Most governments in developed countries want to ensure their populations have accessible, high quality, affordable health care. Building blocks for achieving this objective include providing the population some form of universal coverage of comprehensive benefits, investments allowing a decent level of quality of care to be provided, and regulating care providers, in particular the medical profession.
As good quality care does not necessarily flow from these basic ingredients, most countries have developed approaches to try to ensure it. Put simply, at one end of the spectrum are those that largely seek to mitigate the worst safety risks to health, perhaps in response to significant and well publicised lapses in quality. In the middle are an extensive range of initiatives that seek to improve care each in specific high priority areas. And at the other end are countries with a comprehensive and coherent strategy comprised of multiple approaches. Many countries aspire to the latter but are in the middle part of the spectrum. The ability to design a comprehensive strategy is difficult, but the ability to deliver it is more so, given the historical context, assets and power structures within countries to make or break progress. Some countries lack the ability to make needed changes, as power over different levers is widely distributed across different parties or different levels of the system – so agreeing and implementing a national strategy is possible but considerably more difficult.
It is refreshing when occasionally, as in Dreiher et al’s report with respect to the health care system in Israel [1], there is an attempt to lay out the key approaches used in a particular health care system to improve quality and assess progress. The feat is exceptionally challenging because quality of care is a slippery multifaceted concept and difficult to measure. And initiatives cover a multitude of dimensions, from regulation to measurement to financial incentives to public reporting to patient choice and more. How individual initiatives are meant to impact on quality may not be particularly clear, still less on how they might interact with others. Some initiatives may have indirect and lagged effects and may not be seen as quality initiatives at all. While direct and significant national initiatives may be well described, how they stack up as a whole is often not.
The easier job is to compare with other countries – is one country’s set of initiatives missing anything big being tried somewhere else? Are there glaring differences in outcomes? But the more difficult task is to assess whether, taken as a whole, policies in a country represent a coherent and balanced strategy. This is a tall order for any group of national leaders to assess, be they in a ministry, university, a quality institute or professionals in the health care system itself. And yet it is important to try, and keep trying, because doing so gives the best chance to make progress.
Concepts to consider in developing a coherent strategy
One way forward is to identify some basic concepts within a strategy, before categorising policies under them to assess balance, identify gaps, and point to where efforts should best be directed. Here I draw heavily on the work by Sutherland and Leatherman [2, 3] Molloy et al. [4], Darzi [5] and others for the NHS in England. As in other countries, in England there have been several attempts to produce an overall strategy for quality of care in the National Health Service, seen most recently in the policy High Quality Care for All led by Lord Ara Darzi, published in 2008, which attempted to put quality at the centre of policymaking [5].
The obvious first step is to be clear about what is meant by quality of care and which are the objectives to achieve in any strategy. Many countries use the Institute of Medicine’s (IOM’s) definition of six domains: safety, effectiveness, patient-centredness, timeliness, efficiency and equity (equal access for equal need) [6].
The second is to consider in a strategy the balance of three core functions in achieving high quality in any industry, as outlined in the Juran trilogy: planning; improvement; control. In the context of health care this means effective strategic planning for quality at national level; support for organisations and professionals to improve care (for example using quality improvement techniques [7]); and control mechanisms to ensure progress and mitigate risks (including regulation and inspection, and also accountability through for example management and use of metrics). These three core functions are clearly linked, and Juran thought it important not to rely on any single one. For example a country heavily relying on regulation and inspection, might drive out professional motivation to improve care, or perversely encourage behaviour which may reduce quality.
