ABSTRACT
The COVID-19 pandemic has been a challenge as well as an opportunity for healthcare. The pandemic has exposed the inherent weaknesses in health systems globally while, at the same time, revealing strengths on which post-pandemic health systems can be built. We propose lessons on improving quality and safety post-pandemic from a global perspective based on recent policy publications and our global experience. Nine possible lessons are discussed. These lessons can ensure that healthcare does not return to the old normal, but rather builds on what we have learnt as we deliver on the Sustainable Development Goals and universal health coverage. Quality and safety are an essential component of healthcare strategy. Post-pandemic systems require a transparent compassionate culture, with integration of care at its core. The workforce must be trained in the skills to improve care, and patient and healthcare worker protection (both physically and psychologically) needs to be a given. Any development of systems will best be co-produced with the people who receive and deliver care in an equal partnership. Finally, the new systems need to be conscious of emerging threats (such as the challenge of climate change), building sustainable health systems that also address the structural inequities that currently exist.
Introduction
Health systems require safety and quality to be at the core of their activities to implement universal health coverage (UHC) and deliver Sustainable Development Goals (SDGs).1 The safe delivery of high-quality healthcare is a challenge in many countries. In 2018, three reports outlined the state of healthcare quality and patient safety globally, with lessons and recommendations for the future.2–4 Before any meaningful action could be taken, the COVID-19 pandemic disrupted normal activities and health systems worldwide have been adversely affected, no matter where they are located.
As we emerge from the pandemic, the question is: ‘How can we develop resilient services that can respond to crises and remain safe, effective and person centred?’ The World Health Organization (WHO) Global Patient Safety Action Plan, released in August 2021, is the first major report to position patient safety within a post-COVID-19 world.5 This action plan, as well as the pre-COVID-19 reports, provide guidance and, here, we distil the key lessons from these reports to be applied in the post-COVID-19 era, with examples from the global community based on our experience. We propose nine lessons and share an example for each that have been delivered (Box 1).
Nine global lessons post-COVID-19 pandemic
Lesson 1: The future for quality is bound up in managing complex systems
Over the past 20 years, it has been recognised that an understanding of how the different component parts of healthcare interact is essential. The reports concur on the need for improved quality measurement, learning and improvement, alongside integration and coordination across the healthcare continuum within a systems framework.2–4 In Fig 1, the way that we can conceptualise systems thinking for quality healthcare is shown.3
High-quality health system framework. Adapted with permission from Kruk ME, Gage AD, Arsenault C et al. High-quality health systems in the Sustainable Development Goals era: time for a revolution. Lancet Glob Health 2018;6:e1196-252 (Licence: CC BY 4.0).
The systems approach to improvement requires accountability from leaders to tackle challenges such as corruption, inequity and climate change. Quality and safety in fragile states is particularly difficult.6 Nevertheless, there are examples of implementing quality strategies in low- and middle-income country (LMIC) settings that offer learnings, as shown in Case study 1.7–9
Developing strategies for quality in complex systems in Ethiopia
Lesson 2: Quality and safety are an integral part of the healthcare strategies
The WHO framework on how to develop a quality strategy consists of eight steps (Fig 2) with supporting toolkits.10
The eight elements of the World Health Organization national quality policy and strategy. Adapted with permission from World Health Organization. Handbook for national quality policy and strategy: a practical approach for developing policy and strategy to improve quality of care. Geneva: WHO, 2018 (Licence: CC BY-NC-SA 3.0 IGO).
These can be supplemented by a framework from the European Observatory, which integrates improvement methodology around three dimensions of quality: effectiveness, safety and responsiveness.11
The lesson from these high-level strategic frameworks is that quality and safety must be at the core of health services, within a foundation of improvement and implementation science. Case study 2 demonstrates the translation of strategy to implementation on a national level.12–14
A national programme to improve quality and safety in Oman
Lesson 3: Develop national learning systems with transparency as a core value
Once a strategy has been developed, it requires a learning system based on the values of transparency and openness. A focus on what works well, as well as clinical incidents and near misses, supports greater accountability and fosters safety and quality.15 For example, the National Reporting and Learning System (NRLS) in Thailand, developed as part of a national policy on patient and personnel (2P) safety has collected more than 1,300,000 incident reports utilising handheld devices, web and cloud-based technology between 2018 and 2020. Greater transparency can also help to counter potential corruption.16
In the quality learning system, research on safety and quality should be prioritised to build a firm evidence base of what works, using both the traditional research methodology as well as alternative ways of learning in real time.15,17 Case study 3 demonstrates how one can learn in times of crisis.18–20
Learning and developing preparedness approaches from periods of crisis
Lesson 4: Develop the future workforce to deliver the strategy
The development of leaders in patient safety and quality is essential to improve the quality and safety of care. Education for safety is a key priority of the WHO action plan that notes that programmes targeting undergraduate and postgraduate students, and other medical professionals, are essential interventions.5 Educational resources and activities can be shared globally, especially in areas not previously exposed to improvement science.22 Case study 4 demonstrates examples of capacity building in LMICs.23,24
Developing future leaders in patient safety to deliver solutions
Lesson 5: Ensure the safety of patients and healthcare workers with respect and kindness
The WHO has designated 2020-2030 as the decade of patient safety.25 The pandemic demonstrated the importance of patient safety as well as protecting the wellbeing of all health workers, recognised by the 2020 WHO World Patient Safety Day.26,27 Organisations and industries outside healthcare value investing in the psychological safety of their workforce.28 A systems approach to healthcare worker burnout is essential.29 Leaders in healthcare need to recognise and support the physical and mental health needs of the global healthcare worker population.30 Compassionate leadership aims to supports all leaders and workers at every level of the organisation.31 The need for a kind and caring approach, as opposed to a technical approach to healthcare has become apparent.32–34 This is a challenge in settings where hierarchy is the paradigm, with inappropriate use of professional, gender, racial and religious power dynamics.35,36 Case study 5 illustrates how safety can be improved through collaboration.37–39
Ensuring kindness and respect are part of systems and processes
Lesson 6: Co-design solutions with people receiving and delivering care
People, whether they are patients, providers or carers, must play a central role in the development of healthcare services. Co-production implies the sharing of power, which is a challenge for health systems but can be very valuable.40 An NHS England study of 17 organisations found that patient leaders can focus more clearly on what patients want.41 In the UK, a range of co-production policy and guidance, including the co-production model, have been developed (Case study 6).42–45
Co-production in Scotland
Lesson 7: Ensure integration of care
The Lancet Commission identified integration of care as a priority to reduce the burden on patients and increase safety, quality and efficiency across a health system.3 Practical attempts at integration of care, particularly in LMICs, have had mixed results as the focus has been on increasing access and efficiency, rather than integrating existing services and patient experience.2 National quality planning processes should integrate quality improvement into services.46 Digital solutions may offer an opportunity for integration though a range of challenges with inequity must be considered and addressed.
The WHO published a report with examples of integration of care across high-, middle- and low-income health systems.47 Examples include the integration of community-owned primary care health networks in Mali (where there has been a measurable increase in curative care episodes, greater antenatal provision and improved vaccination coverage) and the integration of HIV/AIDS and tuberculosis programmes to disadvantaged communities in Kenya. Case study 7 illustrates an example of integration in an upper-income country.48–51
Integration of care to better support the elderly in Singapore
Lesson 8: Recognise sustainable healthcare as a new domain of quality
As health systems around the world are increasingly affected by the impact of climate change, sustainable healthcare must be built into processes in quality improvement planning. This is important for health systems globally, but particularly for LMIC systems. Climate change will add additional pressures to maintaining the health of populations, the ability to provide health services and the management of limited financial resources, all of which are essential to achieve UHC; for example, climate change will increasingly cause periods where health services will be disrupted by facilities damage, disrupted supply chains and workforce shortages as staff are affected by climate events.51
Sustainability, in the healthcare context, refers to the capacity of a health service to deliver healthcare over time, with consideration for future generations.52 Training of health professionals on ‘resource stewardship’ can drive decision making and resource allocation.52 Low-carbon alternatives (including minimising the waste of medications, consumables and energy) are possible.52 In the context of the COVID-19 pandemic, it has been estimated that, globally, 3.4 billion single-use face masks/face shields are discarded daily, reversing momentum around discouraging the consumption of single-use plastics in healthcare.53 Case study 8 illustrates the role of stakeholder collaboration in driving sustainable healthcare.54–56
Driving sustainable healthcare research, policy and innovation within a supportive ecosystem
Lesson 9: Address structural inequity and the social determinants of health
Societal inequities have far reaching implications on population health.57 Wilkinson and Pickett highlight the health implications of inequity, finding a strong relationship between higher prevalence of mental illness and income inequity across 11 of the 12 countries analysed.58 Similarly, life expectancy and infant mortality in high-income countries was found to be related to inequity, with health being poorer for the whole society in countries where inequity is high.58
The COVID-19 pandemic exposed inequity in healthcare globally and nationally. Major health inequities have been demonstrated across health systems.59 Mortality rates from COVID-19 were substantially higher among ethnic minority groups in the UK, with the rate of death among Black men 4.7 times higher than those from a White ethnic group.60 Globally, the race for vaccinations in high-income countries has led to disparities in the proportion of inoculated populations between high-, middle- and low-income countries.61
Two reports, one just prior to the pandemic and one 10 months into the pandemic, document the social determinants impacting on health.62,63 A report from the NHS Race and Health Observatory calls for proactive leadership, targeted interventions and better use of data.64 Hirschhorn et al recommend that we disaggregate data to reveal inequity and then design services to address the inequity at scale.65
The future workforce must be made conscious of inherent bias and structural inequity, as well as the potential for bias in new health technologies and applications (eg artificial intelligence).66 Case study 9 outlines the changing research agenda towards addressing health inequities.49,50,67–71
Funding to support research into COVID-19 health inequities
Conclusion
The onset of the COVID-19 pandemic has strained health systems globally, increasing the challenges in providing safe quality care. The reports we have referenced offer a solution, although implementation will be a challenge.2–5,72 The pandemic shed new light on the value and benefits of active safety and quality improvement in periods of crisis. It is an opportunity for us to think differently and to redesign our services to be person centred, eco-friendly and safe.73 This also requires proactively responding to the social determinants that define health and outcomes for many people.
Going forward, as health systems address the long-term effects of COVID-19, global learning is now more critical than ever to drive continued improvement. The global health community can learn from best practice, adapting interventions and implementation to their own context to facilitate improvement.
- © Royal College of Physicians 2021. All rights reserved.
References
Jump to section
- Article
- ABSTRACT
- Introduction
- Lesson 1: The future for quality is bound up in managing complex systems
- Lesson 2: Quality and safety are an integral part of the healthcare strategies
- Lesson 3: Develop national learning systems with transparency as a core value
- Lesson 4: Develop the future workforce to deliver the strategy
- Lesson 5: Ensure the safety of patients and healthcare workers with respect and kindness
- Lesson 6: Co-design solutions with people receiving and delivering care
- Lesson 7: Ensure integration of care
- Lesson 8: Recognise sustainable healthcare as a new domain of quality
- Lesson 9: Address structural inequity and the social determinants of health
- Conclusion
- References
- Figures & Data
- Info & Metrics
Related Articles
Cited By...
- No citing articles found.