The work of health leaders is broadening in scope, scale and urgency to respond to massive global changes and challenges – including risks to safe, accessible and high-quality healthcare, threats to planetary health, crises in workforce resiliency and erosion of public trust and confidence. To address these issues and deliver on other imperatives around equity and inclusive service co-production, health leaders must again fashion a new quality improvement (QI) agenda fit for the times and the future, aligned with the move from digitization to personalization. The new era, Health Quality 5.0, must enable and be embedded in an integrated, coordinated and people-centred health system, supported by a learning health system and new QI approaches.

Introduction

The fifth Global Ministerial Summit on Patient Safety was held on February 23 and 24, 2023, in Montreux, Switzerland (WHO 2023). Senior delegations from more than 80 countries, including 28 ministers of health and leading experts, gathered to take stock of the state of quality and safety post-pandemic and to delineate how to help health systems consistently yield safer care. What struck me most while attending this summit was the convergence of ideas and collective will to tackle quality and patient safety as a shared global challenge, despite the daunting realities of economic, environmental, political and social challenges facing countries and leaders around the world.

Skeptics could dismiss this as yet another think-fest producing more reports to sit on the shelf. There are certainly precedents to support that view. Canada's embarrassing failure to send an official delegation was a glaring omission that belies the fact that we have much to contribute to global solutions and much to learn from others.

We are facing unprecedented challenges that threaten the health and well-being of individuals and entire populations. It is easy to feel overwhelmed and retreat into our heads and to well-worn ways of working at local levels. Collaborations, partnerships and learning across silos and systems take time, energy and resources – all in particularly high demand right now. However, to inspire action on the real-world problems now on health leaders' plates, we must envision and work within the global landscape so we can reframe and reimagine how to advance locally. We will make progress when we unpack the big issues and tackle them in focused and concrete ways while measuring results and sharing what our successes and failures teach us.

There has never been a better time for healthcare leaders to make a positive impact on the quality of health and care around the world. We know the focus on safety and quality cannot be confined to the four walls of traditional healthcare institutions and systems. We need to define a new health quality agenda together, one up to the critical job ahead. That requires thinking about health quality and the work of health leaders in a new way, expanding imperatives, expectations and perspectives about what health leaders bring to the quality improvement (QI) table. We need a movement and the motivation to kick-start it: a shared vision of the next era of QI – Health Quality 5.0. But before looking ahead, here is a quick look at where we began and what distance we have covered.

The Road(s) Taken

The four phases of industrial revolutions that emerged over the past 250 years have had a profound impact on how healthcare has evolved. Industry 1.0 saw the transition from agricultural to new manufacturing processes with a focus on production efficiency. As electrical power and mass production were introduced, Lean manufacturing and its associated quality methods arrived, defining Industry 2.0. Then came the third revolution, the era of automation, followed by the fourth industrial revolution – Industry 4.0: Digitalization – where we remain.

Digitalization is changing the way everything and everyone is connected, including healthcare services. We have seen the traditional, more mechanistic quality assurance and improvement methods strain under the pace and impact of new technologies while we struggle with the consequences. In the midst of this, the notion of a fifth era – Industry 5.0 – was introduced post-pandemic at the World Economic Forum (Gauri and Van Eerden 2019; Nakanishi 2019; Van Eerden 2020).

Why Health Quality 5.0 and Why Now?

Industry 5.0 is all about personalization and the impact that major forces of change are having on the lives of individuals and communities. From what I see and hear around the world post pandemic, this is resonating with industry and healthcare leaders. A people-centric dynamic, it presents opportunities to reconnect with our core purpose and rebuild the public's trust and confidence in the quality of our healthcare systems while infusing that faith back into our workforces.

Our next step is to shape a corresponding Health Quality 5.0 model while driving an action-packed implementation agenda. This is a time to act decisively (but not hastily) to tackle the vulnerabilities of health systems and make them more resilient, while ensuring that the choices we make have a positive impact on the lives of every individual and community. Elevating quality as the priority in health planning, policy and practice is key to securing changes that can deliver on new imperatives and long-neglected needs. We must be successful in securing this shift as much is at stake – everything from the status of the population, planet and healthcare workforce to the sustainability of the system and the trust and confidence of the public.

Facing Reality

To examine the significant obstacles to achieving strong outcomes across all those fronts, we have developed a year-long series called “It Is Time for Health Quality 5.0 – Are You Ready?” Concentrating on healthcare quality as a driver and destination, the series looks at current and emerging risks to the quality of care, new avenues and approaches for QI and attributes that can help leaders succeed when working in new spaces where no manual exists.

The series will explore the top challenges facing global health leaders today using a quality lens and offer fresh perspectives to help stimulate discussion, debate and, most of all, action. The challenges include the following:

• Putting safety of all forms back on the front burner. Harm is increasing post pandemic – not decreasing; new approaches to physical, psychological and cultural safety are needed to turn the tide.
• Addressing the global workforce crisis. There is no quality without a healthy, competent and engaged workforce. The gaps we are experiencing have a profoundly negative impact on quality, limiting our ability to advance new models of care and introduce other innovations.
• Co-producing the future of health and care so all voices are heard and in meaningful ways. This must become expected practice. People-centred integrated health systems will help unlock the future, and co-production is the key. We know it is the right thing to do, but why is it so hard?
• Reducing inequities in access to quality care. The pandemic and recent world events have highlighted tragic and unacceptable human conditions that have a devastating impact on individual and community health. By addressing equity issues, we put a human face on the consequences of our actions or inactions.
• Mitigating the risks to planetary health that face everyone. The World Health Organization has declared climate change the biggest health threat facing humanity (WHO 2021). The global healthcare sector is the fifth largest emitter on the planet (Karliner et al. 2019). We must arm ourselves to better prevent and handle the increasing natural and human-made disasters.
• Addressing the crisis in confidence and trust in our healthcare systems – for the public and for all levels of leadership. Misinformation is at an all-time high, and the consequences to accessing essential health services are real.

We know this is a big list and that none of these issues are isolated from each other – in fact, they are intertwined. We will explore each of them, looking at how they impact each other so that a clear and comprehensive picture of quality can emerge.

The series presents a global view of healthcare quality. National and international experts will share their perspectives, drawing on decades of experience working across sectors, settings, roles and regions and engaging with national and international system leaders, executives, clinicians, family and patient partners and policy makers.

Readers can expect to learn about how different countries with variously developed health systems are handling common issues, often through collaborative efforts in jurisdictions such as Canada, Europe, the Caribbean and the Middle East. Industry trends and tools, case examples, inspiring ideas and cautionary tales will be woven throughout the series – all aimed at making the future of healthcare more fair than fearful.

As leaders tackle these macro challenges, we hope that this series provides more imaginative options for collaboration, a broader sense of comparable risks, better prospects for success – or just food for thought.

Where Are We with Quality?

The hurdles to providing worldwide access to safe, high-quality healthcare have been rising over the past several years – as has the incidence of healthcare-related harm. In a 2020 BMC Medicine article analyzing three 2018 landmark studies on quality and global health systems, Braithwaite et al. (2020) identified a common refrain and call to action. The takeaway was that “poor-quality care remains an entrenched, wicked problem” and that system leaders must “lift their game” when it comes to quality (Braithwaite et al. 2020: 6).

We know that universal health systems are associated with positive health outcomes that depend on high-quality care. We are also aware that investments and planning in health human resources and system infrastructure have failed to keep pace with shifts in demographics and population health. Patchwork fixes have been layered onto fundamental flaws in service design and delivery, and cyclical workforce shortages have become the norm. The consequences of fractured systems appeared well before COVID-19 came along.

The pandemic put more and immense pressure on the system and healthcare providers, creating conditions that further compromised people's access to safe, quality care, especially for populations disproportionately harmed by COVID-19. The disparities inside and outside healthcare, across sectors and society were exposed and expanded during the pandemic, producing predictably poor health outcomes and personal suffering.

Leadership that Steps Up

The expanding portfolios and new and additional accountabilities that health leaders shoulder are a product of the times, as well as the pandemic, and reflect the range and realities of today's challenges. On any given day, our work may include improving the effectiveness of efforts to mitigate climate change or address inequities or ensuring that our services are financially sustainable and the experiences of our workforces, patients and caregivers are safe in every sense. It is understandable if leaders feel overwhelmed and unprepared for the tasks at hand and on the horizon. In this complex, demanding environment, the pursuit of quality may seem out of reach to people inside and outside the system, as research shows (Le Fanu 2012).

But as Don Berwick, president emeritus of the Institute for Healthcare Improvement, recently wrote: “I know you are working hard already. But you do not get a free pass on these societal issues” (Berwick 2022).

New eras emerge when leaders step up, not despite difficult realities but because of them, and when they envision what might and must be and pursue agendas to achieve it. Leaders in the quality field have done that before: moving from QI within the walls of healthcare to and through integrated people-centred health systems – for instance, expanding accountability for improved population health over lifespans or persistently promoting interdisciplinary teams and collaborative care delivery models.

An Agenda Driven by New QI Approaches and Reliant on Learning Health Systems

Now we need to make QI the norm, the new order of things; it should no longer be an extra or a distraction.

The quality era we envision enables and is embedded in an integrated, coordinated, people-centred health system. Health was deemed the most complex of human endeavours at the turn of the century (Kruk et al. 2022; M3 Global Research 2022), and the system supporting it has since become immeasurably more complicated. We need learning health systems to achieve Health Quality 5.0 to maximize the opportunities of the future and diminish its dangers. The systems must be connected through strong infrastructure that allows healthcare researchers, providers, stewards and stakeholders to access, populate, share and act on meaningful data and new findings. These systems will only thrive in a culture fully supportive of people's continuous skill and knowledge building and their active engagement in entrenched intuitive improvement processes.

A Discussion Based on Hope, Not Despair

As a healthcare leader who has worked in many and diverse roles – always with an ear to the ground – I am aware that embracing this goal takes energy and fortitude, both in short supply these days. But this series arises out of hope, not despair. Healthcare improvement is not inevitable – no whiggish interpretations here – but it is possible even now, especially now. We know that losing confidence and trust in leaders, systems and institutions is bad for one's health. I remain an unapologetic optimist who believes that we can push past today's challenges if we work together in new ways.

Maybe we can do something else at the same time. An earlier reference to health system leaders needing to “lift their [quality] game” (Braithwaite et al. 2020: 6) prompts this thought: maybe we also need to lift our heads – from our devices (and perhaps our hands) – and remember the lift that comes from inspiring action, from knowing we have made a difference. Maybe that begins our journey back to joy.

Meanwhile, let us make quality our North Star and abide by another wise assertion from Don Berwick: “[t]he quality improvement movement is about making life better for everyone” (Berwick 2022).

As our series unfolds, we welcome your thoughts and ideas. By sharing experiences and ideas from around the world, we aim to stimulate discussion and debate on some of the most wicked problems ever faced by healthcare leaders. We look forward to hearing your reflections and your experiences – what are you doing to address the biggest healthcare challenges of our lifetime and how are you faring? By marshalling forces and learning together, we can shape the future of quality improvement and usher in the new era of Health Quality 5.0 with more hope, confidence and collective will to make change happen.

There is a lot at stake and no time to waste in the journey toward safer care and a healthier world, for all.

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