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International collaboration: harnessing differences to meet common needs in improving quality of care
  1. Sheila Leatherman,
  2. Liam J Donaldson,
  3. John M Eisenberg
  1. Judge Institute of Management Studies, University of Cambridge, UK and School of Public Health, University of North Carolina, USA sheila_t_leatherman{at}
  2. Chief Medical Officer, Department of Health, Richmond House, London SW1A 2NS, UK
  3. Director of the Agency for Healthcare Research and Quality, Rockville, Maryland 20852, USA

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    A growing number of countries worldwide are recognising a common need to build systemic capacity for safeguarding and improving quality of health care. Each country has a unique set of priorities and dynamics driving the speed and the substance of the quality agenda, constrained by the reality of the availability and distribution of resources. While acknowledging the considerable variation in context between countries, it is imperative to explore the role for, and potential of, cross-national collaboration to advance our common goals regarding improved performance in health care quality.

    Often the conventional basis for collaboration is a perception of similar need and/or convergent initiatives. As useful as such collaboration may be, building a partnership on common needs but different initiatives may be more useful. It could build on the complementarity of experience and expertise, as well as the commonalties. Divergent legacies and orientations may point to the richest areas for learning through cross-fertilisation to facilitate transfer of insights and expertise.

    One example of binational collaboration, building on both common challenges and different solutions, is the emerging repertoire of partnerships between the USA and UK in health care quality. These two countries, with stark differences in their health care systems, easily recognise their commonality of need as quality becomes a prominent focus of national health policy.

    Identifying commonality of experience and need

    Collaboration between the UK and the USA derives from the understanding that there are significant areas of convergence and divergence. In both these countries, as well as a growing number of others worldwide, the following dynamics are influencing the quality movement: increasing evidence of widespread problems in quality of care; attention to the gaps between research and practice highlighted by evidence-based medicine; increasing concern of the public about the quality and safety of their care; heightened debates regarding the role of professional self-regulation versus external oversight or government regulation; and pressures for investment in the infrastructure required to systematically improve care (e.g. information technology). Propelling the quality agenda in both the US and the UK are the growing number of movements at the citizen level which are nominally patient-centred in the UK and consumer-orientated in the US, but both focused on shared decision making and divested authority by health care professionals. In both countries accountability has become a part of routine discourse, though questionably yet a part of consistent execution in either.

    Harnessing complementary experience

    The USA and UK provide an interesting case study of how health systems can learn from one another—in fact, how the dramatic differences in structure, ethos, and resources which have predisposed the countries in contrasting directions provide a fertile basis for cross-learning.

    Building systemic national capacity to remedy and improve quality in health care requires coordination and integration of activity at four levels:

    • national policy formulation;

    • national and system level infrastructure for monitoring and oversight;

    • system level governance and operational management;

    • clinical provision of services.1

    The US and the UK exhibit strengths in different levels. The UK has produced exemplary national policy, created new infrastructure (such as the National Institute of Clinical Excellence and the Commission for Health Improvement), and designed functions for system level management and monitoring such as the National Service Frameworks and the National Performance Framework. These accomplishments derive from the monolithic structure of the NHS where policy, processes, and resources are more readily aligned. The USA is recognised internationally as a leader in quality measurement and reporting approaches, a strength largely explained by its market approach to the delivery of health care with a concentration of quality efforts at the level of corporate governance and operations management. The most powerful role of government in quality is that of purchaser (through the Medicare programme), with its ability to require compliance in order for providers to qualify for payment. The national commitment to developing quality measurement and improvement strategies for both public and private sectors is manifest in the re-authorisation and renaming of the Agency for Healthcare Research and Quality. Likewise, the decentralised market system in the US has driven significant investment in informatics and information technologies. Although the primary motivation has generally been to maximise revenue through improved electronic accounting and billing systems, a secondary gain is that these systems can facilitate expansion and diffusion of quality measurement and improvement initiatives. This potential for building quality improvement on information technology has been demonstrated in those few US institutions that have taken advantage of the opportunity.

    Recognition of such complementarity of expertise and experience has resulted in Anglo-American collaboration. Assisted by The Commonwealth Fund (USA) and The Nuffield Trust (UK) and facilitated by two annual meetings of leaders from both countries at Ditchley Park, UK, agreements are being completed to pursue work in mutually identified priority areas. Among the areas targeted for collaboration are national quality reporting, informatics, and patient safety and adverse event/error reduction. The first—national quality reporting—is a prime example of complementary experience where the UK has developed the template for a national approach while the USA has developed significant expertise in measure development and has had a fitful experience in the public disclosure of quality performance data.2 In the second area, that of medical informatics, Dr Detmer's paper in this issue of QHC reinforces the point that “the national differences have resulted in complementary strengths” in information technology at the same time as both countries face common challenges in policy issues such as capitalisation of their information technology needs, data standards, privacy, and confidentiality.3 The third area is that of adverse events and medical errors; optimising patient safety has attracted substantial public and press attention, and both governments have labelled patient safety as a priority. In both countries significant new reporting systems have recently been recommended45 and the proposed approach for the NHS is the subject of Lucian Leape's editorial in this issue of QHC.6

    Above and beyond the specific areas noted, the policy, managerial and academic leadership at the Ditchley Park conference unanimously agreed that a major challenge for the state of the art is to improve the evidence basis for the effectiveness of interventions to improve quality. Despite some investment in evaluating the scientific basis for health care quality measurement and improvement in both nations, much remains to be learned, especially in translating the research into practice and policy. The evidence base is insufficient and/or equivocal in evaluating the strengths and weaknesses of critical levers for change such as professionalism, regulation, financial incentives, performance feedback, and governance.

    Advancing multinational collaboration

    Recognition of both the commonality and complementarity of experience and expertise can provide a foundation for international collaborations. Three compelling arguments for organised international collaboration can be put forward. Firstly, the field of quality evaluation and improvement has universally applicable goals, methods, and intended outputs. Secondly, because the necessary research and development is resource intensive, technology transfer and expertise sharing are desirable. Thirdly, fair and valid international comparisons are possible only through formal international cooperation.

    To provide support for international collaboration, a more systematic assessment and sharing of the experience and expertise of various countries will be valuable. Binational collaboration, such as that emerging between the US and the UK, as well as multinational collaboration such as that orchestrated by the World Health Organization, will need more than periodic conferences. It will require development of shared languages of measurement and evaluation, implementation of complementary programmes in each nation in keeping with its national character and its health care culture, and long term commitment to maintaining programmes for mutual benefit.


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