Help more than hurt. Choose partnerships over charity. Create sustainable solutions rather than temporary relief. These are familiar themes at global health conferences around the world. Interestingly this month’s issue of Lancet Global Health features a work by Kruk et al that draws us to consider, Quality Improvement (QI), a measure I hear much more often discussed at hospitals close to home. Indeed, U.S. institutions are placing an ever increasing emphasis on QI. Even my own training institution has developed a “QI pathway” for interested residents. Kruk et al propose the need for a Quality Revolution in Global health. We’ve realized it isn’t just about trying to practice in low resource settings, but on finding ways to ensure that the care provided is truly improving health outcomes. It would seem that quality improvement is indeed a global health issue, so where did QI come from? Since the Institute of Healthcare Improvement’s (IHI) landmark To Err is Human failures of healthcare have been a focus for hospitals and policy makers (2). Since that time the IHI has developed six principles that they believe should be used to guide health systems and improve quality. The IHI’s principles demand for care that is safe, effective, patient centered, timely, efficient, and equitable. Kruk et al sought to apply these quality dimensions to countries in sub-Saharan Africa. The authors selected outcomes they felt were reflective of at least one of these six dimensions. For example in “safety” they chose a metric like “facility has water on site nearby” or “effective” metrics like how many women aged 18-69 had received a pelvic exam. In this later measure they highlight that only 18% of women received a pelvic exam. They infer that yes there may be access to a clinic for these women, but that it wasn’t effective because the women weren’t given a proper exam. This is where I worry we fall short in our assessment on QI. Before knowing if this was truly a quality measure of the health center I would want to know of the women who did have an abnormal pelvic exam have access to the subsequent treatment. Perhaps practitioners in these clinics weren’t resourced with the solutions to the pathology they might find. Would I want to screen a woman for a cancer I had no treatment for?
It has been my high-resource experiences that have led me to be skeptical of how we measure QI. One area of quality care across institutions in the U.S. is a well-documented code status. The idea is to prevent an invasive and painful attempt to save a life that may be against the patient’s wishes, beliefs, or clinical situation. On the surface this makes a lot of sense. Yet as I write this one of my overnight resident colleagues is surely trying to discuss the idea of a code status with someone’s admitted grandmother. Our grandmother is inevitably tired from the day in the ED on top of feeling very ill or in pain. She has met six doctors for the first time today and now appears my co-resident asking at 2:00 AM all of the same questions…and just at the end “ma’am what would you like us do if your heart stopped?” For many patients this is first time they’ve been asked this question. Yet, every patient will have a verified code status by the time I arrive tomorrow morning. Did the quality of our admissions improve? What was the quality of that code discussion and how much time could the overnight physician dedicate to that encounter. Our measure of verified code statuses looks better but I’m not so sure about the quality of care. Whether local or global we unquestionably need to seek opportunities to improve the care we provide. In this way I’m a big fan of Quality Improvement. I only hope that our “quality revolution” in global health is a mindful pursuit because the health of the world’s most vulnerable populations depend on it.
(2) Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century.National Academy Press, Washington, DC; 20