I’m working on a nursing multi-part question and need an explanation and answer to help me learn.

After watching the videos and information 

identify and discuss one area of health care that you would like to see improved. Identify the proposed improvement and discuss your thoughts. References are required.

As you’re seeing, based on where someone lives and certain characteristics at birth, there are significant differences in the type of health and health care they’re likely to experience. This is often true even within the same country or hometown.

For example, consider the following differences based on 2015 statistics from the World Health Organization (WHO):1

• The lifetime risk of maternal death is 1 in 11 in Afghanistan — compared to 1 in 17,800 in Ireland.
• In the US, African Americans represent only 12 percent of the population, but account for almost half of all new HIV infections.
• About 80 percent of noncommunicable diseases are in low- and middle-income countries.
• In London, when travelling east from Westminster toward Canning Town, each tube stop represents nearly one year of life expectancy lost.
• In Japan, life expectancy at birth is more than 80 years; in several African countries, it’s fewer than 50 years.

The root causes of the differences we see by no means begin or end in the clinical setting. As WHO’s Commission on Social Determinants of Health has put it:2

Water-borne diseases are not caused by a lack of antibiotics but by dirty water, and by the political, social, and economic forces that fail to make clean water available to all; heart disease is caused not by a lack of coronary care units but by lives people lead, which are shaped by the environments in which they live; obesity is not caused by moral failure on the part of individuals but by the excess availability of high-fat and high-sugar foods.

2021 World Health Statistics

Now in the US, it’s quite fashionable these days to blame these gaps and disparities on a broken health care system, and incompletely insured population, lack of alignment between payment and care delivery, and a host of other factors. I’m sure you have your own challenges wherever you live. But we believe that the systematic application of sound improvement science can make a difference even in systems that would benefit from a transformative overhaul.

Now, I can’t emphasize strongly enough that policy and payment reform alone cannot achieve the very high level of health care quality we need. And we always need to be mindful that dramatic changes in the health care system almost always have unanticipated consequences and can leave caregivers and patients struggling to deal with new, often confusing regulations, payment structures, and reporting requirements.

Now, I also want to make it clear that while good quality improvement is really important, improvers and change agents always should celebrate and attempt to leverage advances in technology and therapeutics. When you get to be as old as I am, you’re really going to appreciate the miracles of modern medicine. The virtual elimination of a growing list of vaccine-preventable infectious diseases, drugs that have turned AIDS into a chronic disease rather than a death sentence, oral drugs that can cure hepatitis C, a startling fall in hospitalizations and mortality for heart attacks and heart failure. So that’s the paradox — a so-called “broken” system that nonetheless continues to produce medical miracles.

Our work, as improvers and change agents, is to make sure that these miracles are available to all people who could benefit, regardless of wealth, education, race, ethnicity, gender, sexual preferences, or geographical location. At the same time, we need to make sure that patients who cannot benefit from these treatments don’t receive them inappropriately, which merely incurs needless cost and may actually lead to side effects and harm. We also can do a much better job partnering with patients and families, so that they participate in their care and can voice their own preferences and concerns.

Well, there’s a window of opportunity right now to do this. Right now in the C-suite of most big, complicated delivery systems — or honestly even smaller practices, where I know lot of the IHI membership is working — there is this top-down directive from policy-makers and payers and others to be accountable for both the quality and the cost of services. We know that.

We also know there’s mounting bottom-up pressure from our patients. More Americans are in high-deductible plans than ever before. An average deductible if you get a silver plan on any health insurance exchange in the country is $3,000 to $5,000. That’s like real money no matter who you are or what kind of income you have. It’s not money you want to blow, for sure.

So, clinicians in the front line are feeling this, and people that are at the health system leadership level, they, I think, often and set the culture. I think culture is often set in a top down way. You now have an aligned interest around this.

So I think if you’re leading a health system, in 2013 your health system was probably like a revenue center. That’s how you ran it. You thought about it as a revenue center, like, “I need to get more patients in it so we can make more money.” But now it’s being managed more like a cost center, like, the way to protect our margins is to figure out where the waste is and get rid of it.

The people that know where the waste is are the people that are running the show for real. The truth is you can walk onto any ward of any hospital in the United States and ask anybody there — the unit clerk, the nurses, the residents, anybody — “What are five things that we do every day that are wasteful, that don’t need to happen?” And they could give you 10. So, lots of opportunity there.