The Fourth Dimension: What we talk about when we talk about quality of care

The UN’s Sustainable Development Goals act as a vital catalyst, urging countries worldwide to strive for Universal Health Coverage.  This encompasses the twin objectives of providing financial risk protection and ensuring equitable access to high quality essential health care services.  But how exactly do we define quality of care?

To shed more light on this important topic,  WHO/Europe has launched a brand new podcast called "The Fourth Dimension", which is entirely dedicated to quality of care. 
This podcast is produced and hosted by our expert team in Athens, Greece, who specialize in this field. 

For this episode of Health In Europe, we are going to play you the premiere episode of "The Fourth Dimension".   If you enjoy it, we encourage you to follow the Fourth Dimension on your favourite streaming service (or from wherever you get your podcasts).  Enjoy!

More about Quality of Care from WHO: https://www.who.int/health-topics/universal-health-coverage/quality-of-care#tab=tab_1

CREDITS
Hosted by: Thanos Myloneros
Edited by: Thanos Myloneros and David Barrett
Health in Europe Theme Music by: Ben King

Transcript

00:00:00:00 - 00:00:53:11

DAVID BARRETT

Hello and welcome to Health in Europe, a public health broadcast by the World Health Organization. I'm your host, David Barrett. This episode is about quality of care and what we talk about when we talk about quality of care. 

The UN Sustainable Development Goals act as a vital catalyst. They urge countries worldwide to strive for universal health coverage. Now, this encompasses the twin objectives of both providing financial risk protection and ensuring equitable access to high quality, essential health care services.

00:00:53:13 - 00:01:28:12

DAVID BARRETT

But how exactly do we define quality of care? To shed more light on this important topic, WHO/Europe has launched a brand new podcast called The Fourth Dimension, which is entirely dedicated to quality of care. This podcast is produced and hosted by our expert team in Athens, Greece, who specialize in this field. So for this episode of Health in Europe, we are going to play you the very first episode of The Fourth Dimension.

00:01:28:14 - 00:01:59:17

THANOS MYLONEROS

Hello and welcome to the Fourth Dimension, a WHO monthly podcast focus on discussing issues around quality of care and patient safety. I am Thanos Myloneros and I will be hosting this podcast series developed by the WHO Athens Office on Quality of Care and Patient Safety. And the concept of quality of care in health policy has been receiving increasing attention during the last decades.

00:01:59:19 - 00:02:31:14

THANOS MYLONEROS

It's rather indicative that the literature on quality of care has increased threefold since the nineties. Most recently, quality of care is mentioned in the context of the SDGs with the target 3.8, which calls for access to quality, essential health care services and access to safe, effective, quality and affordable essential medicines and vaccines for all. Despite this profoundly universal acknowledgment of its importance, though, sometimes there is no common understanding of the term quality of care and what this entails, let alone what needs to be done to improve it.

00:02:31:16 - 00:02:48:19

THANOS MYLONEROS

For that reason, on our very first episode of this new podcast series, we'll try to introduce you to the concept of quality care and describe some of its key aspects before we further dig deeper into the subject in the upcoming episodes. Our very first guest is Dr. Joao Breda, which I think is the most appropriate person to tell us.

00:02:48:19 - 00:03:14:00

THANOS MYLONEROS

What we talk about when we talk about quality of care, as he's the head of the WHO office Office on Quality of Care and Patient Safety. Dr. Breda, welcome to our show. 

JOAO BREDA

Hi. Hello. Thank you for having me. 

THANOS MYLONEROS

So, Dr. Breda, I understand that there are quite a few definitions of quality of care and patient safety out there.

00:03:14:00 - 00:03:45:06

THANOS MYLONEROS

How would you describe quality of care to someone that is not much related to health care or health care terminology? 

JOAO BREDA

Well, the truth is that there are quite a few definitions for quality of care. The first attempt in defining what quality of care entails have been identified already in literature several decades ago. These preliminary definitions, they describe more or less health care quality as a systematic effort to increase the possibility of good health outcomes.

00:03:45:11 - 00:04:21:17

JOAO BREDA

Initially, when the definitions were in fact around these aspects of being systematic and being focused on the results and the outcomes and using the best available evidence, which, as you know, it's always evolving and changing over time. However, what changed ever since and I like this and an extremely important aspect of health care, it is adding the element of listening to what the individual patient, the person and healthcare services users perceive as quality of care.

00:04:21:18 - 00:04:50:12

JOAO BREDA

This is very important. This is critically important, I would say. What patients have to say about their own health is as important as a good health outcome and one cannot go without the other. Actually, it's not only about disease prevention and treatment and cure when possible, but it's also about the individual. It's about the experience. It's about in a way of respecting the values.

00:04:50:14 - 00:05:19:13

THANOS MYLONEROS

You mentioned health outcomes. What is a good health outcome? 

JOAO BREDA

A good health outcome presupposes that care is effective. Practice is being always included in all the definitions, which is evidence based, health care and safe, right, which is avoiding causing harm to those who receive their care, which is eventually the most important, really avoiding causing harm. I would like us to stay a bit more on this because this is important.

00:05:19:14 - 00:05:51:07

THANOS MYLONEROS

Can you please elaborate? 

JOAO BREDA

I'll give you an example. Central line associated bloodstream infections were normal and expected in the past. They were very common, but gradually with small, big improvements in the care workflow, in the quality of the procedures, we can eliminate the risk of such infections and there are countries and there are in hospitals, for example, where these type of events have zero or very close to zero.

00:05:51:09 - 00:06:27:13

JOAO BREDA

So in a way, what was once considered inevitable is now highly preventable. WHO also further underlines and comments that in order to realize the benefits of quality health care, health services must also be provided on time. They need to be of the same quality to everyone, regardless of gender, ethnicity, geography, geographic location, income, socioeconomic status and education, and include the full range of health services throughout the life courses.

00:06:27:15 - 00:07:02:02

JOAO BREDA

This is very important because there are many stages and moments in our life where we are more vulnerable. And of course, health problems can arise easily. And quality is eventually even stronger. Growth, they also have to be and it's part of the definitions of quality. That was your question. They need to to be efficient, which is in a way, in a sense refers to ensuring equity by allocating more resources where they are needed the most.

00:07:02:04 - 00:07:37:09

THANOS MYLONEROS

Okay. So if I understand correctly, then quality of care is not just supplementary to universal health coverage, but it seems like an integral component of it. 

JOAO BREDA

Look, I mean. Exactly. Absolutely. You are totally right. If we look carefully to the definition of universal health coverage, it mentions that all people should have access to the full range of quality health services they need when and where they need them without incurring into financial hardship and catastrophic expenses.

00:07:37:11 - 00:08:11:06

JOAO BREDA

So this is very important in the definition of universal health coverage. Quality plays a very strong draw. Care that is unnecessary or inappropriate not only creates more problems than it solves, it can be extremely dangerous. We know, for example, for the fact that low quality health care is increasing the burden of disease and increases the costs. My view, my perspective to the three dimensions of universal health coverage, which are population coverage, range of services and financial protection.

00:08:11:08 - 00:08:42:24

JOAO BREDA

We should actually should have the dimension of quality of care because the lack of quality or even worse bad quality can really undermine all the other three dimensions of universal health coverage. For those not familiar with the term universal health coverage, it means that all people have access to the full range of quality health services they need when and where they need them without any financial hardship.

00:08:43:00 - 00:09:08:05

THANOS MYLONEROS

So, Dr. Breda, would you care to give us an example of how universal health coverage is actually connected to quality of care? 

JOAO BREDA

Let's consider that cancer patients are have access to chemotherapy without any financial burden. Let's imagine that ten of them at some point receive the wrong treatment or the wrong notes. Fortunately, it's relatively rare, but it can happen and it's a matter of also patient safety.

00:09:08:07 - 00:09:44:08

JOAO BREDA

And this in consequence leads to severe health implications that they will in turn affects also their quality of life increase the burden of disease. Obviously, these ten people will also require additional support. That means extra resources and these ones could be used elsewhere and so on and so forth. It's kind of a simplistic approach. Example, I acknowledge that, but I suppose you understand my point that increasing service coverage that important but alone isn't like it to produce better health outcomes.

00:09:44:09 - 00:10:07:15

JOAO BREDA

This needs to be done in tandem by increasing quality at the same time. 

THANOS MYLONEROS

So is that the reason why patient safety is included in the title of the WHO Athens Office?

JOAO BREDA

Well, because I mean, it's a good question. And, you know that quality of care clearly means that it has to be safe. However, there's a small distinction between patient safety and quality of care.

00:10:07:17 - 00:10:31:09

JOAO BREDA

Of course, patient safety focus on preventing adverse events, quality, focus on improving all the aspects that might affect the final health outcome. But they are together and they should be addressed together. 

THANOS MYLONEROS

And what does it take to improve quality of care? Do we need a lot of resources? 

JOAO BREDA

Maximizing quality perimeter does not necessarily equal better outcomes. 

00:10:31:09 - 00:11:04:16

JOAO BREDA

We need to always contextualize and understand when and where an improvement is optimal. An example state of the art surgical equipment for caesarean sections does not necessarily mean improved quality of maternal and neonatal care because the risk is higher compared to normal delivery. The cost is higher as well. The decision to proceed with this operation might be supported by the providers financial motives and the mother might be poorly or not at all informed about the risks.

00:11:04:18 - 00:11:52:00

JOAO BREDA

And this is a very common situation for fortunately in our region. 

THANOS MYLONEROS 

So this contextualized support. You mention this is the work of the office, right? 

JOAO BREDA

This is where we come in to really revisit aspects of quality supporting countries in addressing the classic challenges around quality of care. At the same time, so focusing on quality assurance, quality improvement, but also moving into far less, less rights based health care, making sure that patient has not only a strong voice but is part of the process in that process of co-creation, not only decision making, but that capacity to design the system in a way that improves society as a whole.

00:11:52:04 - 00:12:47:04

THANOS MYLONEROS

This is very interesting. Actually, I recall that in an episode of Health and Europe podcast series by WHO/Europe, where you were invited to talk about quality care, you mentioned that quality of care has been dormant for many years. I guess the establishment of the Athens office proves that this is no longer the case, right? 

JOAO BREDA

Well, absolutely. I mean, the quality kind of was always and of course, within the concern and and the policies implemented in generally in most of the countries and but it became a subject that in a way was not so much on the agenda, was not so much in fashion and was although there was still an interest from the different

00:12:47:04 - 00:13:30:02

JOAO BREDA

stakeholders to ensure that quality is is is part of the discussion. I would say that in terms of prioritization, the European region was very good some decades ago and then it sort of disappeared from the main discussions. And I think and here I have to pay justice to our regional director that with with Hans Kluge was really very decisive in terms of bringing this back to the agenda and really discussing with the with our partners, notably the many member states and particularly the Ministry of Health in Greece, that it was capable of in a way recentering the discussion a bit around quality of care.

00:13:30:02 - 00:13:54:13

JOAO BREDA

And we are very proud and humbled and grateful to be part of this sort of exercise, which is bringing, in our view, innovation and is putting quality again and in in a position that in a way I think it deserves.

00:13:54:15 - 00:14:22:14

THANOS MYLONEROS

I know that the office has been operating for less than two years now, almost two years, if I'm not wrong. What are some key achievements until now and what should we expect from the office from now on? 

JOAO BREDA

Yeah, I mean, I think that we in this basically 24 months, we already covered a lot of ground. We developed collaboration with more than a dozen countries in a very intensive way.

00:14:22:16 - 00:14:51:24

JOAO BREDA

Countries, boards from the southern part of the Jubilee to a Libyan region, also reaching out to Central Asia countries. In recent weeks with work very directly with countries like Albania and North Macedonia, also working here in Greece and and many other more. So as I said, more than a dozen and increasing. So I think that I would like to maybe underline that as one of our greatest successes.

00:14:51:24 - 00:15:16:17

JOAO BREDA

And countries are reaching out agencies of quality. You know, people working in patient safety are reaching out to our office on a daily basis almost because we are starting to be better known and we are starting to we are able to provide support at the moment that people need and we are creating the networks. So there are some really interesting projects.

00:15:16:17 - 00:15:36:05

JOAO BREDA

So I think people should watch this continue to watch as in the future. 

THANOS MYLONEROS

Well, that was an informative discussion and thank you, Dr. Breda, for being here with us and looking forward to talk to you again. 

JOAO BREDA

Thank you very much. I would be delighted to do that. Thank you for having me today. 

THANOS MYLONEROS

Thank you.

00:15:36:07 - 00:16:29:12

DAVID BARRETT

This was The Fourth Dimension, a podcast developed by the WTO Athens Office on Quality Care and Patient Safety, supported by the WTO Regional Office for Europe. I'm Thanos Millionaires. See you again next month. But that was the first episode of The Fourth Dimension, a new monthly podcast brought to you by W.H.O. Europe. We extend our heartfelt appreciation to the producer and host of the fourth dimension, Thanos Merlin Millionairess.

00:16:29:14 - 00:16:58:16

DAVID BARRETT

Now, if you enjoyed what you just heard, we encourage you to subscribe to the fourth dimension from your favorite streaming platform or from wherever you get your podcasts. And from all of us here at Health in Europe and indeed the World Health Organization. We wish you good health.