13
Aspden P, Wolcott J, Bootman JL, Cronenwett LR (eds.). The Betsy Lehman Case. Preventing Medication Errors: Quality Chasm Series. 2007. 14
Altman LK. Big Doses of Chemotherapy Drug Killed Patient, Hurt 2d. New York Times. 1995. 15
Dignified Person Centred Care - Learning from the USA. 2013. 16
A key word in the patient involvement movement is “transparency,” meaning that patients are integrated into the system and have access to relevant information on their safety. They are even members of major committees across the Dana-Farber organization, ranging from board level committees to committees on quality improvement and risk management. One example is the Patient and Family Advisory Council that serves as an important part of the organizational structure for quality improvement. Another is the Adult Oncology Clinical Services Quality Improvement Committee, where patients review patient falls and accidents, medication errors, and patient survey results. Another initiative aimed at involving the patients at the Dana-Farber Cancer Institute is Patient Safety Rounds, which was implemented in 2004. Patient Safety Rounds help the institute identify and eliminate patient safety risks through two methods: internal staff communication about actual and potential safety problems,17 and interviews between former and current patients and families about their perception of safe care, with the ultimate goal of improving patient safety at the institute.18,19 Now, more than 20 years after the death of Betsy Lehman, the Dana-Farber Cancer Institute offers a free toolkit for other healthcare providers to become inspired and learn how to implement Patient Safety Rounds. The Institute has received a line of recognitions for its work of improving patient safety through patient involvement. The Leapfrog Group, for instance, recently named Dana-Farber Cancer Institute to its annual list of Top Hospitals. The Leapfrog Top Hospital Award is given to less than seven percent of all eligible hospitals nationwide – based on their demonstration of excellence in hospital safety and quality. Additional recognition comes from News & World Report’s Best Hospitals 2010 Guide, which ranked Dana-Farber Cancer Institute the top Cancer Center in New England and 5th overall in the USA. 20
This model has been positively evaluated both at the Schwartz Center for Compassionate Healthcare in Boston, USA and a pilot project at two UK hospitals. The Kings Fund. Evaluation of the UK Pilots. 2011. 17
AHRQ. Organizational Change in the Face of Highly Public Errors. The Dana-Farber Cancer Institute Experience. 2005. 18
Institute for Patient- and Family-Centered Care. Partnering with Patients and Families to Design a Patient and Family-Centered Health Care System. 2008. 19
TAKE AWAY Formalized patient involvement and creating a culture where tapping into patients’ thoughts, worries and experiences is the ‘new normal’ opens the door to effective improvements in patient safety.
The Dana-Farber Cancer Institute. Paths of Progress Volume 2011; 20(2). 20
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FROM OPPORTUNITY...
Healthcare: more than the sum of its parts Integrated care, patient involvement, and shared
This approach can help break down borders and
decision making are the headlines for healthcare
bridge the gap between healthcare partners –and
in the coming years. Today, person-centered
thus facilitate a far more person-centered healthcare
care is championed by the WHO and Healthcare
system. 22
authorities from the USA to the UK, Denmark to China, and Sweden to Singapore are supporting and exploring it as a precondition for delivering safe and quality healthcare. Despite the broad endorsement, the reality is that a transition to healthcare systems that are much more person-centered than those we know today is far from easily done. It demands radical change, where new partnerships and collaborations are valued over the status quo – and where each healthcare system is seen as a whole, rather than as individual and fragmented parts. 21 Creating more integrated and collaborative healthcare systems could be made possible by taking on a ‘whole system approach’. A healthcare system based on the whole system approach is one that recognizes and understands the wider system within which services are embedded, and any and all service improvements must take place within this broader context. Such a model values the contribution of all partners – including the patients – in ensuring the delivery of high quality care.
DNV GL and Monday Morning Sustainia. Person-Centred Care. 2014. 21
The bmj Spotlight. Patient Centred Care. 2014. 22
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Strong alliances create integrated healthcare What can the healthcare sector learn from the world of construction?
Ministry of Health. NZ Health Systems, Key Organizations, Health alliances. 2011. 23
Gauld R. NHS can learn a lot from New Zealand’s healthcare system. The Guardian. 2014. 24
Ministry of Health. Better, Sooner, More Convenient Health Care in the Community. 2011. 25
DNV GL and Monday Morning Sustainia. Guide to Person-Centred Care. 2014. 26
PERSONCENTERED CARE
... TO ACTION IN NEW ZEALAND
Looking at healthcare systems that are defined by fragmentation and a lack of collaboration, the short answer is actually a great deal. In New Zealand the aim of improving the quality of the healthcare system has led to a new “alliancing” model based on how construction work is managed. The model is specifically inspired by the way in which contractors on large projects work collaboratively and share resources needed to get the job done on time and on budget. The primary objective of these new healthcare alliances is to get all actors in the healthcare sector to work toward a common, shared goal. Through these alliances and their joint incentive structure, healthcare stakeholders in New Zealand are encouraged to engage in new partnerships and cross-sector collaborations. This ensures that everyone is working towards the same goal. 23,24 Today the alliance model is a vital part of the government’s ‘Better, Sooner, More Convenient’ care initiative that aims to improve the quality and person-centeredness of the healthcare sector in New Zealand. 25 The motivation for working with and developing the alliance model is the conviction that strong collaborations between healthcare stakeholders are crucial in improving the quality of healthcare in areas such as equity, access, integration and prevention. 26
THE ALLIANCE INITIATIVE IN NEW ZEALAND INITIATOR
SCALE
Policy makers
New Zealand
INVOLVED ACTORS
TYPE OF CHANGE
Professionals
Creating more integrated and collaborative care for the patient
PRIMARY DRIVER
Whole system approach
125
In 2013 the dream of having at least one alliance in each of New Zealand’s 20 healthcare districts became reality. This decision was based on the evaluation of nine alliancing pilots, which were initiated in 2010. The evaluation concluded that the alliance model had improved the position of primary care and increased opportunities for achieving integrated care in the nine piloted districts. 27,28 More specifically, the alliance model requires providers in each of the 20 healthcare districts to work collaboratively within a whole system approach to ensure that services are designed with what is best for patients and the public in mind. Each alliance is a way to bring together a range of providers from across a healthcare district and encourage them to work collaboratively on what the system should look like from a patient perspective. 29 Alliance members are healthcare leaders from different service areas, such as GPs, nurses, and professionals in aged care, ambulance services, public health and different hospital specialties. Each alliance member signs a charter which binds them to work together and build trust in one another. The charter stipulates that they focus on the whole system, and not the specific interests of the sector they may work for, and that they agree to help one another to achieve the alliance’s goals. These goals include a wide range of elements focused on improving and redesigning healthcare services, such as integrated services for older people with chronic care needs, or access to GP-referred specialist service. 30 The evaluation of the first nine alliance model pilot projects indicates that one of the positive outcomes was that the alliances helped drive new initiatives to provide better support for patients with complex needs in primary care settings by enabling general practitioners to work together with hospital specialists and other providers. Furthermore there was also evidence of reductions in emergency department admissions and of more services traditionally provided in hospital settings now being delivered in the community, such as specialist outpatient consultations, older people’s health, and emergency response services that might otherwise require a hospital visit. Furthermore, the healthcare stakeholders that took part in the alliances considered it to be a model that helps steer the health system and service design in an important new direction. 31
Cumming J. Integrated care in New Zealand. International Journal of Integrated Care Special 10th Anniversary Edition 2011 e138. 27
Gauld R. What should governance for integrated care look like? New Zealand’s alliances provide some pointers. The Medical Journal of Australia. 2014. 28
126
Gauld R. New Zealand’s ‘integrated performance and incentive framework’: Will it drive a ‘whole of system’ approach to health service design? University of Birmingham. 2014. 29
Cumming J. Integrated care in New Zealand, International Journal of Integrated Care Special 10th Anniversary Edition: e138. 2011. 30
Gauld R. What should governance for integrated care look like? New Zealand’s alliances provide some pointers. The Medical Journal of Australia. 2014. 31
TAKE AWAY A clear and binding contract committing healthcare providers to work towards a common goal – instead of working on the basis of individual interests – is crucial in creating a healthcare system that is person-centered.
FROM OPPORTUNITY...
Knowing the value of healthcare is key Rising costs, distorted incentive structures and errors
The need for forward thinking and innovative mind-
in diagnosing and providing care are all great challeng-
sets has never been greater, as new ideas are vital for
es for healthcare systems across the globe. These chal-
meeting the demands of more cost-efficient health-
lenges threaten not only patient safety and well-be-
care sectors of the future. This is precisely what the
ing, but also the cost-efficiency and sustainability of
concept of value based healthcare entails. Value based
healthcare models. Overcoming these challenges and
healthcare has emerged as a strategy for delivering
making healthcare systems more cost-efficient is vital,
healthcare at lower costs. It has been championed by
as the demand of providing more healthcare for less
Professor Micheal Porter 32, who believes value should
money is projected to become a major challenge for
define the framework for performance improvement in
healthcare systems throughout the world.
healthcare. As Porter notes, “rigorous, disciplined measurement and improvement of value is the best way to
Cost-efficiency often is associated with layoffs, fund-
drive system progress.”
ing cuts and increasing the speed of operations. But making a healthcare system more cost-efficient need
Yet value in healthcare remains largely unmeasured
not come at the expense of quality. On the contrary,
and misunderstood. Value should always be de-
it can lead to improved healthcare services, a much
fined around the customer, and in a well-functioning
needed freeing up of resources and new means of
healthcare system, the creation of value for patients
delivering care.
should determine the rewards for all other actors in the system. 33 A value based approach to healthcare has
This demands that healthcare systems make a change,
been implemented by a few pioneering providers, such
and focus on being leaner and smarter rather than just
as Kaiser Permanente and Cleveland Clinic in the USA,
slashing budgets.
Martini-Klinik and Schön Klinik in Germany—discussed below—and Terveystalo, the largest private healthcare provider in Finland.
QU AN TIT
Y
Y T I L A QU
In the future, the concept could very well become a common standard in healthcare systems throughout the world. The prospects of improving the costs of healthcare through the value based
approach are substantial. According to Boston
Consulting Group, a value-based approach to hospital operations could improve performance by up to 30%. 34
Porter ME. A Strategy for Health Care Reform — Toward a Value-Based System. The New England Journal of Medicine 2009; 361: 109-112. 32
Porter ME. What Is Value in Health Care? The New England Journal of Medicine 2010; 363: 2477-2481. 33
Budryk Z. Value-based model could improve hospital performance 30%. Fierce Pharma. 2014. 34
127
Improving quality by measuring the true value of care “Measurable. Tangible. Better“. This is the motto for the Schön Klinik
... TO ACTION IN GERMANY
– a hospital group consisting of 17 hospitals across Germany, special-
COST-EFFICIENCY
ized in orthopedics, neurology, and psychosomatic medicine. Over the past years, the clinic has become one of the leading international pioneers in value based healthcare as a new approach to healthcare. 35 The Schön Klinik has made the approach standard in their healthcare delivery and services.
THE SCHÖN KLINIK IN GERMANY
Their work is based on the idea that the direct costs of patient care, such as nurses, physicians, and consumable supplies can be assigned
INITIATOR
directly to the individual patients – and that knowledge of the value
Healthcare provider
and costs of each step of a patient’s treatment and care is crucial to continuous improvement of the clinic’s efficiency and performance
INVOLVED ACTORS
in delivering healthcare. The basic idea is to know the value of their
Management, professionals
healthcare – what they deliver, and at what costs. Therefore, the Schön PRIMARY DRIVER
Klinik focuses intensely on measuring health outcomes of specific
Measuring the price and quality
patient groups and understanding resource requirements and costs in
of healthcare
the context of these outcomes.
SCALE
Schön Klinik’s 17 hospital units
The Schön Klinik’s goal is that the combination of accurate outcome and cost measurements will empower the local personnel – physicians,
TYPE OF CHANGE
nurses, and administrators – at the Schön Klinik’s different sites to
Knowledge of specific value
improve the value of care they deliver, but also to open the door to
improve the cost-efficiency of
benchmarking across the 17 different hospitals in order to identify and
healthcare
share best practices. This focus has led the Klinik to develop 1,500 value indicators – a mixture of outcome and process measures as well as patient evaluations. The data is collected with a focus on the medical condition and not the department – underlining the idea of focusing on the direct costs of care. 36 One specific example of how the Schön Klinik’s is taking on the value based cost and outcome approach is an improvement initiative focused on the knee replacement process, which was implemented throughout the Klinik’s hospitals in 2009.
Kaplan RS, Witkowski ML, & Hohman JA. “Schön Klinik: Measuring Cost and Value.” Harvard Business School Case 112-085, 2012. (Revised December 2014.) 35
Porter ME & Guth C. Redefining German Healthcare: Moving to a Value-Based System. 2012. 36
128
At that time the Schön Klinik, like other hospitals in Germany, had reduced the capacity of its knee replacement rehabilitation units in part because the existing cost system portrayed them as less profitable than acute-care units. But during the Schön Klinik’s value based cost measurement of the knee replacement process, they discovered that the existing cost system allocated support-department costs largely on the basis of length of patient stay, not on the patient’s use of support resources. Since knee replacement patients at the Schön Klinik’s hospital units spent 75% of their stay in the rehab facility, rehab had been allocated about 75% of support department costs. The analysis showed, however, that the demand for many support-unit services, such as medical billing, is far higher during the days a patient spends in the acute-care facility than during rehab days. With support costs properly assigned, the rehab facility showed improved profitability. Based on the value analysis, the Schön Klinik thus began to contemplate the expansion of its rehabilitation capacity—a complete reversal of common standard in Germany— and shifted its focus more intensively on reducing support costs incurred during the acute-care stay. 37 The Schön Klinik has received international recognition for the value based approach to patient care – from, among others, Harvard Business School.
TAKE AWAY
Kaplan RS & Porter ME. The Big Idea: How to Solve the Cost Crisis in Health Care. Harvard Business Review. 2011. 37
Knowing what we do, why we do it, at what price and with what specific outcome is vital information that can help reduce the costs – and not the quality – of healthcare.
129
FROM OPPORTUNITY...
Knowledge sharing helps healthcare do its job How do we ensure the right level of treatment
Thus, relevant and effective models that can help
and the right level of medication? How do we
measure the quality of treatment procedures, patient
measure and improve healthcare performance?
experiences and operational performance are in high
Simply put, how do we best ensure that health-
demand within the healthcare sector. Such initiatives
care systems do their job: provide the appropri-
can help limit over- and under-use of services and
ate care to the appropriate patients? These are
realign incentive structures to best meet the needs
some of the big questions countries around the
of patients.
world must ask themselves when it comes to improving and ensuring high quality standards in
Innovative ways to ensure increased effectiveness by
the healthcare sector. Answering these questions
measuring and comparing performance mark a new
will become an increasingly pressing concern in
era in the delivery of healthcare.
the years to come.
130
Commissioning for Value increases effectiveness
EFFECTIVENESS
Since 2010, the UK government has pushed a line of
COMMISSIONING FOR VALUE IN THE UK’S NHS
reforms through the National Healthcare System – the NHS. This has led to heated debate and negative cri-
INITIATOR
tique of some of the resolutions. The report “The NHS
funded healthcare system
under the coalition government” from the UK-based
INVOLVED ACTORS
The Clinical Commissioning Groups PRIMARY DRIVER
Measuring the value of healthcare – benchmarking the performance with the best SCALE
England TYPE OF CHANGE
Using performance measurement as a vehicle for improving healthcare
... TO ACTION IN ENGLAND
Policy makers and publicly
King’ Fund, published this year, concludes that the reforms “have resulted in top-down reorganization of the NHS and this has been distracting and damaging” and “new systems of governance and accountability resulting from the reforms are complex and confusing.” 38 Despite the clear downsides of the reforms, it is not all bad. The development of the NHS over the past few years also entails stories of success and improvements. One such story is the “Commissioning for Value Initiative,” in which knowledge about performance and the identification of specific possibilities for improvements are used as drivers for creating better outcomes, higher quality and more efficient healthcare. The Commissioning for Value initiative is a collaboration between NHS Right Care, NHS England and Public Health England. It is aimed directly at the 211 Clinical Commissioning Groups (CCG) in the NHS – which are groups of primarily general practitioners that work together to plan and design local health services throughout England. The initiative gathers and shares a series of information on each CCG’s performance and identifies a series of different areas and healthcare services that have unexploited potential in terms of improving the delivered healthcare. These results help each local CCG decide ‘where to look’ and ‘what to do’ in order to improve outcomes and increase the quality of their healthcare service.
The King’s Fund. The NHS under the coalition government. 2015. 38
131
An important element in the initiative is the “Commissioning for Value Packs,” initiated with the goal of identifying “local opportunities for improvement in health outcomes, patient experience, or finance.” In 2013 the first packs were distributed, which triangulated data on spending, outcome, and quality and identified value opportunities where each of the specific CCG was an outlier compared to equivalent CCGs. A year later, a second round of packs provided in-depth data for the 13 patient conditions with the greatest potential for improvement. There are a number of examples of CCGs that have used the numbers and recommendations from Commissioning for Value initiative to improve their performance and quality of healthcare. One example is the CCG in Warrington where the Commissioning for Value approach was used to identify where savings could be made to help overcome a $38.3 million funding shortfall in 2011-12. 39 In the Commissioning for Value Packs, “respiratory services” were identified as one of the main improvement opportunities, but at the time, Warrington was spending $2.3 million more on these conditions than equivalent CCGs. As a response, the respiratory service in Warrington was redesigned. The primary changes included: • Extending the pul-
• Targeting patients
monary rehabili-
with acute epi-
• Commissioning consultant-led
tation service to
sodes of illness
multi-disciplinary
include a home-
teams to carry out
based program
Hospital at Home visits
Following the changes, quality, patient outcomes and pathway management all improved. Warrington also reduced its spending on respiratory services significantly, now spending $600,000 less than other CCGs providing the same service. 40
NHS Warrington CCG. Commissioning for Value Insight Pack. 2013. 39
Wellards. What is commissioning for value? 2014. 40
132
TAKE AWAY Measuring the impact of healthcare and learning from the best are vital in ensuring long-lasting and profound improvements to the effectiveness of healthcare delivery.
FROM OPPORTUNITY...
Bridging time lags with better communication In recent years, a myriad of technologies has become
Technology opens the door to a much more direct and
vital in the delivery of healthcare. These technologies
easy communication between healthcare providers
are currently transforming how healthcare is provided
and patients, including, for instance, booking appoint-
in regions all over the world – opening healthcare sys-
ments online, communication on estimated waiting
tems up to new possibilities in healthcare services, new
time in doctors’ offices and information on the interval
types of treatments, new healthcare monitoring, and
between referrals and treatment. It also allows for
ensuring new and improved communication channels.
much more widespread, proactive and timely communication between healthcare providers, including
The development and adaptation of technology can
communication between departments or booking new
not only improve the standard of healthcare, but can
appointments with specialists. 41
also serve as an important driver for augmenting patient-provider relationships and supporting human needs throughout the healthcare journey. Electronic medical records and mHealth apps are two well-known examples of how technology is improving the speed and ease of healthcare delivery, all while prioritizing patient needs.
Nhavoto JA & Grönlund Å. Mobile Technologies and Geographic Information Systems to Improve Health Care Systems: A Literature Review. JMIR mHealth and uHealth 2014; 2(2). 41
133
It’s time for a change in healthcare provision Imagine a Chinese woman, 55 years old and suffering from a severe case of osteoporosis. Her pains are worsening, so her family urges her to go to the nearest hospital to see a specialist. Sick, tired and in pain, she has to get up at one o’clock in the morning, drive three
... TO ACTION IN CHINA
hours by car to reach the nearest hospital, and then stand in a line in front of the hospital entrance. Eight hours later, she reaches the reception desk and gets her appointment to see a specialist – in two weeks. This kind of story is far from rare in China. On the contrary, long waiting times just to book an appointment are commonplace.42 Fortunately, this kind of healthcare experience could soon be in China’s past, thanks to blossoming technological healthcare platforms, like Guahao. Guahao means scheduling a patient appointment in Chinese, and this is exactly what the platform enables the Chinese healthcare consumer to do. Through Guahao, healthcare consumers are able to schedule appointments with doctors online based on location, medical specialties and other criteria. The Guahao platform lets patients assess their personal calendars, local hospitals, and physicians to make an appointment one day to two weeks in advance. In addition, the healthcare consumers can read medical advice and suggestions for different kinds of medical treatments.
TIMELINESS
THE GAUHAO HEALTH TECHNOLOGY PLATFORM IN CHINA INITIATOR
SCALE
Providers, policy makers and private
China
company TYPE OF CHANGE INVOLVED ACTORS
Improving timeliness through
Patients, professionals
communication technology
PRIMARY DRIVER
Communication technology
See Health Systems in Focus – China chapter page 46. 42
134
In recent years online healthcare platforms have become very popular with Chinese consumers, allowing services like Gauhao to revolutionize the interaction between users and providers and improve the quality and timeliness of healthcare immensely. This type of online reservation service also opens the door to a much more person-centered approach to healthcare delivery. Furthermore, online scheduling provides healthcare providers with the ability to better predict patient flow and more efficiently allocate resources. 43 Guahao was founded in Shanghai in 2010 as a collaboration between the Chinese Health Education Network, Fudan Hospital and Healthcare Management Co., and the Chinese Hospital Association, and later expanded nationally. Today the online platform has spread to all of the country’s 23 provinces and boasts over 37 million verified users, around 120,000 registered doctors and covers more than 900 major hospitals in China.44 The site has a team of 3,000 personnel that helps patients who are new to internet usage make appointments with doctors. Guanhao also launched a mobile phone app in 2013, making its services even more convenient and user-friendly. In late 2014, China’s internet giant, Tencent, invested $120 million in the platform. The Tencent investment is expected to expand Guahao’s user base as the health platform seeks to upgrade its WeChat payment service. WeChat is a mobile text and voice messaging communication service developed by Tencent.45 Hoath, B. Guahao: VC Fantasy. Online Appointment Registration System for China’s 700 Million Internet Users. The Health Care Blog. 2013. 43
44
Guahao. 2014. www.Guahao.com
Asia First. Health platform Guahao gets USD120m Tencent investment. 2014. 45
TAKE AWAY Technology targeted at improving the communication ‘gap’ can help bridge some of the main obstacles standing in the way of quality, timely healthcare. These innovations lay the groundwork for a more convenient, quicker and more person-centered interaction between patients and the healthcare sector.
135
FROM OPPORTUNITY...
Green thinking is becoming the new normal Environmental sustainability is becoming reality
This tells a story of a healthcare system where
for healthcare systems across the globe. Increas-
sustainability is no longer an afterthought, but is
ing pressure from rising costs in energy, water and
becoming a necessary and integrated aspect of
carbon are currently leading many governments
the healthcare sector.
and healthcare providers to focus on the value of sustainability within the health system. Energy is a particularly difficult challenge; American hospitals spend roughly $8.5 billion per year on energy costs and consume almost twice the energy per square foot as traditional office space.46 Brazil’s hospitals are reported to account for 10.6% of the country’s commercial energy use.47 There is also a growing recognition of the effects of climate change on health and the fact that these effects will continue to drive up the cost and the demand for health services around the world. Among others, the National Institute of Environmental Health Sciences in the USA has concluded that climate change “stresses our healthcare infrastructure and delivery systems.” 48 Environmental sustainability is quickly moving up the agenda of healthcare providers. A 2013 poll that surveyed top American and global representatives from hospitals and healthcare systems shows that more than 87% of American hospitals are incorporating sustainability into their decision-making processes and operations. 49
KPMG. Trends, risks and opportunities in healthcare. 2012. 46, 47
National Institute of Environmental Health Sciences. Climate Change & Human Health. 2014. 48
Greenbiz. Kaiser, Metro Health bet big on sustainability. 2013. 49
136
Hospitals are leading the green battle A sustainable healthcare system – within reach or a distant utopia? A group of progressive healthcare stakeholders in the USA are trying to make sustainability a reality in the American healthcare system. 12 healthcare providers are leading this charge and inspiring others to follow suit, with the ultimate goal of catapulting the nation into a future
... TO ACTION IN THE USA
where green is the new black for the healthcare industry. Launched in 2012, the Healthier Hospitals Initiative (HHI) is a threeyear, national campaign that advocates for the improvement of environmental sustainability within the healthcare sector. This call-toaction to the entire healthcare sector was born out of a partnership between 12 of the largest, most influential American health organizations, comprising approximately 500 hospitals with more than $20 billion in purchasing power. These organizations, including many well-known healthcare institutions, such as Dignity Health, Kaiser Permanente and the Cleveland Clinic, collaborated with three leading environmental organizations focused on ‘greening’ healthcare to create HHI as a guide for hospitals to reduce energy and waste, choose safer and less toxic products, and purchase and serve healthier foods. The goal of the initiative is to prove that implementing strategies to reduce costs, improve environmental performance and meet broad environmental health goals is, in fact, possible for hospitals and healthcare providers. The 12 healthcare providers are working to actively pool their collective sustainability experience, purchasing power and industry representation in order to accelerate the process of greening the entire healthcare system. Consequently, the initiative is not limited to Healthier Hospitals Initiative. What we do. 2012. 50
ENVIRONMENTAL SUSTAINABILITY
the 12 founding members, but invites healthcare organizations across the country to join and to become an active part of the initiative. 50
HEALTHIER HOSPITALS INITIATIVE IN THE USA INITIATOR
SCALE
12 healthcare systems
The HHI campaign had more than 1,000 total enrollees nationally in 2014
INVOLVED ACTORS
The American healthcare sector
TYPE OF CHANGE
Promoting sustainable healthcare care for PRIMARY DRIVER
the patient
Advocacy and campaigning
137
Two years into the initiative, one of the main outcomes has been the creation of six specific guides for hospitals and providers to reference when aiming to improve their sustainability. These how-to guides include strategies for handling six particular challenges: engaged leadership, healthier foods, leaner energy, less waste, safer chemicals, and smarter purchasing. When joining the HHI, hospitals and hospital systems are encouraged to adopt at least two of the above challenges in their commitment to sustainability. Other than these guides, the HHI has also developed a range of different tools intended to make the fulfilment of this mission as easy as possible. These are: • Easy-to-use mechanisms
• Interactive, content-focused
for identifying metrics and
webinars
collecting data • Insight into how others have • Access to a broad-based
achieved success – case
community through the HHI
studies, success stories,
network
leadership insights 51
• Hospital-to-hospital mentorship programs
The initiative has already had an impressive impact. In 2012, The White House Council on Environmental Quality hosted a discussion on “Greening America’s Hospitals” highlighting the importance of the HHI. 52 Evidence from the HHI’s 2013 Milestone Report backs up this recognition. The national HHI campaign has reached more than 1,000 total hospital enrollees in 2014. More than $45 million was saved as a result of single-use medical device reprocessing, a 33% increase from 2012. Additionally, the majority of the hospitals reported spending more than 15% of their food budget on local and sustainable food – amounting to $23.7 million. 53 These figures represent an increase of more than 350% in local and sustainable spending from the previous year. The aim of the HHI is to enroll at least 2,000 hospitals by the end of the three-year initiative.
Healthier Hospitals Initiative. What we do. 2012. 51
The White House. Greening America’s Hospitals Part 1. 2012. 52
138
Health Care Without Harm. Healthier Hospitals Initiative’s 2013 Milestone Report Shows Sustainability Trends Catching on Among U.S. Hospitals. 2014. 53
TAKE AWAY The power of role model clusters and specific guides on how to achieve change can spearhead new agendas and promote behavioral shifts throughout the healthcare sector.
THE CHANGE MAKERS In this publication, we have journeyed from challenges to opportunities hoping that you will feel inspired to meet the challenges that are holding the quality of care back in your part of the world.
We have established that healthcare systems are complex organisms. They consist of various fields of expertise, a multitude of stakeholders with different objectives and numerous terms for the same concept. However, the complexity of healthcare systems shouldn’t hold us back from trying to change them for the better. To move from great ambitions to real change takes leadership, examples of success and people who dare to defy the norm. Therefore, we present to you three change makers in healthcare, from China, Europe and the USA, who dared to challenge the status quo and succeeded in creating a better tomorrow.
139
CHANGE MAKER IN EUROPE JEFFREY V. LAZARUS
CLOSING THE “KNOWING-DOING” GAP IS KEY TO IMPROVING THE STATE OF HEALTHCARE One of the greatest challenges within healthcare systems today is the “knowing-doing gap”: often we know what to do, but fail to do it. Overcoming this challenge is the primary driver for Jeffrey Lazarus, a leading figure in the fight against HIV in Europe.
140
For years Jeffrey Lazarus has been on a quest
lion people infected with HIV in the European
to bridge the knowing-doing gap in HIV test-
Region, one in three remains undiagnosed.
ing and care through a series of research proj-
This situation is resulting in significant levels
ects, initiatives and collaborations. This quest
of late diagnosis, ill health, and HIV trans-
is what motivated him to co-found the HIV in
mission across the region. Furthermore, the
Europe Initiative – a platform for increasing
region is characterized by large variations in
early diagnosis and timely care for people
HIV testing recommendations and in access
living with HIV across Europe.
to prevention, testing, care and treatment.
Since its founding in 2007, the initiative has
During its first eight years, the HIV in Europe
brought together an independent group of
Initiative has had a great impact. It has proven
experts representing civil society, policy-mak-
to be an effective vehicle for putting the issue
ers, health professionals and European public
of earlier diagnosis of HIV on the political
health institutions – all working to create
agenda at the highest levels in Europe. It also
awareness of and improve the evidence base
has promoted the sharing of knowledge and
around the importance of providing earlier
best practices across different European re-
HIV testing and care. Considering the course
gions and institutions – ultimately broadening
of the HIV epidemic in Europe over the last
HIV awareness. A prominent example of this
decade, this work is very much needed.
is the European HIV testing week, initiated in
Despite the fact that there is now widespread
2013. The second European HIV testing week
knowledge of preventive tools such as con-
was held in November 2014 with more than
doms and access to life-saving antiretroviral
700 organizations across Europe hosting ac-
therapy in most European countries, the situ-
tivities intended to make more people aware
ation is still gloomy: of the estimated 2.5 mil-
of their HIV status. HIV testing and awareness
INTERVIEW
WHAT SPARKED YOUR
INVOLVEMENT WITH THE HIV IN EUROPE INITIATIVE? I am very much driven by the research-to-action gap. We know so much, the evidence is there, yet too often people remain unaware of this evidence and ‘what we know works’ does not get translated into healthcare standards. This was what led me to join four experts and start the HIV in Europe Initiaactivities took place on the streets, in clinics, at universities, in gay clubs and saunas, and at other venues in 52 countries.
tive, while I was at WHO. Back in the mid-2000s we had made immense progress in
Another example of how the HIV in Europe Initiative has
terms of treating HIV. We finally
contributed to growing awareness of HIV testing is the 2012
had the biomedical tools to really
publication, “HIV Indicator Conditions: Guidance for Imple-
reduce the staggering number of
menting HIV Testing in Adults in Healthcare Settings,” which
HIV-related deaths in Europe and
translates scientific evidence into a practical approach to iden-
around the world. But what kept
tifying HIV-positive people who might not otherwise be tested.
us from seizing this great opportu-
The guide is targeted at healthcare providers in all relevant
nity was the fact that not enough
specialties and settings, as well as at administrators and pol-
people were testing for HIV. And
icy-makers responsible for overseeing HIV testing programs
not enough of those who did learn
at the national and local levels. Today it is increasingly used in
they were HIV-positive went on to
healthcare systems across the region.
initiate treatment.
BIOGRAPHY
JEFFREY V. LAZARUS DIRECTOR OF HEALTH SYSTEMS GLOBAL
Jeffrey V. Lazarus is a Senior
at WHO’s Regional Office for Europe
Researcher based at CHIP, the Centre
was followed by a stint at the Global
for Health and Infectious Disease
Fund to Fight AIDS, Tuberculosis
Research and WHO Collaborating
and Malaria, where he led knowledge
Centre on HIV and Viral Hepatitis at
translation and oversaw publication
the University of Copenhagen. He
of the Fund’s global and regional
is also a Professor at the Lithuanian
impact reports. Upon his return to
University of Health Sciences, Medical
Copenhagen in 2012, he became the
Academy, and an Affiliated Professor
co-founding Secretariat Director of
at the Institute of Public Health,
Health Systems Global, an international
University of Porto.
health systems membership society.
His ten-year career as a health systems and communicable diseases expert
141
It was estimated that almost half of all people living with HIV in Europe were unaware of their status – a totally unacceptable figure, from my perspective, especially in a region with so many well-functioning and well-resourced healthcare systems. This was the impetus for founding the HIV in Europe Initiative.
WHAT WAS YOUR FIRST STEP? We started as five people who came together from different fields. In addition to myself there were two clinician-researchers and two representatives of HIV community and nongovernmental organizations.
at the highest political and expert
At that time I was working for the
technical levels in the region. One of
WHO Regional Office for Europe.
the primary outcomes of the confer-
Our first step was to invite 15 experts
ence was a call to action regarding
and key stakeholders within the field
what to do next. Since then we have
of HIV in Europe to be part of the
been arranging these conferences
initiative. We also invited some 10
every two years – each with a man-
organizations including WHO to join.
ifesto for the coming years as an
They all became part of the steering
important take-away.
committee, some as observers, guiding the initiative forward, identifying and launching new projects, and involving a broader constituency in the fight against HIV.
HOW DID YOU GET RESOURCES TO CREATE THE CHANGE YOU WANTED?
– whether it is our conferences,
To introduce the initiative and
We started with funding from
advocacy activities, research or the
increase awareness of our work, we
industry. We also applied for and
European HIV testing week. We do
arranged a major conference on
received grants from the Europe-
not just focus on reaching one type
earlier diagnosis of HIV. It was held in
an Commission. For example, we
of stakeholder – we are trying to
Brussels in 2007 and had more than
recently initiated “Optimizing Testing
engage everyone who is or should
300 participants from 27 countries
and Linkage to Care for HIV across
be invested in this issue. From the
– including the European Commis-
Europe,” where I sit on the advisory
beginning, we have worked as a
sioner for Health and Consumer
board. And there is a lot of volunteer
multidisciplinary team because we
Protection.
time from the Steering Committee,
are convinced that broad action
not least from our co-chairs.
is needed to meet this challenge.
With the conference we wanted to create a common understanding of the role of HIV testing and counseling in optimizing diagnosis and of the need for earlier care. We chose Brussels as our kick-off location in
142
“We know so much, the evidence is there, yet too often people remain unaware of the evidence and ‘what we know works’ does not get translated into healthcare treatment standards.”
Participants at our conferences, for HOW DID YOU INVOLVE OTHER PEOPLE, AND WHOM DID YOU INVITE?
example, have diverse backgrounds. They include clinicians, researchers, policy-makers, community representatives, and NGO advocates
order to be close to the political
We always have put a great deal
– all in the same room to talk about
epicenter of Europe, and we were
of effort into involving a wide range
how they can play an important part
successful in engaging stakeholders
of people through our activities
in overcoming this challenge.
subsequent evaluation leads me to
is being widely used by professionals
think that we are successfully evolv-
and specialists – this is clear proof
ing in a way that will incorporate a
that what we do is driving change
focus on hepatitis into the HIV in
and having an impact. I truly believe
The first barrier we faced was
Europe Initiative’s long-term vision.
that the guide was a major European
getting people involved. That was
Several hepatitis experts have joined
action to co-create healthcare. It
actually a barrier that we were able
our Steering Committee since the
encompassed the key stakeholders,
to overcome quickly because the
conference.
including physicians, researchers,
WHAT WERE THE MAIN BARRIERS AND HOW DID YOU OVERCOME THEM?
people whom we were approaching were, in one way or another, already involved in the fight against HIV and could clearly see the relevance of our initiative. Our second barrier was funding. This also proved to be surmountable
NGOs and the affected communities. HOW HAVE YOU MEASURED THE IMPACT OF THE HIV IN EUROPE INITIATIVE? CAN YOU ELABORATE ON THE POSITIVE CHANGES THAT IT HAS HAD?
This is why it has gained prominence in healthcare systems across the region. Through the years we had a payoff in terms of Europeans’ growing awareness of their HIV status. The
thanks to support from the man-
We have been measuring the
situation has improved considerably
ufacturers of HIV diagnostics and
effects of our work since the begin-
since the Initiative was launched, and
medicines as well as from the Euro-
ning. We evaluate our conferences
I am excited to see what else we can
pean Commission, which understood
by getting feedback from attendees.
accomplish as the HIV-related needs
the added value of European-wide
We also evaluate our project activ-
of European populations continue to
activities.
ities and research activities on an
evolve and as we engage in the field
ongoing basis.
of viral hepatitis.
Now, almost ten years later, we are confronted by other types of
An early result of the initiative
barriers. We are working on main-
was the development of a consensus
taining momentum and making sure
on the definition of a ‘late presenter’
that we continue to be relevant. For
for HIV treatment. This definition has
instance, we are currently working
been adopted across Europe. Also,
on integrating viral hepatitis issues
the response to HIV Testing Week
into our work. Hepatitis looks like
in 2013 and 2014 has confirmed that
HIV did when we started: there is a
our work has a positive impact on
huge gap between knowledge and
society. We received a lot of support
action across Europe. We are clearly
and made more people aware of
failing in terms of seeing that knowl-
the Initiative. From the first to the
edge about testing and treating
second year, the number of partners
hepatitis is actually reflected in the
and the number of people who got
care Europeans receive. This is par-
tested increased greatly. Here it is
ticularly concerning now that there
important to stress that the Initiative
is an effective cure for hepatitis C.
often functions as an umbrella
Incorporating a focus on hepatitis
organization that adds value to
brings about some challenges for
work already happening. For Testing
the HIV in Europe Initiative in terms
Week there were thousands of
of our identity, which is very much
people, including many people who
linked to our experience of working
volunteered their time to provide
on HIV for all of this time.
on-the-ground testing and raise
We made the first effort to put hepatitis squarely on our agenda at
“Now, almost ten years later, we are confronted by other types of barriers. We are working on maintaining momentum and making sure that we continue to be relevant.”
awareness. Also, we can see that our 2012
the Initiative’s 2014 conference in
guide, “HIV Indicator Conditions:
Barcelona. Interest from conference
Guidance for Implementing HIV Test-
participants and feedback from the
ing in Adults in Healthcare Settings,”
143
CHANGE MAKER IN USA SUSAN SHERIDAN
IMPROVING PATIENT SAFETY THROUGH ADVOCACY – A FIGHT TO RECTIFY A SYSTEM FAILURE From personal tragedy to national advocacy, Susan Sheridan’s story is one of patient empowerment. She and her organization, PICK, are tirelessly working to improve the awareness of kernicterus and elevate patient safety higher on the national healthcare agenda.
No one is born with kernicterus. It is a brain
cated to research, education, prevention and
injury that occurs when jaundice is misman-
outreach for individuals with kernicterus and
aged in the first days and weeks of a baby’s
their families, PICK’s mission is “passionately
life. This happened to Susan Sheridan’s son,
pursuing ways to make the future of individu-
Cal. He suffered severe brain damage five
als with kernicterus brighter.”
days after his birth in 1995 because his neonatal jaundice was untreated. A one dollar
The story of PICK is a story of success built
bilirubin test could have prevented it. This
upon Susan Sheridan’s and the six other
led Susan Sheridan to leave behind a career
moms’ personal tragedies. Since its founding,
as a banker in trade finance and to become a
PICK has managed to mobilize great support
leading activist in the patient advocacy battle
and expand its activities in order to create
– a battle to put the awareness and improve-
awareness about kernicterus and strategies
ment of patient safety at the forefront of the
for putting an end to this easily preventable
healthcare agenda.
patient injury. Throughout the last 15 years, many families and medical professionals have
144
One of her first steps was to found the
become involved with PICK, forming a strong
non-profit organization, Parents of Infants
community of support. With Susan Sheridan
and Children with Kernicterus, PICK, together
as one of its leaders, PICK has also succeeded
with six other moms and dedicated research-
in developing strong partnerships with federal
ers in October 2000. An organization dedi-
and non-governmental organizations related
defined as the “kind of mistake that should never occur” in the field of medical treatment. In 2001 , PICK played an important role in getting the Center for Disease Control and the Joint Commission to issue alerts to all accredited hospitals and public health professionals in the USA saying that all healthy infants are at potential risk of kernicterus if their newborn jaundice is not monitored and not adequately treated. Furthermore, Susan Sheridan and the other mothers of PICK have played an important role spreading awareness of the risks of kernicterus among healthcare consumers. One of their initiatives was the parent education campaign, “Did you know that jaundice can sometimes lead to brain damto healthcare. PICK’s focus in these partnerships
age in newborns?,” which was initiated in 2006.
is to actively involve healthcare professionals as key players in the change process – working for
The effect and significance in PICK in the fight for
a system change to improve the monitoring and
eradicating kernicterus has been widely recog-
treatment of jaundice.
nized. Susan Sheridan and the six other mothers of PICK were honored at the national Patient
Through this work, Susan Sheridan and the six
Safety Partnership Symposium as a success
other moms have managed to put kernicterus on
story of partnership between consumers and the
the healthcare agenda and to push forward more
healthcare system to initiate system-wide im-
research and increased awareness of the prob-
provements. And in 2009, Sheridan was named
lem. In 2002, they successfully advocated for the
to Modern Healthcare’s list of the Top 25 Women
classification of kernicterus as a “Never Event” by
in Healthcare.
the National Quality Forum. ”Never Events” are
BIOGRAPHY Susan Sheridan became involved
organization that seeks a safe,
in patient safety after her family
compassionate and just healthcare
experienced two serious medical
system through proactive partnerships
system failures. Her son, Cal, suffered
between consumers and providers of
severe brain damage called kernicterus
care. Sheridan served at President of
five days after his birth in 1995 when
CAPS from 2003-2010.
his neonatal jaundice was untreated. Her husband, Pat, died in 2002 after his diagnosis of spinal cancer failed to
SUSAN SHERIDAN DIRECTOR OF PATIENT ENGAGEMENT FOR THE PATIENT-
be communicated.
From 2004-2011 Sheridan lead the World Health Organization’s Patients for Patient Safety initiative, a program under the WHO Patient Safety
Sheridan, MIM, MBA, DHL is currently
Program that embraces the collective
the Director of Patient Engagement
wisdom of patients, and values patient
for the Patient-Centered Outcomes
empowerment and patient centered
Research Institute. She is also
care.
CENTERED OUTCOMES
co-founder and past President of
RESEARCH INSTITUTE
Parents of Infants and Children with
(PCORI)
Kernicterus (PICK), and in 2003, she co-founded Consumers Advancing Patient Safety (CAPS), a non-profit
Sheridan received her BA from Albion College and her MIM and MBA from Thunderbird School of Global Management.
145
INTERVIEW
WHAT SPARKED YOUR
INVOLVEMENT WITH PICK? For me it was personally motivated. I – as the other moms who co-founded PICK – had a baby who
ington. This led to a front page article in USA Today on kernicterus – where I got to share my story nationally. It got a lot of reactions from other families with similar stories. Ultimately this led to a meeting in
“It was personal, it was passion and it was very healing for me to feel that my story could become part of a greater system-wide change.”
suffered brain damage because of
Chicago, where we – seven mothers
newborn jaundice, which is prevent-
to babies with kernicterus along with
able. I wanted to prevent this from
dedicated researchers – decided to
happening to other babies and fam-
form PICK as an NGO. We started
ilies. It was personal, it was passion
out by developing a structure, an
and it was very healing for me to feel
objective and a timeline for our ini-
happening. Leading up to this, the
that my story could become part of
tiative. One of our first decisions was
mothers formulated a to-do-list for
a greater system-wide change.
to go big and to focus on the entire
the healthcare system, researching
healthcare system. We did not want
and identifying the responsibilities
risks and consequences of the
to stay local, because the mistreating
and roles for each stakeholder in
current protocol and improve the
of newborn jaundice was happen-
the healthcare system. We created a
guidelines for practicing pedia-
ing across the country. This also
security blanket showing what could
tricians. I wanted to contribute to
meant that our mission and what we
and should be done to prevent this
getting kernicterus on the radar for
worked for was a nationwide system
from happening again.
the US healthcare authorities, which
change. We wanted to implement a
it was not at that time. There was
universal bilirubin test for the entire
a perception that this disease was
healthcare system for all newborns,
simply not happening in the USA.
to create awareness of the problem
Thus, we parents needed to get
and to push forward education of
involved and to tell the story – that
parents and professionals.
I wanted to tell the story of the
this was a preventable patient injury
Our basic idea was then, and still
HOW DID YOU GET RESOURCES TO CREATE THE CHANGE YOU WANTED? At the beginning all we had was our own time, so we used a lot of our
that was, in fact, a reality in the USA.
is, that if you want to drive change,
time and resources. As the initia-
We were the only ones who had
you have to work in partnerships.
tive grew, we also began working
the knowledge of what happened,
So in the forming of PICK we
more actively on getting funds for
we knew the history of healthcare
reached out to nationally well-known
research and specific activities.
failures that led to our babies’ brain
researchers, doctors and safety
The Academic Institute helped
damage. There was a profound goal
experts and asked them to become
fund some of the first steps. The
of making the patient voice count.
a part of the initiative. Based on this,
researchers that we partnered with
We wanted to advocate for the
our first big step was to work with
also received money from govern-
importance of bringing patients,
our lead researchers to organize
ment agencies to conduct research.
patient advocates and family mem-
the roundtable, “Strategies for a
One grant came from The Centers
bers to the table to help redesign the
System-wide Change in the Manage-
for Disease Control and Prevention
healthcare system and to improve
ment of Neonatal Hyperbilirubinemia
to conduct more research on a
patient safety.
to Prevent Kernicterus,” in February
database of children with kernicter-
2001. At this roundtable we brought
us, and to create a public education
basically the entire healthcare sys-
campaign. We also got some funding
tem to the table. Accreditors, regula-
from parents through our fundrais-
tors, researchers, payers, healthcare
ing events and advocacy. It was kind
happened to my son at an Agency
systems and government represen-
of a grassroots effort.
for Healthcare Quality & Research
tatives sat down to discuss what was
WHAT WAS YOUR FIRST STEP? In 2000, I testified about what
146
summit on patient safety in Wash-
HOW DID YOU INVOLVE OTHER PEOPLE, AND WHOM DID YOU INVITE? From day one we built our work
ago, having moms setting this kind of agenda was almost unheard of in the healthcare sector. The healthcare system was not used to listening to patients – especially not those
HOW DID YOU MEASURE THE EFFECT OF THE CHANGE? HOW DO YOU KNOW IT WORKED? The implementation the biliru-
on a partnership strategy. We
demanding radical change. This is
bin test nationally has really been a
did not want to leave anyone out,
very different from today, where the
great victory. We helped change the
because the backing from all actors
patient voice has become standard
standards of care. I am not saying
was crucial if we were to make this
in our healthcare system.
that it is perfect, but research shows
kind of radical change throughout the entire healthcare system. We saw our own role as being catalytic for bringing the partners together. In terms of getting the right
that once the test was made a HOW DID YOU OVERCOME THESE BARRIERS? There was no silver bullet, but
national standard, newborn readmissions decreased by 30%. We have also managed to change the way people talk about jaundice –
people to attend our first round-
there was will. We were complete-
both in the healthcare system, where
table, we had opened some doors
ly mission driven – focused on our
the previous misinformation about
when I testified in Washington. At
north star. We just had to look at our
the seriousness of jaundice has been
that summit there were a number of
children, as they were a constant re-
replaced by more fact-based discus-
leading figures within the healthcare
minder of the importance of pushing
sions on the risks of not getting your
system, including the Joint Commis-
through and making kernicterus a
baby tested, as well as in families,
sion, who I reached out to when we
phenomenon of the past.
where parents now demand that
decided to have the first roundtable.
We were very true to our mission.
their babies be tested.
I picked up the phone and talked to
We focused on consistency and a
their CEO, and he agreed to come to
clear message that was not attack-
based on the anecdotes we hear.
our event – the first one to step up.
ing, but trying to engage and involve
We get many personal stories from
This opened the door to get other
the system. This helped us get
moms and dads that have just had a
stakeholders involved, because we
through and make a difference. We
baby that had jaundice and was test-
could say that the Joint Commission
focused on speaking the healthcare
ed with bilirubin. Those letters really
was supporting it.
language, being informed, know-
matter and make us confident that
ing our partners as means of being
we really made a difference.
WHAT WERE THE MAIN BARRIERS First of all, we moms were not
considered a serious and important voice. We overcame a lot of the barriers
healthcare professionals. So at first,
by making the concept of partner-
in terms of eradicating Kenicterus,
ships a very important aspect of our
we did not see the barriers, but
work. We did not know it was a great
only the possibilities. But one of the
strategy at first, but it was key for
challenges when we started was
our success as a vehicle for bridging
that they asked us: where is the
patients and professionals. In regard
evidence? We lacked evidence of the
to this, we also had immense help
extent of kernicterus and the treat-
from some remarkable partners
ment failures. We had to take on the
within the system. They were bold
task of uncovering and making this
and progressive enough to support
research available.
us even though this meant support-
Another great barrier was to
Success, for us, is also very much
ing a radical change.
“We overcame a lot of the barriers by making the concept of partnerships a very important aspect of our work.”
create a patient voice and make it count. When we started 16 years
147
CHANGE MAKER IN CHINA STEPHEN MACMAHON
BRIDGING THE GAP: LIFESEEDS AND CHRONIC DISEASE MANAGEMENT IN RURAL CHINA Steven MacMahon’s spearheading efforts at LifeSeeds are training village doctors and improving the treatment of cardiovascular disease in China’s “stroke belt”.
On the 2nd of June, 2011, the Salt Reduction
and doctors, LifeSeeds is introducing effec-
and Health Education Campaign launched in
tive, low-cost and sustainable interventions
Lianghu– a small village in the Shanxi prov-
for cardiovascular disease that will enable
ince of Northern China. The launch was or-
widespread prevention and management
chestrated as a village celebration equipped
programs to be implemented in rural China.
with drummers and dancing. Healthcare
LifeSeeds is thus addressing a greater health
experts gave inspirational speeches explain-
challenge in China, one in which chronic
ing the risk of high salt intake and told people
diseases are growing by the minute and cur-
how to reduce their salt consumption. As in
rently account for more than three-quarters
many other villages and towns in Northern
of all deaths.
China, in Lianghu it is common to use a large amount of salt in everyday cooking. This high
Cardiovascular diseases are, at present, the
salt consumption is becoming a health risk
leading cause of death in China, responsible
and these small communities are seeing a
for about 2.6 million deaths annually. And
steady rise of hypertension and other cardio-
predictions for the future assess that this
vascular diseases.
number will only grow in the coming years, likely to reach 4 million deaths per year by
The campaign is part of The China Rural
2020. In rural China, where access to basic
Health Initiative – also called LifeSeeds – and
health services is difficult, these problems are
is a flagship project of the George Institute for
particularly significant.
Global Health. The project is designed to improve healthcare in China’s rural areas, home
Cases of heart disease, stroke and diabe-
to more than 700 million people. It involves
tes are rising rapidly in rural China and the
120 townships in five provinces in Northern
control and treatment of diseases are lagging
China and is supported by the Ministry of
behind.
Health. By working with local governments
148
LIFESEEDS’ TWO PRIMARY ACTIVITIES: • Training of “village doctors” through the Healthcare Provider Program – a primary care-based program seeking to build up the capacity of village doctors in cardiovascular prevention and management and thus enhance the identification and medical management of individuals at high cardiovascular risk. • Educating the people through a Community Education Program seeking to improve blood pressure control in those already affected, and to prevent hypertension and reduce overall salt consumption in the population and provide recommendations of salt substitutes. A recent meta-study on hypertension in rural China
This dual focus is motivated by the fact that the chal-
deemed the overall hypertension prevalence rate to be
lenge lies not only in the behavior of the people, but also
22.81%.1 Even more worrisome, a 2015 study in rural
in the healthcare system. Rural China is characterized
Northeast China concluded that 51% of the population
by low awareness, poor disease management, limited
was hypertensive. 31.2% were taking medication to ad-
resources and a healthcare service without well estab-
dress the problem but only 6% had their blood pressure
lished evidence-based clinical guidelines for the man-
under control. 2 These gloomy numbers are due both to
agement of hypertension and cardiovascular disease.
a lack of knowledge of healthy living among the Chinese people, and to a healthcare system that is currently
So far the success has been great. An evaluation of the
not properly managing these health challenges. The
first part of the project showed that the people in rural
campaign launched in Lianghu marks a new beginning –
northern China reduced their salt intake after participat-
confronting the lack of knowledge and action from both
ing in a community-based sodium reduction program.
the healthcare consumers and providers.
120 villages from five of the Northern provinces of China - Hebei, Liaoning, Ningxia, Shanxi, and Shaanxi – are par-
Chen X, Li L, Zhou T, Li Z. Prevalence of Hypertension in Rural Areas of China: A Meta-Analysis of Published Studies. PLOS One 2014; 9(12): e115462. 1
Li Z, Guo X, Zheng L, Yang H, Sun Y. Grim status of hypertension in rural China: Results from Northeast China Rural Cardiovascular Health Study 2013. Journal of the American Society of Hypertension 2015. 2
ticipating in and benefitting from the various elements of implementation of LifeSeeds.
BIOGRAPHY
STEPHEN MACMAHON PRINCIPAL DIRECTOR OF
Stephen MacMahon is one of the founders
As Principal Director of The George
of The George Institute for Global Health
Institute, Professor MacMahon is
and is currently its Principal Director. He
responsible for more than 500 staff at
is Professor of Medicine at the University
Institute research facilities in Australia,
of Oxford and is an international authority
China, India and the UK. In 2008, he
on the causes, prevention and treatment
received the Australian Government’s
of common cardiovascular diseases.
highest award for achievement in medical
His special interest is the management
research and in 2012, he was elected as
of chronic and complex conditions in
Fellow to both the Australian Academy
resource-poor settings, particularly in the
of Science and the Academy of Medical
Asia-Pacific region.
Sciences.
THE GEORGE INSTITUTE FOR GLOBAL HEALTH
149
INTERVIEW
WHAT SPARKED THE
CREATION OF LIFESEEDS? We’ve had a long term interest
ultimately the whole project has been designed and run by our team in Beijing – all of whom are Chinese and several have joint appointments
in the treatment and prevention of
with Peking University. Therefore, it
heart disease and stroke in Asia. One
wasn’t an Australian or British study.
of the lessons we learned early on is
Fundamentally, it was run, as is ap-
that a large majority of patients who
propriate, by people who understand
either had already experienced a
the Chinese health system, politics
heart attack or stroke – or those who
and culture, all which are critical in
are at very high risk – weren’t getting
any shift in healthcare.
“the West has so much experience in the management of these chronic conditions, that we have something to offer China and other emerging markets”
any care at all, and those who were getting care were usually getting suboptimal care. That was the scenario we faced, and clearly the status quo of healthcare services was far short of what was required.
STARTING LIFESEEDS? We didn’t have many models to follow, because at the time we start-
we not focus on the most or least developed provinces, but rather find provinces in the middle, where there was the greatest potential for change and scale-up.
Therefore, we commissioned a
ed working with China in this area,
small pilot study in China working
there wasn’t much focus on stroke
ly the “stroke belt” of China, which
with the Ministry of Health to look at
and heart disease. Most of the global
runs from the middle of China above
a few clinical centers in some rural
interest in healthcare in China had
Beijing to the east coast. Here stroke
areas to see what was going on, par-
focused on issues like SARs, which
rates are very high, and while there
ticularly in terms of stroke preven-
were seen as possible threats to the
are major limitations in the level of
tion, as stroke is the leading cause
West. So ailments that weren’t a
care provided, the health systems
of death and disability in China.
threat to the West, like heart disease
are strong enough to support the
And the results were pretty grim in
or stroke, weren’t on the Western
implementation of new programs.
terms of the treatments people were
agenda. Part of the rationale for es-
And as it has turned out, the Minis-
receiving if they’d had a stroke, and
tablishing The George Institute was
ter’s advice was extremely helpful
the absence of anything being done
that the West has so much experi-
and the provinces we chose to be
for those at risk.
ence in the management of these
great places to run this project.
On that basis, we put together
So we focused on what is basical-
chronic conditions, that we have
a partnership with Peking Universi-
something to offer China and other
ty – it also involved the Ministry of
emerging markets, experientially and
Health and Bureaus of Health in rural
financially.
provinces. We developed a program
At the outset, we knew there
HOW DID YOU GET RESOURCES TO CREATE THE CHANGE YOU WANTED?
to train “village doctors,” who are
was a big difference in the quality
After identifying the provinces
healthcare workers with very modest
of healthcare in the cities and rural
with which to work, we sought fund-
training. The program was very
areas in China. I had previously had
ing from the US National Institutes of
simple and aimed to enable them to
the opportunity to host the Chinese
Health, which had a specific program
identify people at high risk of stroke
Minister of Health, Mr. Gao Qiang, on
devoted to improving healthcare for
or who had had a stroke, and provide
a visit to Sydney and he emphasized
heart disease and stroke in low and
low-cost evidence based treatment.
that the most important challenge
middle income countries. We suc-
The program ran for 2 years and
was to improve care in Chinese rural
ceeded in gaining their support, and
then we assessed the outcomes.
communities. We discussed with
they funded the project for the best
him the selection of provinces for
part of 5 years.
I was involved in raising financial support for this project, but
150
WHAT WERE YOUR FIRST STEPS IN
LifeSeeds and he suggested that
Until very recently, the Chinese
Ministry of Health (now the National
ilarly, once we had a plan for action,
referral, treatment and follow-up.
Health and Family Planning Commis-
we identified the key stakeholders
We believe that these personalized
sion) has not had access to research
including the Ministry of Health and
instructions for clinical management,
funds, so it was not in a position to
provincial health bureaus, and we
together with continuous monitoring
contribute financially but it has acted
worked closely with them as well as
of practice quality, have the potential
as strategic partner. Additionally,
a range of others, like the Chinese
to greatly improve the quality of
the regional health bureaus in the
Center for Disease Control and Pre-
care provided. That said, without the
provinces contributed by providing
vention. So we made a deliberate
extension of the human resource,
access to facilities and staff. But we
effort to identify and engage all the
there will always be limitations.
had to raise all the research funds
key stakeholders, and take account
We’ve shown that we can improve
outside of the country, which is –
of their views as to how best to
the care provided by what are effec-
today - unsustainable. China has
achieve our goals.
tively non-medical workers, and if
an enormous economy and therefore the days of the United States, Australia, the UK and other Western countries providing research funds to China are over. We’d like to get
by building technology systems to WHAT WERE THE MAIN BARRIERS IN STARTING LIFESEEDS? The major barrier was that that
support them we can substantially improve the quality of care, then it will be very cost effective to hire more of these non-medical health-
China more directly involved with
the village doctors were already
care workers because they are, of
healthcare research funding in the
overwhelmed with work, so ex-
course, very inexpensive compared
future. To do so, we’re focusing on
tending their reach, even to cover
to regular doctors. As long as we
closer engagement with the Ministry
something as important as stroke
can ensure safe, effective care, this is
of Science and Technology.
prevention and treatment, was not
potentially a very scalable solution.
The George Institute is a global
a straightforward task. Also, the
We’ve begun some work on this,
organization, and not a techni-
very modest level of training of
and have shown that a very basic
cally Chinese organization, so we
doctors was an issue. So while the
prototype technology has the ca-
cannot seek resources directly from
stroke prevention program clearly
pacity to improve outcomes. What
the government, as only Chinese
improved the quality of the care that
we now need is a bespoke Chinese
organizations can apply for funding
was delivered, the impact was still
version and a completely new phase
from the Chinese government. That
well short of what we had hoped for.
of LifeSeeds, targeting the same
said, we need to find other ways to work with the government through partnerships or joint venture with Chinese organizations with interests in improving healthcare for the poor.
HOW DID YOU INVOLVE OTHER PEOPLE AND ORGANIZATIONS AND HOW DID YOU CHOOSE WHO TO INVITE? When we first established our
or similar populations, to assess HOW WILL YOU OVERCOME THESE BARRIERS? AND WHAT ARE THE CHALLENGES TO OVERCOME IN THE FUTURE? The next phase of this project will
whether this approach to care works. We do not yet have funds for this, but it is something we will continue to seek. There is also a need to extend the reach of the program to urban com-
use new IT technology to commu-
munities. If you are wealthy in China,
nicate with the village doctors. So
you can get 5 star medical service in
rather than training the doctors and leaving it to them to follow the guidelines and implement the pro-
Institute in China, we developed it as
gram, we will provide mobile internet
a partnership with Peking University.
based programs, which provide
We chose Peking University because
instructions directly to the doctor
it’s the leading university in China,
about how to manage the patient
so in that sense it was a carefully
in front of him or her. This includes
planned strategic partnership. Sim-
instructions about risk assessment,
“As long as we can ensure safe, effective care, this is potentially a very scalable solution.”
151
any of the major cities, but if you’re
the national level. If we can achieve
of 2 generic drugs that cost about
poor, and particularly if you’re a
the results we are aiming for in terms
10 cents a day. If we could show
migrant, then there are big challeng-
of stroke prevention, then we could
widespread uptake and persistence
es in accessing quality care. There is
take a similar approach to other
in that sort of care, we would know
therefore a demand for accessible,
major health problems in China such
we are on track to make a major
affordable care in urban areas, as
as lung disease, cancer, and mental
difference in clinical outcomes for
well as in rural areas.
health.
this very large patient population.
Of course, the actual implemenHOW DO YOU ENGAGE ALL THE ACTORS INVOLVED WITH LIFESEEDS?
work is that there is a clear currency:
the provincial or national levels is
death or hospitalization. It’s the type
the responsibility of governments,
of thing you can easily count.
unless – and this is possible – China
But, of course, it’s not only
There has been very a good engage-
opens up the healthcare sector to
counting the bodies that matters.
ment with the village doctors and
foreign ownership and operation.
We need to make sure treatments
this is demonstrated by the improve-
I think that’s in the cards. Already,
and initiatives are cost effective. You
ment in care we have observed.
the planned free trade agreement
could spend a fortune and only save
We’ve also had great support from
between Australia and China will
a few lives, or you could spend much
the Chinese bureaus of Health,
allow Australians to own and operate
less and save many lives. And in all
Peking University and the Ministry of
healthcare facilities in China. This
resource poor environments, you
Health, so I don’t think engagement
could be the start of much more
need to veer on the side of the latter
has been a major challenge.
global engagement with China in
– and do things that are affordable
the development of solutions for its
as well as accessible. That said, the
greatest health challenges.
resources that are currently available
The bigger challenge will come when it comes to scale up. Translating evidence from projects such as LifeSeeds directly into national programs is extremely challenging. What we have learned is that a better option may be to first try
in rural China are not adequate, so H0W DO YOU MEASURE THE EFFECT OF LIFESEEDS? HOW WILL YOU KNOW IT WORKED?
any sort of implementation of better quality care is going to require greater resources. Our hope is that if we can show the LifeSeeds programs
to achieve scale up in a provincial
There are national and interna-
are cost effective, this will result in
program. A successful provincial
tional guidelines about how patients
resource allocation that will allow
program could then provide a model
with certain conditions should be
these programs to be scaled up.
for a national program. Our view
treated and their recommenda-
at the moment is that although we
tions are based on strategies that
have improved the care provided in
have been shown, unequivocally,
these villages, we don’t yet have the
to reduce the risk of death, stroke
solution that we should be scaling
and other diseases. Therefore, if
up. We’ve proven the principle that
we can show there are meaningful
you can change the care provided
improvements in the application of
by village doctors, but we still need a
those strategies in the populations
more powerful intervention that will
served by LifeSeeds we can make a
deliver larger improvements. If we
precise estimate of the effect these
can achieve this in the next phase of
programs will have on death and
LifeSeeds then I think we will really
disease. For instance, if a patient has
have something we could promote
had one stroke then that person’s
at a provincial level.
risk of a second stroke is high (say,
From there, we’d have a model of success that we could then bring to
152
The great thing about this kind of
tation of any such programs at either
20% over 5 years). We know that this risk can be halved by a combination
“The great thing about this kind of work is that there is a clear currency: death or hospitalization. It’s the type of thing you can easily count.”
153
WHO’S BEHIND SUSTAINIA is an innovation platform where companies,
The objective of strategic research is to enable long-
NGOs, foundations and thought leaders come together
term innovation and business growth in support of the
in creating tangible approaches to sustainability. With a
overall strategy of DNV GL through new knowledge and
focus on readily available solutions, Sustainia’s mission
services. Such research is carried out in selected areas
is to mature markets and sectors for sustainable models,
that are believed to be of particular significance for DNV
products, and services. The work of Sustainia equips
GL in the future. DNV GL will seek out the best practices
decision makers, CEOs, and citizens with the solu-
in risk thinking to support the further development of
tions, arguments, visions, facts, and networks needed
high quality, person-centered care. We welcome the
to accelerate a sustainable transformation in sectors,
opportunity to work with others to make this vision a
industries, and our everyday lives.
reality for all. To learn more about our work to establish a collaboration, please visit us at: www.dnvgl.com/pa-
The concept of Sustainia was developed by Scandina-
tientsafety
vian think tank, Monday Morning, in a collaborative effort with global companies, foundations, organizations, and experts. Since 1989, Monday Morning has addressed megatrends in our society: sustainability, healthcare, welfare, and financial systems, to name but a few. On a
Erik Rasmussen Founder of Sustainia and CEO of Monday Morning
national and international level, Monday Morning works
Stephen Leyshon
for an innovative society where old barriers between
Deputy Programme Director - Principal Advisor in Patient Safety
sectors, institutions, and leaders are torn down in an ef-
DNV GL - Healthcare | Strategic Research and Innovation
fort to locate common challenges and shared solutions. To find out more, visit: www.sustainia.me
Eva Turk Senior Researcher DNV GL - Healthcare | Strategic Research and Innovation
DNV GL is driven by its purpose of safeguarding life, property, and the environment, DNV GL enables organizations to advance the safety and sustainability of their business. DNV GL provides classification and technical
Stephen McAdam Global Technical Director for Healthcare DNV GL - Healthcare | Business Assurance
assurance along with software and independent expert
Fabijana Popovic
advisory services to the maritime, oil and gas, and
Project Manager, Monday Morning Sustainia
energy industries. It also provides certification services to customers across a wide range of industries. Combining leading technical and operational expertise, risk
Esben Alslund-Lanthén Research Analyst, Monday Morning Sustainia
methodology and in-depth industry knowledge, DNV
Monica Keaney
GL empowers its customers’ decisions and actions with
Project Coordinator, Monday Morning Sustainia
trust and confidence. The company continuously invests in research and col-
Anna Fenger Schefte Journalist, Monday Morning
laborative innovation to provide customers and society
Lisa Haglund
at large with operational and technological foresight.
Head of Design, Monday Morning Sustainia
DNV GL, whose origins date back to 1864, operates globally in more than 100 countries, with its 16,000 professionals dedicated to helping their customers make the world safer, smarter, and greener. Always looking
SUSTAINIA
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154
a part of
MONDAY MORNING
INSPIRATION FOR FURTHER READING DNV GL and Sustainia have created multiple publications on the subjects of healthcare and health. We hope State of Healthcare has inspired you to keep reading and exploring our work. We have listed a selection of reading material below:
BMJ SPOTLIGHT: PATIENT CENTRED CARE, 2015 Healthcare faces serious threats to its sustainability. Ageing populations, the rise of co-morbid chronic conditions, an unenviable safety record and the impact of austerity collectively mean that health systems around the world have to change if they are to achieve improved well-being for individuals and populations. Such change is possible if we join the power of systems thinking with the engagement of service users as equal and active partners alongside practitioners, provider organizations and policy makers. This is the message of the new publication on person-centred care from the BMJ and DNV GL.
MIXED METHODS: IMPROVING THE ASSESSMENT OF SAFETY CULTURE IN HEALTHCARE, 2014 Safety culture is the way in which organizations live and breathe safety. If there is to be improvement in the quality of healthcare, the assessment of safety culture is paramount. This position paper makes the case for using a mixed methods approach, in which quantitative and qualitative methods are combined to improve the accuracy of results in the assessment of a healthcare organization’s safety culture.
THE GUIDE TO CO-CREATING HEALTH, 2014 Guide to Co-Creating Health describes a not-too-distant future society in which different arenas work together to create a health-empowering society. The guide looks at schools, workplaces, the food sector, healthcare and communities and examines their roles in creating a society that truly values health. By using clear language and easily read illustrations, the book portrays the healthy society we could live in ten years from now based on solutions available today.
THE GUIDE TO PERSON-CENTRED CARE, 2014 While the current healthcare systems of the world are unsustainable, their challenges also present the greatest opportunities to co-create healthier societies. In PersonCentred Care, we set forth a bold vision for what healthcare could look like if personcentered care is made a reality for all. The guide features interviews with world leaders in person-centered care, 10 illuminating case studies from around the world, a review of the challenges and obstacles to person-centered care and an accessible and engaging review of the evidence.
155
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THE STATE OF HEALTHCARE From Challenges To Opportunities
To be sustainable, people and societies need to be healthy and to be healthy we need to be able to rely on quality healthcare. This publication offers a look at the current state of global healthcare and points towards solutions, technologies and people that inspire a new and brighter future. DNV GL and Sustainia joined forces with key stakeholders from healthcare systems all around the world in order to start the discussion about the future of healthcare. Our ambition is to help change the conversation from only focusing on challenges to an approach that highlights opportunities and co-creates positive change.
SUSTAINIA
a part of
MONDAY MORNING
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