THANOS MYLONEROS
Hi. Welcome to the Fourth Dimension at - a WHO Europe podcast developed by the WHO Athens Office on Quality of Care and Patient Safety. I'm Thanos Myloneros,and on today's episode, we will look into how quality of care is linked to public health. It is not rare that people, professionals and policymakers distinguish these aspects of health policy as something different. However, they are part of the same spectrum of the organized efforts of our societies to improve well-being all the way from molecules to socioeconomic determinants. Quality of care might extend beyond the narrow walls of health care facilities into the community, and prevention policies and public health has a lot to learn from the ever evolving process of quality improvement. Our guest to discuss this important topic is Dr Válter Fonsec, Health Systems and Quality of care Technical Officer for WHO. Válter has a wide background, from frontline health care to frontline public health policy, especially during the pandemic and from academia and research to healthcare management. That is why I believe he is the best person at the moment to dissect into the connective tissues of quality of care and public health.
Válter, welcome and thank you for doing this.
1:55
DR VÁLTER FONSEC
Thank you for inviting me.
1:59
THANOS: So Válter, having transitioned from the clinical aspect of healthcare services to public health emergency response during the pandemic, and now as a technical officer for quality of care, what do you think there is common between these things and where do they differ? I mean, what are some characteristics that apply both in quality of care and public health?
VÁLTER
That's very interesting. And it… I can go back some years ago and see what is my what was my path until here. at WHO. Indeed. I started as a clinician. I was an internal medicine doctor for some years in, in Lisbon. And I was, you know, my mindset was for individual health. So the patient was is always my first priority. Then I had the chance to to move for a public health environment when I was leading for some years, the Department for Health Care Quality at the Directorate General of Health in the Ministry of Health in Portugal. And there was a statement that changed my life.
A former colleague told me once that if you want to be a great doctor, you will always be working on a 1 to 1 ratio. Okay, you and the patients. But if you want to make the difference, for instance, for 10 million people that are the population of Portugal, you need to work on public health. So this was a game changer. You know, this ratio or perception that things are really different in terms of dimensions. So I was there. It was an amazing time in my life, lots of challenges. And I really learned what was public health about during my daily life with lots of colleagues, different backgrounds that were working towards public health. And it happens that in the middle of this period of my life, COVID-19 occurred. It was very interesting because when we were establishing the ways to go and to fight the pandemics or to deal with it, to manage it, it was actually a bit of a tension between an individual oriented perspective of our sector and the population oriented perspective of the health sector, meaning clinical medicine and public health. And in the end, I think it's all about the two things being highly complementary and not two different worlds without any kind of connections.
5:14
VÁLTER
I remember reading the paper published by David Hunter in the New England Journal of Medicine in 2021, already in the pandemics. That clearly shows that, of course, you have different mindsets and different disciplines in public health and in clinical medicine. But in order to achieve the best outcomes possible, you need to complement the two things. And I think we will talk about it a little in some minutes. And I think one of the best ways to bridge these two worlds is through quality of care.
THANOS
I don't know why some people or some professionals think that these are not complementary, I believe it was Martin McKee who said that public health is from molecules up to determinants and you name it, on how we organize our society. So it's all the spectrum. And that includes as well quality of care. I mean, I will quote now another professor, Sandro Galea, who, uh, said that as an example in public health, if we think of it as a soccer game. Right? And I know in Portugal you like soccer. It's probably, in Greece as well. So, in soccer, if it's public health the field, then the goalkeeper is healthcare and doctors and medical services. Once the ball is in their area, it's already a bit too late. And defense is what we do as all this to limit and reduce the risks. And then the offense is all the things we do as a society to promote health and well-being. Where do you see quality of care fitting in that picture in this soccer game?
7:20
VÁLTER
That's a lovely analogy. It's very interesting because it's very visual. You can clearly see that you have a path starting from you as a person without any kind of risk factor or any kind of sickness or disease, and then you are moving until you eventually have some problem with your health and you need to go for the services. So I think usually or let's say the classical way to see the health sector and the society in in a way it's connecting with the health is public health. Then you have the system and then you have clinical medicine. So you have these kind of three layers that you can use from the broader components
8:10
involving many sectors economy, transport and education, social measures and so on until clinical medicine. So I think quality of care is actually the path in which you can apply some principles that are the principles of quality of care in order to everything that you do in, in, in the health sector is engaging with these principles. But let me be a bit more specific. So quality of care can be seen in two perspectives. One is as a goal. So all the systems and services in the health sector needs to work towards high quality standards, which is usually the more
9:01
simple and straightforward way to see quality. But what can we learn with quality of care? We also learned that quality of care is about ensuring that the practices are effective and evidence based, ensuring that everyone is safe and ensuring that we actually attain people's needs and expectations. So I don't know better principles to apply in everything. So I think when we look for quality of care and we actually learn that quality of care is about
9:38
putting these three things as foundations of everything that we do in the health sector. It's not only about the services, it's also about the measures you apply in public health is also about the reforms you do in the health system. So if we just focus on these, quality of care becomes both a goal but also a framework to improve.
10:12
THANOS
So in in quality care, there are processes and procedures that you clearly identify what is working and what not. And then you revisit and then you try to improve some elements and so on.
10:28
Where do you think this could apply in public health policies as in clinical environment?
VÁLTER
Yes, that's a very good good question. And again I think sometimes we we look for quality of care as a thing of clinical care when a patient is already too late as in the analogy in the primary health care center or the hospital and we look for public health as measures for the country at the national level, for all the population and so on. We … as two completely different things. And they are not actually and regarding your question, quality of care is not only about procedures and processes. That is a classical way to look for quality of care.
11:18
And sometimes it's a bit boring. Yeah, but quality of care is not boring. It's really interesting. And why? Because the main principle of quality of care is not processes and procedures is a learning culture. So when we work through quality of care principles, what we are doing is first let's see what are the best practices that we can implement. And let's be sure they are evidence based. And then let's implement together with those practices a way to see if this implementation is actually making the difference. And considering the results of the implementation, we can adapt, adjust and do better the next time. So this - I'm basically talking about the quality
12:08
improvement cycle that was firstly uh put forward in the 50s by Deming - but this can be easily applied to public health measures. So if we want to apply any kind of measure and on public health rules or regulations or whatever, if we follow these kind of principles and we assure that we will implement evidence based practices, we will have a way to monitoring them and then to do something better next time.
12:51
VÁLTER
Care provision nowadays is not facility binded, meaning that we are increasing the settings in which we are providing care. So when we talk about safety, it's also when a person is receiving home care is also when a person is just having a smartphone in his or her hands, looking for some information about health. All of these settings that sometimes are called care without an address needs to be. Also, think of when we talk about quality of care in these principles. So as long as we are providing technical support for many countries in the regions to embed
13:41
health reforms and to drive positive transformations for health systems following quality of care principles. We are at the same time working again together with frontline workers to improve quality of the services, but also at the policy and system level to ensure that system follows this drive driving force. For instance, we we will publish shortly a state of the play around quality of care and patient safety in the European region. And we will have, for the first time, some data on how different countries are moving in this direction.
14:39
THANOS
What you would consider like quality of care and patient safety in the primary care level and the community side as you mentioned in the home care. That's very interesting because we are still in an era in in which quality of care is usually easier to talk about in the hospital sector. It's more…
VÁLTER
Exactly it's a more classical approach. So it's about the guidelines, about patients that are going, uh, undergoing surgeries and hospital associated infection. So many of the things around quality of care classically are coming from the hospital environment. But regarding safety if we look for the figures that WHO has on patient safety, we find we found out that it
15:29
actually in the primary healthcare settings, there are many things arming patients and when we look for primary health care, one of the biggest challenges is diagnostic errors and medicine safety. It's not about surgeries or hospital associated infections, but things that are connected to the way you are being diagnosed and to the way you manage. And you take the medicines that were prescribed to you. So if we look for the data, we can we can clearly see that, for instance, it is estimated that around 80% of the patient safety incidents in this kind of settings are preventable. This is a huge number. So it shows that we have many things to do and to improve in the community settings as well.
16:32
THANOS
So what we're talking about is how? Because in in the phrase quality of care, it is implied that someone is already patient. But actually it's also linked to people that are not sick yet. So on the prevention side, on the soccer game, quality of care goes pretty in the middle.
VÁLTER
I mean, it goes yeah, in the middle of yeah, I think quality of care starts at the beginning and and probably not. It is very easy to to explain that. For instance, when it when we talk about screenings, for instance for cancer or when we do uh strategies regarding immunizations, quality of care is there. And it's straightforward to think on it because we of course need need effective measures. The screenings, the the vaccines needs to be safe. And of course, we are trying to attain specific needs of the population. So it's also people centered it.
17:38
But quality of care can begin even before when we talk about health promotion and and disease prevention. Because as as you mentioned before, when it comes to communication, health literacy, lifestyle, all that needs also to follow these kind of principles. So this is not only about when, you know, the ball is already near the the goal mark. It's way before it.
THANOS
So it's like when these rare occasions when the goalkeeper puts a goal on the other side.
VÁLTER
Yes. That that will show, for instance, for instance, that that quality of care is everywhere.
THANOS
And before we close, I would also like to ask you, where do you think they should? There is plenty of opportunities regarding the collaboration between the professions of public health and professions. More on the clinical side. How could they learn from each other?
VÁLTER
That's very interesting. Uh, and I think we talked in the beginning that, uh, there is still this idea that we have two separate niches. One is public health and the other one is clinical practice, let's say like this but actually when we look, for instance, for cardiovascular diseases, it is very clear that both sides contribute
19:12
usually to improve um, health outcomes for cardiovascular diseases, because it's not only the drugs or the procedures that you do in the hospital when you have a myocardial infarction, but also also the strategies to quit smoking regarding salt reduction in the diet, uh, physical, uh, exercise and so on. So both things are trying to with different strategies
19:46
to achieve the same objectives, because we are always talking about improving health outcomes and the quality of life of our citizens. So I think quality of care can be a touching point, a common place in which we can bring people with different backgrounds and different perspectives, population perspective, individual perspective to have a common understanding and work together for the same ultimate goal.
20:23
THANOS
Well, it's been an amazing discussion. I don't know if you have something else to add before we we close this episode.
20:33
VÁLTER
No, I think just the point here is that quality of care should actually be seen. As for me, of course, as a as a policy framework to do better for the health sector. And not only, you know, a small office in a hospital dealing with procedures.
THANOS
Nice. Thanks a lot for doing this.
VÁLTER
Thank you Thanos.