Healthcare 2050 position paper

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A vision of safer and smarter health services


CONTENT Introduction........................................................................................................................................ 4 Our vision of healthcare............................................................................................... 6 Healthcare in 2050................................................................................................................. 7 No one left behind – a global reality by 2050................... 11 The main challenges for safer and smarter healthcare.......................................................... 12 The growing burden of physical chronic diseases.................................................................................. 12 The growing burden of dementia......................................................... 12 The changing needs of an ageing population............... 12 Unsustainable costs........................................................................................................ 13 Unequal access....................................................................................................................... 14 Unsafe care.................................................................................................................................... 14 Climate change...................................................................................................................... 14 The demand for new service patterns............................................ 15 The obstacles preventing the transition to safer and smarter healthcare............................................................. 16 Healthcare does not know how to achieve sustained system improvement................................ 16 Fragmented organizations................................................................................. 16 Perverse financing............................................................................................................. 17 Underutilization of ICT............................................................................................... 17 Naïve view of ICT................................................................................................................. 17

Ethical and legal hurdles....................................................................................... 17 Shortage of healthcare workers................................................................ 18 The strategic agenda for safer and smarter healthcare......................................................................................... 20 Value and risk thinking.............................................................................................. 21 Priorities for research on organizational quality improvement to create safer and smarter healthcare......................................................................................... 22 Use of knowledge-based, international standards and accreditation processes to reduce variability and improve the patient experience........................................................................................................ 22 Changing culture and mindsets to build a foundation for sustainable seamless services............................................................................................................ 23 Improving assurance and predication of quality through smarter data analysis................................ 24 Safety cases for healthcare................................................................................. 24 Conclusion...................................................................................................................................... 26 About the authors and contributors.................................................. 28 Endnotes............................................................................................................................................ 30

EXECUTIVE SUMMARY Everyday around the world millions of people are treated and cared for by health services successfully. Yet we face major challenges to the delivery of high quality care. Ageing populations, emerging disease patterns, climate change, rising costs, inequitable access and an unenviable safety record mean that business as usual is not an option. In this position paper, we analyze the challenges and obstacles that healthcare faces. We set out a vision for healthcare in 2050 and a strategic agenda for realizing that vision. In support of that agenda, we have identified four strategic research themes that build on DNV GL’s proven services and where we will focus our research and innovation to add value:

¾¾ Using accreditation and standards to promote person-centered care, reduce variability and improve quality. ¾¾ Creating cultures and mindsets that embrace continuous quality improvement. ¾¾ Improving quality assurance and risk prediction with smarter data analysis. ¾¾ Developing safety case methodologies to manage risk locally. We welcome the opportunity to work with others in supporting high quality healthcare.

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INTRODUCTION DNV GL has worked with high risk sectors to safeguard life, property and the environment for 150 years. We are committed to building partnerships with others to improve the quality of healthcare by sharing the learning from our experience. In the position paper, we set out a vision for what a safer and smarter healthcare sector should look like by 2050. We identify the global challenges that we have to solve and the obstacles we face, which, individually and collectively, pose major foreseeable hazards to realizing that vision. From our analysis and synthesis, we suggest a potential strategic agenda as well as priorities for research in quality improvement to help organizations overcome the hazards.

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“Healthcare is highly complex and delivered in demanding and pressurized environments. Understanding the key challenges we face and, most importantly, how to manage the risks that these present is paramount to providing safer and sustainable care to patients" Karen Timmons Global Healthcare Business Director, DNV GL

“The potential for safety critical sectors to learn from one another is great. Together we can redefine the scope of safety and quality in healthcare” Stephen McAdam Global Healthcare Technical Director, DNV GL

“We must engage with the system risks to delivering healthcare if we are to achieve sustainable value for service users and society” Morten Pytte Head of Healthcare Programme, DNV GL Strategic Research and Innovation

"In DNV GL we live and breathe risk management. Throughout our history we have combined cutting edge research with risk thinking to help organizations safeguard life, property and the environment. This position paper draws on that experience and is a contribution to the on-going discussion on how to improve quality in healthcare” Rune Torhaug Director, DNV GL Strategic Research and Innovation

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OUR VISION OF HEALTHCARE Healthcare should be free from preventable harm, personalized to individual needs, seamless in its delivery and with equitable access. In this way healthcare will be safer, smarter and person-centered and it will support each of us in achieving our maximum well-being (see figure one).

INDIVIDUAL WELL-BEING Populations and differences across groups

Quality of life Health status Work-life balance Education and skills Social connections Civic engagement and governance Environmental quality Personal security Subjective well-being

Material conditions Income and wealth Jobs and earnings Housing

SUSTAINABILITY OF WELL-BEING OVER TIME Requires preserving different types of capital Natural capital Economic capital

Figure 1: Components of well-being (source: adapted from OECD1)

Human capital Social capital

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HEALTHCARE IN 2050 Healthcare in 2050 will be characterized by the four P’s: prediction, prevention, personalization and participation2. It will be possible for each of us to have a whole life health plan that combines health promotion and early intervention based on our individual risk factors. The plan will be guided by health coaches who will support us in learning to take healthy choices throughout our life and in making best use of healthcare services. Although technology alone will not solve the challenges healthcare faces, increasing power and lower costs of technology3, particularly genome sequencing4, will enable earlier intervention based on our personal risks. For example, we will interact with our health coaches through mobile technology using applications to show us how to maintain or change to healthy behaviors. Each of us will have the option to monitor our health in real-time using a transcutaneous sensor. If our readings deviate from expected ranges, we can select settings that enable our health coaches to provide rapid intervention to modify our behavior before lasting harm occurs or to guide us to further services that can help restore us to health or enable us to live with a chronic condition. Our transcutaneous health sensor will link to additional applications and services. When we are exercising, the sensor will connect to applications that will tailor our activity to meet our needs and abilities; when we are at the supermarket or shopping online, the sensor will connect to ‘smart shelves’ that will prompt us to choose healthier food and products. The use of personal sensors will be just one example of healthcare forming new partnerships with

information and communication technology (ICT) sectors. Service users will be able to share their experiences of healthcare to compare provision and choose the optimal provider; automated semantic analysis of comment feeds will enable the early detection of quality issues and rapid action. Crowd sourcing, cloud networking and faster data processing will enable the collection and analysis of data in real-time: driving models of research away from traditional randomized controlled trials with small samples and limited timeframes to large scale and continuous evaluations that enable more efficacious drug design. Our homes, workplaces and leisure venues will become part of an interconnected network of monitoring replacing traditional models of screening and surveillance that rely on an individual visiting a medical facility. For example, our mirrors at home will be able to detect changes in body shape and skin condition and alert us to early warning signs, such as potential cancers. There will be fewer hospitals, which will have lower costs due to reduced wastage and more targeted treatment. Hospitals will be centers of excellence providing care to those with the acutest level of needs. If treatment is needed much of this will be at genetic and cellular levels: modifying gene sequences to arrest mutation and using nanotechnology to make cellular repairs. Where people are living with chronic conditions, much of the care will be delivered in the home or other location through telemedicine: empowering people to live fuller lives in the environment of their choice. Health will move from being the province of specialist organizations to become everybody’s business. This diffusion will be reflected in greater integration with other sectors to deliver health in its broadest sense: physical, psychological and social well being and not merely the absence of disease.

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Figure 2: Quality dimensions (source: Rasmussen, Jørgensen and Leyshon7 adapted from National Research Council8)

Other sectors will be judged on how they work with healthcare and others to contribute to the health of individuals and populations. For example, new business plans will include how a proposed company or service will improve the happiness, independence and productivity of its workers and customers; schools and colleges will include physical, social and emotional health promotion in curricula across compulsory and post-compulsory years; the building sector will have to demonstrate how each new build contributes to wellness (e.g. through low emissions, encouraging active living, and incorporating shared community resources that engender social capital)5.

use of not only when we are ill but also to prevent us from becoming unwell6.

To support this diffusion further, wellness centers will be embedded in their local communities, providing life-skills training, exercise and relaxation as well as access to doctors, nurses and allied health professionals. Wellness centers will become a combination of learning hubs and spas that we make

In realizing the above, healthcare will deliver the quality dimensions set out in figure two.

As we age, a combination of personalized prevention plans, rapid interventions to stop or slow deterioration, integrated services and support from health coaches and telemedicine will assist us to live longer in our own homes. When it does become necessary to move to supported care, this will be to facilities that are within our local community: enabling us to maintain links to friends and family and to make use of the full range of leisure and learning resources.

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NO ONE LEFT BEHIND – A GLOBAL REALITY BY 2050 Our vision of care that is safer, personalized to individual needs, seamless in its delivery and with equitable access will be for everyone whether from high, middle or low income countries9. How this vision will be put into practice will be different according to local needs and resources. For example, cheaper, more portable basic ICT, with greater reach, will enable the spread of best practice to poorer remote areas with historically limited access. Mobile electronic healthcare and telemedicine (mHealth for short) is increasingly recognized as having the potential to transform the face of health service delivery across the globe10, not just in wealthy nations. According to the International Telecommunication Union11, in developing countries, the number of mobile-

broadband subscriptions more than doubled from 2011 to 2013 (from 472 million to 1.16 billion) and surpassed those in developed countries in 2013. Furthermore, Africa is the region with the highest growth rates over the past three years and mobilebroadband penetration has increased from 2% in 2010 to 11% in 2013. If this trajectory continues, then specialists will increasingly be able to assess and prescribe treatment remotely to individuals living in communities with limited resources: improving equity of access to hard to reach locations12. One health need in which the targeted use of specialist advice via mHealth could be coupled with low tech, inexpensive solutions to have a big impact is child mortality13. Every year around the world over a million children die due to complications of preterm birth. Over 60% of pre-term births are in South Asia and Africa. Yet morbidity and mortality from premature birth can be reduced with simple measures combining assessment and advice aimed at those with the highest risk factors (e.g. hypertension and diabetes). Even with a nascent, albeit rapidly growing, mHealth field in Africa14, the spread of such technology to support local health advisors15, could enable efficient and effective antenatal care for those in most need.

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THE MAIN CHALLENGES FOR SAFER AND SUSTAINABLE HEALTHCARE THE GROWING BURDEN OF PHYSICAL CHRONIC DISEASES Chronic diseases are a mounting problem for low, middle and high income countries16,17,18. 36 million people died from chronic non-communicable diseases in 2008, representing 63 per cent of the 57 million global deaths that year. By the year 2030, such diseases are projected to claim the lives of 52 million people19. People living with chronic diseases require long-term treatment, continuous monitoring, supervision and early intervention to prevent further deterioration. Estimates suggest that people living with poorly controlled chronic diseases account for a disproportionately large share of healthcare spending. For example, in the UK, reports suggest that between 2 and 3% of patients with long-term conditions make up 30% of unplanned hospital admissions and 80% of general practitioner consultations20,21; while in the US, over 20% of total annual health expenditure is on 1% of the population22. The major causal factors leading to physical chronic disease and to further deterioration (lack of activity, diets high in fat, salt and sugar, tobacco use and alcohol and drug misuse) are amenable to

change. Unfortunately, healthcare systems today are principally focused on responding to acute illnesses rather than on intervening early to change behavior23. According to the WHO, most countries do not have policy frameworks, quality systems or essential primary care services in place to meet the chronic disease challenge effectively24. The need to focus on health promotion and illness prevention challenges the culture and mindset of existing healthcare and increases the need for new ways of working that address social and psychological determinants of health. THE GROWING BURDEN OF DEMENTIA The global prevalence of dementia is expected to increase from 36 million people living with the condition in 2010 to 115 million by 205025. By 2050, 71 % of people with the condition will be in what are currently low and middle income countries26. This will present a dual challenge for healthcare as service users will increasingly present with combined physical and mental health long-term conditions. THE CHANGING NEEDS OF AN AGEING POPULATION The world’s population is growing older. From 1950 to 2000 the number of people over the age of 60 years old tripled worldwide and, by 2050, it will have

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The world is getting older - population aged 60 or more 2 500 000 2 000 000 1 500 000


1 000 000

More developed

500 000

Less developed

0 1950





Figure 3: Changing global age profile (source: adapted from United Nations31)

tripled again27. This is not just because the world’s population as a whole has grown it is also because people are living longer28. Rapid population ageing is particularly evident in less developed regions figure three. Although the rapid increase in the number of people living longer is a cause for celebration, it will also present challenges for healthcare in a number of ways. Firstly, as population distributions shift towards being dominated by older adults who naturally seek to retire, there will be fewer economically active people in society to pay for healthcare (whether through out-of-pocket expenses, insurance or taxation) and healthcare will consequently have less revenue, which will increase cost pressures (see below)29. Secondly, as the number of people living with long-term physical and mental health comorbidities increases30 along with life expectancy, so more people will be living longer in poor health. Care giving will have to change from a focus on acute episodes of physical illness to meeting the

demands of people with a combination of long-term physical, social and psychological needs. As a result of these pressures, healthcare will have to integrate with social and civil society services to meet the continuing needs of an ageing population in cost effective ways. UNSUSTAINABLE COSTS Spending on healthcare has been steadily growing relative to GDP for several decades. Health and long-term conditions expenditure is projected to continue rising in OECD countries over the next fifty years. Moving from an average of 6% of GDP in 2006-10, the combined health and long-term care expenditure is projected to reach 9.5% in 2060 according to a cost-containment scenario – which assumes that policies, to a greater extent than previously, will rein in some of the expenditure growth32. In a cost-pressure scenario, which does not make this assumption, spending could reach as much as 14% of GDP. Expected increases are even steeper for some of the BRICS countries, going on average from the current 2.5% to 5.3% and 9.8%

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of GDP depending on the scenario33. The failure to manage increasing expenditure is compounded by healthcare’s limited use of methodologies, such as health technology assessment (HTA), to assess the value of new initiatives against their cost34. Healthcare will have to adjust to measures to control spending while meeting growing needs (increasing levels of chronic conditions and ageing populations). Greater individualization based on targeted treatment offers the potential for improved cost effectiveness35. UNEQUAL ACCESS The 34 OECD countries encompass 18% of the world’s population but account for 84% of world spending on health36. This translates directly to access to healthcare. For example, high-income countries have 56 hospital beds per 10,000 citizens whereas low and middle income countries have 21 and 49 respectively37 (p 129). Despite the limited access to resources, an increasing number of low and middle income countries face a developing triple burden of disease38. The prevalence of risk factors for diabetes, heart disease and cancer increases while they still struggle to reduce deaths caused by infectious diseases and malnutrition and new infectious disease emerge39. Women and girls,


in particular, have greater difficulty obtaining quality healthcare because of gender-based inequalities in education, income, employment and access. Healthcare has yet to solve the problem of limited and unequal access. This remains a significant challenge to improving global health outcomes40. UNSAFE CARE It is 15 years since the publication of the Institute of Medicine’s seminal report on patient safety To Err Is Human41. There has been progress on improving the safety of healthcare42 but there is general agreement that the ambitious targets of earlier years have not been met43. Although the priorities are different44, healthcare remains unacceptably dangerous whether in low, middle or high income countries. Of the 421 million hospitalizations in the world annually, 42.7 million are estimated to be associated with some degree of adverse event – this makes unsafe care the “14th leading cause of morbidity and mortality, comparable to the burden from tuberculosis or malaria”45 (p 813). CLIMATE CHANGE Climate change poses a major threat to health and healthcare46. Changes in the earth’s surface temperature, sea level, rainfall and extreme weather

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events will put the well-being of billions of people at risk and challenge the preparedness and resilience of healthcare. The temperature rise is likely to be greatest in higher latitudes (e.g. Greenland, Canada, Scandinavia) but the profound health effects will be felt by those with the least access to resources47.

professionals compared to earlier generations. There is a demand for easy 24 hour access. This is reflected in policy imperatives for greater personcentered and integrated care both nationally (e.g. Norway49, Sweden50, UK51,52,53,54, US55, Canada56, China57, Japan58, Singapore59, Australia60, Brazil61, Oman62, Rwanda63) and internationally64.

Heat waves will cause increased mortality from respiratory illnesses and heat stress in at risk populations. The changes in global temperatures will also affect health through the altered spread and transmission of water and rodent-borne illnesses. Pathogen maturation and replication within mosquitoes, the spread of insects to new geographies, and the likelihood of being infected are all affected by temperature rise: malaria, dengue and tick-borne diseases will become increasingly widespread. Poor nutrition from reduced food availability, the psychosocial impact of drought, and the displacement of communities will have further impact on the demand for healthcare48.

Health systems are putting increased emphasis on primary care, especially through the use of integrated care delivery models, to meet this expectation and to improve the health of the population65. To succeed, these new models will have to extend their reach outside of the four walls of a clinician’s office or hospital66 so that they can support behavior change beyond traditional clinician-patient interactions. This requires new capabilities, including clinical workflow tools to support patient targeting, care alerts sent to clinicians and patients, enhanced communication and care management support for patients, and remote monitoring.

THE DEMAND FOR NEW SERVICE PATTERNS Consumers of healthcare increasingly expect health services to be modeled on other service sectors. People want to be engaged and consulted by their healthcare providers. Many more are better informed and more likely to challenge health

More fundamentally, clinicians must adopt a personcentered approach when they interact with patients, one that focuses on understanding the whole person and their barriers to change and which utilizes active coaching and partnership approaches to bring about lasting improvement in health67.


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HEALTHCARE DOES NOT KNOW HOW TO ACHIEVE SUSTAINED SYSTEM IMPROVEMENT Although many acknowledge the need for healthcare to change and become more integrated and personalized, there is still a lack of practical understanding of how to do this68,69. This extends from the macro to the micro levels of service delivery. How should we proceed, where should we begin, who should make this change come about? Structured improvement is complex and takes time and, unless the conditions for success are in place, is unlikely to achieve set objectives70. Changes to care are stalled by the lack of evidence-based specific recommendations, guides and models for implementation coupled with political inertia71, ideological divisions72 and the inability of politicians to make long-term decisions73. FRAGMENTED ORGANIZATIONS The organization of healthcare is fragmented into ‘silos’: different sectors, disciplines and professions, each with their own logic, routines and incentives. A holistic, personalized approach to healthcare requires improvements in cohesion, coordination

and communication between systems. As Degos and colleagues note, patient safety incidents “… no longer relate only to episodic errors and failures in procedures at specific times, but also to cumulative failures throughout a patient’s journey within a health system”74 (p 84). Significant numbers of healthcare service users report that they feel unsupported and that there are gaps between the different elements of their care75. This fragmentation is driven in a number of ways. Firstly, funding is usually provided to different providers rather than on the basis of integrated pathways: hospitals are responsible for and get paid for one kind of treatment, GPs another and social care through a different budget altogether. Secondly, different healthcare sectors are staffed by diverse groups of professionals with differing cultures and expectations of their role, which reflects disparate educational backgrounds76. To meet the challenges facing healthcare (particularly those arising from ageing populations with chronic physical and mental health co-morbidities) cultural,

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Processes and patterns


Outcomes The results produced

The way in which the system, the actors and the technology within and connected to it behave

How the parts of a system are organized Culture and mindsets What is important to us and how we put that into practice

Figure 4: Culture, structure, process and outcomes

structural and process issues of fragmentation and its impact on quality will have to be tackled from micro (organizational) to macro (national policy) levels77,78 (figure four). PERVERSE FINANCING In the four dominant healthcare funding models (Beveridge, Bismarck, National Health Insurance, Out-of-Pocket), acute care in hospitals accounts for the greatest single spend. For example, in England, nearly half of the total NHS budget is spent on general, acute and accident and emergency hospital services alone79. This incentivizes activity that takes place after a person has become ill and aims to ‘fix’ them, rather than paying services by the result of keeping communities and individuals healthy, happy, independent and productive. UNDERUTILIZATION OF ICT The use of ICT in healthcare is highly variable within and between different countries80. Although its use is growing81, and there is some suggestion that low and middle income countries could overtake high income countries in its adoption82, underutilization

is a barrier because it makes it difficult to target services while maintaining the scale of provision. The effective use of ICT has the potential to transform healthcare if we can increase its use in situations where it will make the most difference (e.g. telemedicine to allow health professionals to monitor large numbers of people, even if in remote locations, which are at high risk of deterioration and to provide directed coaching and interventions). NAIVE VIEW OF ICT The adoption of ICT in healthcare has not always been easy with positive83, negative84,85 and mixed results86,87. Although ICT can be a powerful tool for service improvement, it will not achieve lower healthcare costs and improved quality of life if it is simply added on to existing ways of working88. Rather, a systems approach is needed to ensure a shared vision across providers and to avoid foreseeable pitfalls and ensure sustained benefits89,90. ETHICAL AND LEGAL HURDLES The increasing view of health as everyone’s concern will raise issues of respect for individual autonomy

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vs. paternalistic attempts to protect the collective good91. For example, should transcutaneous health sensors that can be linked to ‘smart shelves’ in shops be programmed to prevent an individual from purchasing food, drink or products that, based on the person’s risk factors, are unhealthy for him or her? This may seem like a theoretical Huxleyian92 nightmare but this is a real public health issue: although people die from myocardial infarctions and cancer, the true causes are poor diet, smoking, alcohol misuse and lack of exercise93 linked to genetic factors94, economic inequality and limited access to education95. The fear of loss of control, whether justified or not, may create resistance to the use of potentially transformational technology. As the use of mHealth and telemedicine grows, providers will no longer need to be in the same country as the people they serve. This will improve efficiency and access to healthcare but it also raises issues of confidentiality. Where will data go, who will see it and what will they do with it? The lack of harmonized and transparent legal standards and remedies for data use may also be an obstacle to their adoption96. SHORTAGE OF HEALTHCARE WORKERS Healthcare workers represent the foundation of an effective healthcare system, but the ability to attract, train, retain, and distribute healthcare workers poses a serious challenge to both developed and developing economies97,98. For example, the gap in supply of human resources in EU healthcare is estimated to be approximately 1,000,000 health workers; this means that almost 15% of the care for the EU population will not be covered99. While Africa has 25% of the world’s disease burden but only 3% of the world’s health workers100. The lack of healthcare workers contributes to increasing socioeconomic and geographic disparities in access to effective healthcare, and will have a negative impact on achieving our vision of safer and smarter healthcare.

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FOR SAFER AND SMARTER HEALTHCARE Our evaluation of the challenges and obstacles leads us to identify seven core components of a strategic agenda for moving towards healthcare that is safer, personalized to individual needs, seamless in its delivery and with equitable access. Each of the following elements is standalone and, therefore, they can be done in any order. The first three are under the control of organizations, whereas the later steps are macro issues that require regional, national or international coordination. As such the first three elements may be easier to implement initially:

4. Incentivize what matters. Focus payments on the results of the full cycle of care rather than on separate treatments. Use finances to drive improvements in quality and public health by moving from an emphasis on the tasks performed by providers to an emphasis on achieving outcomes104 in terms of sustained well-being. This is not about naively reducing financing but, rather, redirecting funding to where it can make the most difference105: translating national targets into local quality improvement106.

1. Improve safety and quality. Using risk based approaches to redesign systems and deliver services will enable hazards to be identified and managed before they become harms101: reducing variability, improving the service user experience, lowering costs and ensuring change has a sustained and significant impact.

5. Integrate care across specialties and providers. Healthcare is not the sole determinant of health107. Care should be built around pathways that reflect the reality of service users with multiple needs rather than episodes in hospital. Health, social care and civil society organizations should be rewarded by how well they work together in supporting individuals and communities in gaining and retaining happiness and independence.

2. Empower individuals to make choices about their healthcare providers by sharing upto-date information on quality in easy to understand formats. 3. Organize care around the individual’s health needs rather than diseases and physicians’ specialties102. A dedicated team of both clinical and non-clinical personnel should support the individual service user by coaching and active partnerships: providing counseling, education, encouraging adherence and supporting healthy behaviors103.

6. Invest in, and capitalize on, the growth of technology (e.g. the ability to use increasingly large and complex data sets through cloud networks, the decreasing costs of genome mapping) so long as it is supported by systems approaches to risk and change management. Using systems approaches will ensure sustainable change and enable technology to be a key element to personalizing healthcare while achieving manageable costs across populations. 7. Invest in climate change adaptation to ensure healthcare is prepared to cope with the impact of changing weather patterns108.

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VALUE AND RISK THINKING The strategic agenda set out above is essential to ensure health systems deliver maximum value in the context of the growing challenges societies face. Value does not equal activity. Simply doing more of the same is unsustainable. Rather, it is about selecting the activities and services that have the greatest demonstrable impact on health outcomes109 (i.e. the well-being of individuals and populations110,111) per unit of currency112. Increasing the value of outcomes relative to investment will require improved productivity and reduced unwarranted variation113. Organizations

have to be able to ‘do things right and the right thing’114. In order to improve safety and quality and reduce variability, policy makers and providers must identify and implement evidence-based practice. To do this they need to engage with the obstacles to the successful redesign of healthcare115. Risk thinking can help organizations make the leap from vision to reality by providing the tools to assess, prioritize and manage situational specific obstacles. The next section sets out DNV GL’s research priorities for developing the future of risk thinking in healthcare.

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ON ORGANIZATIONAL QUALITY IMPROVEMENT TO CREATE SAFER AND SMARTER HEALTHCARE In 1975, JD Wallace, a Canadian physician, set out a series of predictions of what would happen in healthcare in the next 20 years116. Reading his paper in 2014, what is noticeable is how slow the pace of change has been because healthcare has yet to overcome the challenges and obstacles outlined above. In 2050, where will we be? Will we look back on these years as lost decades or will we have achieved the spread and scale of change needed to create a safer, smarter and sustainable future? Reflecting on the challenges and obstacles facing healthcare between now and 2050, it would be easy to feel that change is impossible. But together we can make a difference. Other safety critical sectors, such as oil and gas, have used risk based approaches to achieve significant and lasting improvements117: mapping and monitoring hazards, setting goals, and creating proportional cultural, structural and process controls. In DNV GL’s experience, using risk based approaches can be a powerful way to drive improvements. To that end, from our analysis of the challenges, obstacles and strategic agenda, we have identified the following priorities for DNV GL’s Strategic Healthcare Research and Improvement

(figure five). These build on proven services that manage safety by combining cutting edge research in the dimensions that offer potentially the biggest impact for quality improvement. USE OF KNOWLEDGE-BASED, INTERNATIONAL STANDARDS AND ACCREDITATION PROCESSES TO REDUCE VARIABILITY AND IMPROVE THE PATIENT EXPERIENCE Experience from other safety critical sectors suggests that improvements can be achieved through the adoption of accreditation and standards. Accreditation is a programme of activity in which trained external peer reviewers evaluate an organization’s compliance with pre-established performance standards118,119 that can be applied to specific areas (such as managing infection risk120) or across an organization’s services121.

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Creating smarter and safer healthcare together Developing safety cases to manage risk locally Improving assurance and prediction of quality with smarter data analysis Creating cultures and mindsets that embrace continuous quality improvement Use of accreditation and standards to reduce variability and improve safety

Figure 5: Combining proven services to manage safety with cutting edge research themes to create safer and smarter healthcare

These iterative processes help an organization to drive best practice in: ■■ Mapping processes (including how processes connect within and between organizations); ■■ Identifying and assessing risks to human, technological and organisational safety and performance; ■■ Establishing prevention and mitigation controls to deliver safe and reliable results; and ■■ Continuously monitoring to evaluate the efficacy of those controls. Healthcare has begun to develop a similar evidence base. For example, data from the EU-wide MARQuIS project suggest that organizations “… that have either ISO certification or accreditation [i.e. organizations that work to objective standards] are safer and better than those which have neither …”122 (p 449). And Alkhenizan and Shaw, in their systematic review, conclude “… that accreditation programs improve the process of care provided by healthcare services … Accreditation programs should be supported as a tool to improve the quality of healthcare services”123 (pp 410-411).

If further improvement in healthcare is to be realized then accreditation and standards must be at the forefront of pushing that change. Knowledge-based, international healthcare accreditation and standards can challenge healthcare to become safer, smarter, sustainable and person-centered while coping with the local contextual demands. CHANGING CULTURE AND MINDSETS TO BUILD A FOUNDATION FOR SUSTAINABLE SEAMLESS SERVICES Improvement initiatives involve humans in complex social settings. Healthcare is perhaps the most complex as it takes place through a series of interacting clinical (micro), organisational (meso), and regional/national/international (macro) systems. Healthcare does not lack ideas, interventions and examples of successful improvement. It does struggle, however, with achieving scale and spread because not enough consideration has been paid to addressing the underlying culture of those working within the systems124. Understanding the cultural norms and mindsets that drive or impede change is essential if sustained improvement is to be achieved125,126. Positive cultural characteristics

Competitive advantage

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What’s the best that can happen?

Predictive modeling

What will happen next?


What if these trends continue?

Statistical analysis

Why is this happening?


What actions are needed?

Query/drill down

Where exactly is the problem?

Ad hoc reports

How many, how often, where?

Standard reports

What happened?


Access and reporting

Degree of intelligence

Figure 6: Business intelligence and analytics (source: Davenport and Harris129 p 9)

include enablement of cross-functional teamwork, support for pooled knowledge, creation of an urgent need to innovate, and sustained focus on the change127. More work is needed to support healthcare organizations in understanding their culture and in changing it to create the structures and processes that will deliver improved outcomes, particularly as organizations integrate to create flatter structures and provide the seamless services that consumers demand. IMPROVING ASSURANCE AND PREDICATION OF QUALITY THROUGH SMARTER DATA ANALYSIS Organizations that aim to be safer and sustainable will have to make better use of data to identify their needs and understand how they can overcome obstacles to quality. Analytics is one means to achieve this. It is a subset of business intelligence: i.e. methodologies and processes that analyze, synthesize and communicate data in an accessible way that helps an organization to understand and improve its performance128. The potential advantage of analytics is that it can help organisations move from simply collecting data to the use of such data

to predict, manage and optimize its performance (figure six). Healthcare, like other sectors, has an abundance of information. Terabytes of data are collected everyday by healthcare organisations around the world. This includes patient specific information (e.g. test results and prescriptions), as well as the way healthcare systems are managed and the outcomes they deliver. Unfortunately, healthcare has been slow to make use of these data in ways that enable it to combine information to predict the antecedents of risk with confidence and to improve performance. The processing potential of information technology and the technical ability to share data between organizations, coupled with the imperatives for change outlined above, means that there is an opportunity to capitalise on the value of analytics for healthcare. SAFETY CASES FOR HEALTHCARE Many of the failures in patient safety have been attributed to the way safety is managed in and across healthcare organisations. Safety critical industries

Healthcare 2050: A vision of safer and smarter health services  25

(such as nuclear, aviation or offshore oil and gas) could provide better models for healthcare to manage risk130. Most of these safety critical industries have changed the way they manage safety. They no longer simply act reactively in response to major incidents. Much of their effort is proactive and predictive: to manage risks that have not become manifest but are potentially deadly.

body of evidence, which provides a comprehensible and valid case that a system is acceptably safe for a given process in a given context. This incorporates both retrospective analyses of incidents as well as prospective assessment of risks to demonstrate that risks are reduced to a level that is ‘As Low as Reasonably Practicable’.

Several industries have taken the initiative to collect all their safety activities together in the form of a Safety Case. The purpose of a safety case is to construct a structured argument, supported by a


26  Healthcare 2050: A vision of safer and smarter health services

CONCLUSION Healthcare faces significant problems. Ageing populations, emerging disease patterns, climate change, rising costs, inequitable access and a poor safety record mean that business as usual is not an option. But change is possible. Together we can make it happen. DNV GL is committed to using its 150 years of experience in risk based approaches to help organizations deliver high quality services for all. In this position paper, we have analyzed the challenges and obstacles that healthcare faces. We have set out a vision for healthcare in 2050 and a strategic agenda for realizing that vision: ■■ Improving safety by using risk based approaches to redesign services. ■■ Empowering individuals to make choices about their healthcare as active partners. ■■ Organizing care around the individual’s needs rather than diseases. ■■ Incentivizing what matters by focusing payments on results and not activity. ■■ Integrating care across specialties and providers. ■■ Investing in technology so long as it is supported by systems approaches to risk and change management. ■■ Investing in climate adaptation.

In support of this agenda, we have identified four strategic research themes that build on DNV GL’s proven services and where we will focus our research and innovation in the immediate future: ■■ Using accreditation and standards to promote person-centered care, reduce variability and improve quality. ■■ Creating cultures and mindsets that embrace continuous quality improvement. ■■ Improving quality assurance and risk prediction with smarter data analysis. ■■ Developing safety cases to manage risk locally. We welcome the opportunity to work with others in undertaking this research and to discuss further how we can make healthcare safer and smarter together.

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28  Healthcare 2050: A vision of safer and smarter health services



Deputy Head of Programme and Principal Advisor in Patient Safety, Healthcare, DNV GL Strategic Research and Innovation

Head of Programme, Healthcare, DNV GL Strategic Research and Innovation

Stephen Leyshon MSc (Lond), MA (Lond), PG Dip (Lond), RN, DN, FHEA

Stephen Leyshon joined DNV GL in 2011, where his responsibilities include managing applied research into person-centred care and risk management. Prior to this, he was the Clinical Lead for Primary Care and Ambulance Services at the UK’s NHS National Patient Safety Agency, working nationally and internationally to develop practice and policy to manage risk and improve the safety of care outside of hospital. A Registered Nurse, Stephen has over 20 years of experience in healthcare and his previous roles include Health Services Manager, Lecturer in Health Policy and Ethics at King’s College London, Research Fellow in Primary Care at King’s College London (a shared appointment with University College London), and LecturerPractitioner.

Morten Pytte PhD, MD

Morten Pytte joined DNV GL Research and Innovation in 2011 where he is now the Programme Director for the Healthcare programme. Morten is a physician by training specialised in anaesthesia and intensive care medicine with more than ten years of clinical experience. Besides anaesthesia and intensive care Morten’s clinical expertise is on sudden cardiac arrest and resuscitation. Between 2005 and 2009 Morten did clinical and experimental research on cardiopulmonary resuscitation and finished a one year fellowship at the Weil Institute of Critical Care Medicine in California in 2007-2008. -–––––––––––––––

Tita A. Listyowardojo PhD, MSc


Eva Turk PhD, MA, MBA Senior Researcher, Healthcare, DNV GL Strategic Research and Innovation Eva Turk joined the DNV GL Research and Innovation, Healthcare programme in Oslo, Norway in January 2012. Recently she joined the Joint Action on Patient Safety, where she is working on implementation of safe clinical practices in the EU. Prior to joining DNV GL, Eva was working at the National Institute of Public Health in Slovenia, where she was responsible for implementation and development of Health Technology Assessment (HTA) in Slovenia. She has been involved in EC DG RTD Frameworks 6 and 7. Her PhD studies were on Patient Reported Outcomes in elderly diabetic patients.

Senior Researcher, Healthcare, DNV GL Strategic Research and Innovation Tita joined DNV GL Research and Innovation in Norway in November 2011. She has backgrounds in Psychology and Human Factors in healthcare. Her focus area now is to develop a global service on safety culture assessment and improvement in healthcare organizations. -–––––––––––––––

Melinda Lyons PhD, MBA, MSc (Eng) Senior Consultant, Healthcare, DNV GL Strategic Research and Innovation

Originally a psychologist, Melinda studied for an MSc (Eng.) in Work Design and Ergonomics, and then specialized in offshore emergency management during her PhD. She has

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More information on the Strategic Research and Innovation - Healthcare:

been a Human Factors professional ever since, specializing in human reliability with a focus on safety. Melinda has worked in consultancy, research and policy advice roles in many sectors – particularly in air traffic management before moving to healthcare in 2004. Melinda joined DNV GL in 2013 where she is leading work on the adaption of safety case methodology for healthcare. -–––––––––––––––

Rune Torhaug PhD, MSc Director, DNV GL Strategic Research and Innovation Rune joined DNV GL in 1988. In his role as Director of Strategic Research and Innovation, he brings over 25 years’ experience in in international management, engineering, development and research in, classification, certification and the supporting technical disciplines of risk and probabilistic modelling, dynamics, hydrodynamics of onshore structures, offshore structures and ships. -–––––––––––––––

Stephen McAdam DPhil (Oxon) Global Technical Director, Healthcare, DNV GL Business Assurance An immunologist by training, Stephen McAdam spent a decade working in laboratories working with pathogens such as HIV and HCV in hospitals in the US, Africa and Europe. Following a post-doctoral period at the National University Hospital in Oslo he spent 10 years in DNV’s Department Research and Innovation exploring systems based approaches to management and risk assessment in areas where the principal hazard is a biological agent (biorisk). Stephen has collaborated with many of the world’s leading organizations in the area of laboratory biorisk management, including the WHO, ECDC, Canadian Science Centre, and the UK Health Protection Agency. Stephen spent two years establishing a research programme focused on patient safety before switching roles within DNV to take on responsibility for developing DNV’s standards in healthcare.


Karen Timmons MBA, MA Global Business Director, Healthcare, DNV GL Business Assurance Karen joined DNV GL in 2011. Formerly, she was President and CEO of Joint Commission International, and also served as a Senior Advisor to Boston Consulting Group. Currently, she serves on the Board of Directors of Planetree, Inc., a not-for-profit organization focused on enhancing patient centered care, and the Institute of Healthcare Improvement’s Global Health Advisory Council. Karen is also serving as a faculty member for the Institute for Healthcare Improvement. She also previously served as Chair of the World Health Organization’s Collaborating Centre on Patient Safety, Chair of the World Health Organization’s HIV Quality of Care Working Group on HIVAIDS and was a past board member and treasurer for the International Society of Quality Assurance (ISQua). Karen is a past Chair of ISQua’s Agenda for Leadership in Programs for Healthcare Accreditation (ALPHA) Council and was appointed to serve on the Scientific Council of ANAES, the French National Agency for Accreditation and Evaluation in Health. -–––––––––––––––

Christine Fløysand Communications Manager, DNV GL Strategic Research and Innovation

30  Healthcare 2050: A vision of safer and smarter health services


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38 39


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122 Shaw C, Groene O, Mora N & Sunol R (2010) Accreditation and ISO certification: do they explain differences in quality management in European hospitals? International Journal for Quality in Health Care 22 (6) pp 445-451

103 Purdy S, Paranjothy S, Huntley A et al (2012) Interventions to Reduce Unplanned Hospital Admission: A Series of Systematic Reviews – available at: projects/unplannedadmissions.pdf - last accessed 9th February 2014 104 King’s Fund (2013) Improving the allocation of health resources in England – how to decide who gets what London: The King’s Fund 105 Hwang J & Christensen CM (2008) Disruptive innovation in health care delivery: A framework for business innovation Health Affairs 27 (5) pp 1329-1335 106 QUASER (2013) The guide for payers - a research-based tool to assess and facilitate quality improvement strategies in hospitals London: UCL/QUASER 107 Dahlgren G & Whitehead M (1991) Policies and strategies to promote social equity in health Stockholm: Institute for Future Studies 108 Costello A, Abbas M, Allen A et al (2009) Managing the health effects of climate change The Lancet 373 (9676) pp 1693-1733 109 Caution should be taken to distinguish between health outcomes and measures of the quality of healthcare. Measures of healthcare quality should include health outcomes alongside other indicators such as safety and the patient experience. 110 Porter M (2010) What is value in health care? NEJM 363 (26) 24772481 111 Porter M (2009) A strategy for health care reform – towards a valuebased system NEJM 361 (2) 109-112 112 Porter M & Teisberg EO (2006) Redefining healthcare: creating value based competition on results Boston: Harvard Business School Press 113 Appleby J, Raleigh V, Frosni F, Bevan G, Gao H & Lyscom T (2011) Variations in Healthcare – The Good, the Bad and the Inexplicable London: The King’s Fund 114 Appleby J, Ham C, Imison C & Jennings M (2010) Improving NHS productivity – More with the same not more of the same London: The King’s Fund

123 Alkhenizan A & Shaw C (2011) op cit 124 The King’s Fund (2012) Leadership and engagement for improvement in the NHS: together we can London: The King’s Fund 125 Dixon-Woods M, Bosk CL, Aveling EL, Goeschel CA & Pronovost PJ (2011) Explaining Michigan: developing an ex post theory of a quality improvement program Milbank quarterly 89 (2) pp 167-205 126 Health Foundation (2011) Measuring Safety Culture London: The Health Foundation 127 Perla RJ, Bradbury E & Gunther-Murphy C (2013) Large scale improvement initiatives in healthcare: a scan of the literature Journal for healthcare quarterly 35 (1) pp 30-40 128 Davenport TH & Harris JG (2007) Competing on analytics: the new science of winning Boston: Harvard Business Press 129 ibid 130 Health Foundation (2012) Using safety cases in industry and healthcare London: The Health Foundation

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DNV GL AS NO-1322 Høvik, Norway Tel: +47 67 57 99 00

DNV GL Driven by its purpose of safeguarding life, property and the environment, DNV GL enables organisations to advance the safety and sustainability of their business. DNV GL provides classification and technical assurance along with software and independent expert advisory services to the maritime, oil & gas and energy industries. It also provides certification services to customers across a wide range of industries. Combining leading technical and operational expertise, risk methodology and in-depth industry knowledge, DNV GL empowers its customers’ decisions and actions with trust and confidence. The company continuously invests in research and collaborative innovation to provide customers and society with operational and technological foresight. DNV GL, whose origins go back to 1864, operates globally in more than 100 countries with its 16,000 professionals dedicated to helping their customers make the world safer, smarter and greener. DNV GL Strategic Research & Innovation The objective of strategic research is through new knowledge and services to enable long term innovation and business growth in support of the overall strategy of DNV GL. Such research is carried out in selected areas that are believed to be of particular significance for DNV GL in the future. A Position Paper from DNV GL Strategic Research & Innovation is intended to highlight findings from our research programmes.

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