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Crossing the Global Quality Chasm: Improving Health Care Worldwide
Improving Health
Care Worldwide
Committee on Improving the Quality of Health Care Globally
Board on Global Health
Board on Health Care Services
Health and Medicine Division
A Consensus Study Report of
Copyright National Academy of Sciences. All rights reserved.

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2018. Crossing the global quality chasm: Improving health care worldwide. Wash-
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COMITTEE ON IMPROVING THE QUALITY

OF HEALTH CARE GLOBALLY
DONALD M. BERWICK (Co-Chair), Institute for Healthcare

Improvement, Boston, Massachusetts
SANIA NISHTAR (Co-Chair), Heartfile, Islamabad, Pakistan
ANN AERTS, Novartis Foundation, Brussels, Belgium
MOHAMMED K. ALI, Emory University, Atlanta, Georgia
PASCALE CARAYON, University of Wisconsin–Madison
MARGARET AMANUA CHINBUAH, PATH, Accra, Ghana
MARIO ROBERTO DAL POZ, Instituto de Medicina Social, UERJ,
Human Resources for Health, Rio de Janeiro, Brazil
ASHISH JHA, Harvard Global Health Institute, Harvard T.H. Chan
School of Public Health, Harvard Medical School, Boston,
Massachusetts
SHEILA LEATHERMAN, Gillings School of Global Public Health,
University of North Carolina at Chapel Hill
TIANJING LI, Bloomberg School of Public Health, Johns Hopkins
University, Baltimore, Maryland
VINCENT OKUNGU, PharmAccess, Nairobi, Kenya
NEERAJ SOOD, Sol Price School of Public Policy, University of Southern
California, Los Angeles, California
JEANETTE VEGA, Chilean National Health Fund, Santiago, Chile
MARCEL YOTEBIENG, College of Public Health, Ohio State University,
Columbus, Ohio; and University of Kinshasa, Democratic Republic
of Congo
Study Staff
MEGAN SNAIR, Study Director (through July 2018)
EESHAN KHANDEKAR, Research Associate
SARAH ANNE NEW, Senior Program Assistant
JULIE PAVLIN, Director, Board on Global Health, and Study Director
(from August 2018)
SHARYL NASS, Director, Board on Health Care Services

Consultants
RONA BRIERE, Arlington, Virginia
JENNIE KWON, National Academy of Medicine Fellow, St. Louis,
Missouri
IRENE PAPANICOLAS, Department of Health Policy, London School
of Economics, London, United Kingdom; Harvard Global Health
Institute, Boston, Massachusetts
LIANA WOSKIE, Harvard Global Health Institute, Boston,
Massachusetts
vi

Reviewers
This Consensus Study Report was reviewed in draft form by individuals

chosen for their diverse perspectives and technical expertise. The purpose
of this independent review is to provide candid and critical comments that
will assist the National Academies of Sciences, Engineering, and Medicine
in making each published report as sound as possible and to ensure that
it meets the institutional standards for quality, objectivity, evidence, and
responsiveness to the study charge. The review comments and draft manu-
script remain confidential to protect the integrity of the deliberative process.
We thank the following individuals for their review of this report:
JEFFREY BRAITHWAITE, Macquarie University

HELEN BURSTIN, Council of Medical Specialty Societies
MIRAI CHATTERJEE, Self-Employed Women’s Association (SEWA)
PETER LACHMAN, International Society for Quality in Health Care
(ISQua)
GINA LAGOMARSINO, Results for Development
MAUREEN LEWIS, Acesco Global
SANELE MADELA, Expectra 868 Health Solutions
NAJMEDIN MESHKATI, University of Southern California
MANOJ MOHANAN, Duke University
DAVID NOVILLO ORTIZ, Pan American Health Organization/
World Health Organization
RAJ PANJABI, Last Mile Health
HOWARD B. ROSEN, Independent Consultant
vii

viii REVIEWERS
AZIZ SHEIKH, The University of Edinburgh

GABE E. TZEGHAI, Summit Innovation Labs
HAROLD E. VARMUS, Weill Cornell Medical College
Although the reviewers listed above provided many constructive com-

ments and suggestions, they were not asked to endorse the conclusions
or recommendations of this report, nor did they see the final draft before
its release. The review of this report was overseen by ENRIQUETA C.
BOND, Burroughs Wellcome Fund Partner, and BRADFORD H. GRAY,
Urban Institute. They were responsible for making certain that an inde-
pendent examination of this report was carried out in accordance with the
standards of the National Academies and that all review comments were
carefully considered. Responsibility for the final content rests entirely with
the authoring committee and the National Academies.

Preface
This report minces no words about the magnitude and costs of the
“global quality chasm.” Although evidence is scattered and incomplete,
the conclusion is inescapable: For billions of people, universal health
coverage—the important mainstay of the World Health Organization’s
(WHO’s) Sustainable Development Goal (SDG) 3—will be an empty vessel
unless and until quality improvement, for all nations, becomes as central
an agenda as universal health coverage itself. In view of the immense
dedication and effort of tens of millions of health care workers worldwide,
often against massive obstacles of resource limitations, political and social
fragmentation, corruption, collusion, and even threats to personal secu-
rity, the central assertion that the current system too often fails to provide
high-quality care is not to be made lightly or with disrespect. The study
committee vehemently rejects the idea that the workforce is generally at
fault, neglectful, or uncaring. On the contrary, without doubt, they deserve
credit and the world’s gratitude for a large proportion of the extraordinary
progress in population health of the Millennium Development Goal (MDG)
and early SDG eras.
What we do believe, informed by the guiding intellectual framework of
this report—“systems thinking”—is that many of these workers, the would-
be healers of the world, are ill served by being embedded in and dependent
on systems of care that impede excellence rather than supporting it, and
that drain their energy rather than nurturing it. Systemic conditions—such
as fragmentation, malaligned payment, unclear goals, poor training, unreli-
able supply chains, burdensome rules, inadequate information flows, lack of
ix

x PREFACE
useful data, corruption, and fear—prevent even the most willing workforce
from carrying out its daily tasks successfully and contributing to the success
of the whole system. As a result, patients suffer needlessly; communities
squander scarce resources; and the workforce itself becomes frustrated and
exhausted as a part of the ill-functioning system.
The good news in this report is that all these problems are remediable—
indeed, preventable. Foundational, of course, are adequate social invest-
ments in health care supplies, personnel, equipment, and space; these are
preconditions for excellence. But alone, they do not assure excellence.
To mobilize change, system leaders must reassess values, principles, and
systems designs. Even in wealthy settings, where resources are abundant,
quality can and does fail because of improper care designs and poor sys-
temic conditions, such as those listed above. Keys to success, given adequate
resources, lie in modern, evidence-based methods of quality assurance and
improvement. They also lie in full-hearted embrace of the new digital age
of medical care, and in making sure that the well-being of patients and the
integrity of their care journeys are the compass bearings for all that we
do. It is leaders, above all, who have the opportunity and responsibility to
nurture those methods and to continually reinforce those aims.
The committee is convinced, after 1 year of study and reflection, that
these values—especially person-centered care—and these systems-based
methods hold as much promise in low- and middle-income settings as in
wealthy ones. This report sets out an agenda for action on policy, manage-
ment, and clinical care that, we believe, can deliver far better outcomes for
the people who depend on us and far more satisfying and respectful condi-
tions of work for those who try to help.
This report joins two others from important organizations: one from a
consortium of WHO, the World Bank, and the Organisation for Economic
Co-operation and Development, and another from The Lancet Global
Health Commission on High-Quality Health Systems in the SDG Era.
Together, this report and these two sibling efforts offer the entire global
health community evidence-based guidance and, we hope, further motiva-
tion to engage in comprehensive health care redesign in pursuit of continual
quality improvement as a priority equal to what is now, happily, assigned
to universal health coverage. The combination can save lives, financial re-
sources, and pride and joy in the workforce, all at the same time.
If 2018 has been a year of study and reports on quality, let 2019 and
beyond be an era of action on quality.
Donald M. Berwick, Co-Chair

Sania Nishtar, Co-Chair
Committee on Improving the Quality of
Health Care Globally

Acknowledgments
This Consensus Study Report would not have been possible without the
invaluable contributions from many experts and stakeholders dedicated to
global health. The committee would like to thank all of the speakers (whose
full names and affiliations are found in Appendix A) and participants who
played a role in the public workshops conducted for this study, as well as
the many others who provided valued insight and responded to rapid re-
quests for information to accommodate our short and demanding timeline.
Many of these contributors are listed below:
Joseph Ali, Johns Hopkins Berman Institute of Bioethics

Gerald Bloom, Institute of Development Studies
Kathryn Coburn, Murphy Cooke Kobrick
Mohammed Dalwai, Open Medicine
Ara Darzi, Imperial College London
Wen Dombrowski, Catalaize
Kate Ettinger, Mural Institute
Kelsey Flott, Imperial College London
Gianluca Fontana, Imperial College London
Isaac Holeman, Medic Mobile
Benoit Kebela Ilunga, Ministry of Health, Democratic Republic of the
Congo (DRC)
Alain Kakule, Ministry of Health, DRC
Edward Kamnuhangire, Ministry of Health, Rwanda
Yaseen Khan, Open Medicine
xi

xii ACKNOWLEDGMENTS
Nardo Manaloto, Catalaize

Emmanuel Manazikira, Gisenyi Hospital, Rwanda
Monique Mrazek, International Finance Corporation (IFC)
Kambale Mughuma Joachim, Ministry of Health, DRC
Kanza Muhindo K. Eric, Ministry of Health, DRC
Solange Mukuayiranga, Gisenyi Hospital, Rwanda
Camila Murga, Hospital Italiano de Buenos Aires
Kasareka Murotso Pius, Ministry of Health, DRC
Zuberi Muvunyi, Ministry of Health, Rwanda
Isaac Muyonga, ComBaptist at the Center of Africa
Nathalie Umutoni, Ministry of Health, Rwanda
Sam Wambugu, ICF International
The committee would also like to thank the sponsors of this study for
their generous financial support: Johnson & Johnson, National Institutes
of Health, U.S. Agency for International Development, and U.S. President’s
Emergency Plan for AIDS with additional support from the Institute of
Global Health Innovation at Imperial College London, Medtronic Foun-
dation, and Wellcome Trust. A special thanks and acknowledgment go to
the Institute of Global Health Innovation and the National Institute for
Health Research Imperial Patient Safety Translational Research Centre for
its time and intellectual contribution in planning the committee’s March
meeting on the future of health care. We also thank Peter Buckle and col-
leagues for their white paper testimony on the role of human factors and
Alain Labrique for his paper on technology and the future of health care;
special thanks also goes to the Harvard Global Health Institute’s Initiative
on Global Health Quality for the analysis estimating the burden of poor
quality health care and its economic consequences.
Finally, deep appreciation goes to staff at the National Academies of
Sciences, Engineering, and Medicine for their efforts and support in the
report process: Lauren Shern and Maryjo Oster on the Report Review
Committee; Greta Gorman and Tina Ritter in the Communications office;
Rebecca Morgan and Jorge Torres-Mendoza at the Research Center for
their assistance in fact checking the report; and Victor Dzau for his assis-
tance in and support of the project.

Contents
ACRONYMS AND ABBREVIATIONS xxi
SUMMARY 1
1 INTRODUCTION 23
The Sustainable Development Goals and the Universal
Health Coverage Agenda, 24
Challenges for Health Care Quality, 27
A Poor Patient Journey, 34
Charge, Approach, and Scope of This Study, 40
Organization of the Report, 46
References, 47
PART I: THE IDEAL VISION FOR FUTURE HEALTH CARE
2 THE PATH TO A HIGH-QUALITY FUTURE:

THE NEED FOR A SYSTEMS APPROACH AND
A PERSON-CENTERED SYSTEM 53
The Need to Redouble Efforts for a Systems Approach, 54
Redesign for a Person-Centered Health System, 64
Summary and Recommendation, 71
References, 75
xiii

xiv CONTENTS
3 OPTIMIZING THE PATIENT JOURNEY BY

LEVERAGING ADVANCES IN HEALTH CARE 79
Global Trends in Health Care, 81
Implications for Quality: Person-Centeredness, Accessibility,
and Equity, 92
Moving from Reactive to Predictive Care, 97
Needed Organizational and Care Delivery Changes, 106
Cautions for Quality in the Future System, 111
Summary and Recommendations, 117
References, 120
PART II: THE CURRENT STATE OF QUALITY IN HEALTH CARE
4 THE CURRENT STATE OF GLOBAL HEALTH CARE

QUALITY 129
The State of Quality Across Domains, 133
The Burden of Low-Quality Care, 151
Data Sources and Limitations, 155
Variability in Quality: Where Are the Gaps?, 156
Tracking Progress in Quality: Where Are the Metrics?, 159
References, 163
5 HIGH-QUALITY CARE FOR EVERYONE: MAKING

INFORMAL CARE VISIBLE AND ADDRESSING
CARE UNDER EXTREME ADVERSITY 169
Informal Health Care Providers: Overview, 170
Health Care Quality in Settings of Extreme Adversity, 181
References, 197
6 THE CRITICAL HEALTH IMPACTS OF CORRUPTION 203

The Impact of Corruption on the Health of Populations, 205
Types of Corruption in Health Care, 206
Challenges to Effective Universal Health Coverage Posed by
Corruption, 211
Strategies for Reducing Corruption in Health Care, 217
References, 221

CONTENTS xv
PART III: THE PATH TO CONTINUAL GLOBAL IMPROVEMENT
7 EMBEDDING QUALITY WITHIN UNIVERSAL

HEALTH COVERAGE 227
The Necessary Link Between Universal Health Coverage
and Quality, 228
Universal Health Coverage as an Opportunity for Quality
Improvement, 235
The Need for Government Commitment to Quality
Within Universal Health Coverage, 251
References, 261
8 ESTABLISHING A CULTURE OF CONTINUAL LEARNING 269

What Is a Learning Health Care System?, 270
The Components of a Learning Health Care System, 275
A Research and Development Agenda, 282
References, 289
APPENDIXES
A PUBLIC MEETING AGENDAS 293

B METHODS FOR RAPID REVIEW 297
C COMMITTEE MEMBER BIOSKETCHES 301
D METHODS FOR CHAPTER 4 309


Boxes, Figures, and Tables
BOXES
1-1 Definition of Health Care Quality, 26
1-2 Statement of Task, 41
2-1 Case Study: Misalignment of Incentives Across

Organizational Levels, 60
2-2 The Committee’s Design Principles in Action, 72
3-1 Case Study: China’s WeChat, 89

3-2 Case Study of Optimizing Community Health Workers, 102
3-3 Optimizing Community Health Systems, 103
4-1 Safety Case Study: Substandard and Falsified Medications, 136

4-2 Effectiveness Case Study: Hypertension, 144
4-3 Timeliness Case Study: Time to Antenatal/Postnatal Care, 147
4-4 Efficiency Case Study: Overuse in Antibiotic Prescribing, 150
4-5 Equity Case Study: Cervical Cancer, 152
4-6 Equity Case Study: Breast Cancer, 153
5-1 Case Study: Palestinian Refugees in the West Bank, 190
6-1 Corruption Is Widespread, 205

6-2 Equipment Graveyards, 210
xvii

xviii BOXES, FIGURES, AND TABLES
7-1 Case Study: Patient Detention, 232

7-2 Examples of Nationwide Accreditation Programs Designed to
Improve Quality, 244
7-3 Pay-for-Performance Schemes, 247
7-4 Case Study: Rwanda’s Community-Based Health Insurance
Program (CBHI), 248
8-1 Case Studies of a Learning Health Care System, 272
FIGURES
S-1 Overall number of deaths from poor-quality care annually in
low- and middle-income countries compared with total deaths,
in thousands, 3
S-2 Guiding framework for the transformation of care delivery, 9
1-1 The patient journey from a life-course perspective, 36

1-2 Health system levels that can impact one another
bidirectionally, 38
2-1 Integration of conceptual frameworks guiding health systems

and quality of care, 57
2-2 Guiding framework for the transformation of care delivery, 65
3-1 Future expectations for the quality of health care globally, 83

3-2 Trends in health care technology throughout the decades, 85
3-3 Percentage of respondents willing or unwilling to use an
“intelligent health care assistant” via phone or computer, 94
3-4 Primary care acting as a hub of coordination to provide person-
centered care, 99
3-5 Principles for digital development, 107
3-6 The PATH-Vital Wave data use cycle, 117
4-1 Stages of health care service coverage, 134

4-2 National levels of dissatisfaction with care, 146
4-3 Variation in mortality rates for ineffective care, low- and middle-
income versus high-income countries, 151
4-4 Total overall deaths and quality-related deaths by condition, 154
4-5 Availability of published literature in low- and middle-income
countries (LMICs) on five safety indicators (2007–2017), 157

BOXES, FIGURES, AND TABLES xix
5-1 Interventions to improve health services in the informal

sector, 179
5-2 Proportion of populations in extreme poverty living in fragile
contexts, 2016 and 2030, 182
5-3 Poor overall patient experience in fragile states compared with all
low- and middle-income countries (LMICs), 186
5-4 Experience of disrespect in fragile states compared with all low-
and middle-income countries (LMICs), 186
6-1 Chain of malpractice in publicly owned health care facilities, 207

6-2 Publications on different types of corruption, 2000 to 2018, 212
6-3 The public–private nexus in institutionalizing corruption, 215
7-1 A conceptual model for mixed health system stewardship, 240

7-2 Framework for improvement in health care quality, 249
7-3 The eight elements of a National Quality Policy and Strategy, 254
8-1 The learning health care system cycle, 271
B-1 Article exclusion flow chart, 299
TABLES
2-1 Proposed New Design Principles to Guide Health Care, 65
3-1 Comparison of Bottom-Up and Top-Down Approaches to the

Development of Digital Health Systems, 86
4-1 Safety Events Occurring in Low- and Middle-Income Countries

(LMICs), 135
4-2 Conditions Represented in the Effectiveness Domain, 138
4-3 Definition of Ineffectiveness Indicators, 139
4-4 Number of People Impacted by Ineffective Treatment for
Communicable Diseases in Low- and Middle-Income Countries,
Annually (millions), 140
4-5 Deaths and Disability Resulting from Ineffective Care for
Communicable Diseases in Low- and Middle-Income Countries,
4-6 Number of People Impacted by Ineffective Treatment for
Noncommunicable Diseases in Low- and Middle-Income
Countries, Annually (millions), 141

xx BOXES, FIGURES, AND TABLES
4-7 Deaths and Disability Resulting from Ineffective Care for

Noncommunicable Diseases in Low- and Middle-Income
Countries, Annually (millions), 142
4-8 Quality-Related Deaths Resulting from Ineffective Care for
Maternal and Child Health in Low- and Middle-Income
Countries, Annually, 143
4-9 Patient-Reported Data on Satisfaction with Wait Time by
Country, Published Literature, 148
4-10 Deaths and Years of Life Lost to Vaccine-Preventable Conditions
(Low- and Middle-Income Countries [LMICs]), 148
4-11 Number of Studies by Country for Selected Safety Indicators, 158
4-12 Primary Data Sources and Number of Low- and Middle-Income
Countries Represented for Selected Conditions, 158
Annex Table 4-1 Excess Costs Resulting from Safety Events Occurring
in Low- and Middle-Income Countries Annually,
Low Estimates (1 × gross national income per capita
in millions), 166
Annex Table 4-2 Excess Costs Resulting from Ineffective Care for
Communicable Diseases in Low- and Middle-Income
Countries Annually, Low Estimates (1 × gross national
income per capita in millions), 167
Annex Table 4-3 Excess Costs of Deaths and Disability Resulting
from Ineffective Care for Noncommunicable
Diseases in Low- and Middle-Income Countries
5-1 Quality-Related Deaths in Fragile States and Low- and Middle-

Income Countries (LMICs) Annually, 185
8-1 Components of a Learning Health Care System, 276
B-1 Search Strategy, 298

Acronyms and Abbreviations
ACT artemisinin-based combination therapy

ADDO Accredited Drug Dispensing Outlet
AFRO African Regional Office (WHO)
AGP Abel Gilbert Pontón
AI artificial intelligence
AMI acute myocardial infarction
ANC antenatal clinic
ASHA accredited social health activist
BCG Bacille Calmette-Guerin

BMAT BioMedical Admissions Test
BMI body mass index
BP blood pressure
BPHS Basic Package of Health Services
CBHI Community-Based Health Insurance

CDS clinical decision support
CHW community health worker
CIN Clinical Information Network
COPD chronic obstructive pulmonary disease
CR citizen representative
CRISPR clustered regularly interspaced short palindromic repeats
CS caesarean section
xxi

xxii ACRONYMS AND ABBREVIATIONS
CVD cardiovascular disease
DALY disability-adjusted life year

DHS Demographic and Health Surveys
DNA deoxyribonucleic acid
DRC Democratic Republic of the Congo
EHIS electronic health information system

EHR electronic health record
EMRO Eastern Mediterranean Regional Office (WHO)
FDA U.S. Food and Drug Administration

FHS Family Health Strategy
FMOH Federal Ministry of Health
FSI Fragile States Index
GBD Global Burden of Disease

GDP gross domestic product
GPW General Program of Work
HCAC Health Care Accreditation Council

HCD human-centered design
HDA Health Development Army
HEW Health Extension Worker
HFE human factors and ergonomics
HIC high-income country
HIV/AIDS human immunodeficiency virus/acquired immunodeficiency
syndrome
HMC Hamad Medical Corporation
HPV human papillomavirus
ICHOM International Consortium for Health Outcomes

Measurement
ICT information and communication technology
IDB International Development Bank
IOM Institute of Medicine
IP informal provider
ISIS Islamic State in Iraq and Syria
ISO International Organization for Standardization
ITU International Telecommunication Union
JICA Japan International Cooperation Agency

ACRONYMS AND ABBREVIATIONS xxiii
LHCS learning health care system

LMIC low- and middle-income country
MCH maternal and child health

MDG Millennium Development Goal
MESH MH Mentoring and Enhanced Supervision at Health Centers for
Mental Health
MOH ministry of health
NAM National Academy of Medicine

NCD noncommunicable disease
NGO nongovernmental organization
NICU neonatal intensive care unit
NIH National Institutes of Health
NPR National Public Radio
NQPS National Quality Policy and Strategy
NQS National Quality Strategy
OECD Organisation for Economic Co-operation and Development

OOP out-of-pocket
ORS oral rehydration salt
ORT oral rehydration therapy
P4P pay for performance

PCA patient-controlled analgesia
PHA Private Hospital Association
POC point-of-care
PPH postpartum hemorrhage
PREM patient-reported experience measure
PRI Panchayati Raj Institution
PROM patient-reported outcome measure
PTSD posttraumatic stress disorder
QEWS Qatar Early Warning System
RCT randomized controlled trial

RSBY Rashtriya Swasthya Bima Yojana
SDG Sustainable Development Goal

SEIPS Systems Engineering Initiative for Patient Safety
SPO Structure-Process-Outcome

xxiv ACRONYMS AND ABBREVIATIONS
TB tuberculosis
TBA traditional birth attendant
UHC universal health coverage

UN United Nations
VAS Vajpayee Arogyashree Scheme
WHO World Health Organization
YLD years of life lived with disability

YLL years of life lost

Summary1
Between the health care that we have and the health care that we
could have lies not just a gap, but a chasm.
Institute of Medicine, Crossing the Quality Chasm, 2001
In 2015, building on the advances of the Millennium Development

Goals (MDGs), the United Nations declared a second global revolution
based on the Sustainable Development Goals (SDGs), which were adopted
by 193 countries. The SDGs include an explicit commitment to achieving
universal health coverage (UHC) by 2030 “so that all people and commu-
nities receive the quality services they need, and are protected from health
threats, without suffering financial hardship.” Accordingly, UHC is the
central theme of global health policy today. Yet, the evidence is clear: Even
if the movement toward UHC succeeds, billions of people will have access
to care of such low quality that it will not help them, and indeed often will
harm them. While the tremendous gains made against the burden of illness,
injury, and disability in recent years warrant celebration, these gains and
the new commitment to UHC are not sufficient to close the enormous gaps
that remain between what is achievable in human health and where global
health stands today, and progress has been both incomplete and unevenly
distributed. Thus, without a deliberate and comprehensive effort to improve
1 This summary does not include references. Citations to support the text and conclusions
herein are provided in the body of the report.

2 CROSSING THE GLOBAL QUALITY CHASM
the quality of health care services globally, UHC will too often prove to be
an empty vessel.
This report focuses on one particular shortfall in health care affecting
global populations: defects in the quality of care. The committee tasked
with conducting this study set out to review the available evidence on the
quality of care worldwide, with a special focus on low-resource areas. The
evidence demonstrates that, even when care is available, quality problems
are widespread and take many forms. For example, a study in China, India,
and Kenya found that providers adhered to evidence-based treatment for
such conditions as asthma, chest pain, diarrhea, and tuberculosis only 25
to 50 percent of the time. Thus, patients who visited a clinician for these
common, simple conditions in those settings often had less than a one in
two chance of being helped by that encounter. Even though the knowledge
for proper treatment exists, providers are not reliably absorbing and using
it for the right patients at the right time.
High levels of inappropriate care are also pervasive. For example,
a World Health Organization (WHO) report on overuse of ineffective
care states that more than 6 million excess caesarean sections are per-
formed every year (50 percent of which occur in China and Brazil). Another
example—the high rate of inappropriate use of antibiotics—not only is
harmful and costly to patients but also is an important contributor to the
global scourge of antimicrobial resistance. In the United States, 30 percent
of estimated prescriptions for antibiotics are found to be unnecessary.
Worldwide, moreover, the journeys of patients and their families through
the health care system are fragmented and difficult to navigate, and in some
cases can constitute such a negative experience that it deters them from
interacting with the system in the future.
THE DIRE STATE OF HEALTH CARE QUALITY

Health care in all global settings today suffers from high levels of
defects in quality across many domains, and this poor-quality care causes
ongoing damage to human health. Hospitalizations in low- and middle-
income countries (LMICs) lead to 134 million adverse events each year, and
these adverse events contribute to more than 2.5 million deaths annually.
More than 830 million people with a diagnosed noncommunicable disease
(NCD) are not being treated, and more than 4 million avoidable quality-
related deaths each year are attributable to ineffective care for NCDs. In
total, between 5.7 and 8.4 million deaths occur annually from poor quality
of care in LMICs for the selected set of conditions the committee analyzed
(see Figure S-1), which represents between 10 and 15 percent of the total
deaths in LMICs reported by WHO in 2015. For some conditions, deaths
due to poor quality contribute to more than half of overall deaths.

SUMMARY 3
FIGURE S-1 Overall number of deaths from poor-quality care annually in low- and middle-
income countries compared with total deaths, in thousands.
* Total deaths unavailable.
NOTE: AMI = acute myocardial infarction; COPD = chronic obstructive pulmonary disorder;
HIV = human immunodeficiency virus.
SOURCE: Institute for Health Metrics and Evaluation, Appendix D.
Poor-quality care is not limited to LMICs. Studies from such countries

as the United Kingdom and the United States reveal far too many prevent-
able deaths due to poor-quality care. These defects have high economic
costs as well. A recent Organisation for Economic Co-operation and De-
velopment (OECD) analysis found that 15 percent of all hospital costs in
OECD nations are due to patient harms from adverse events. Care is also
not reliably person-centered, and patients often report a negative experience
with their health care interactions. Indeed, the reported experiences of care
are sometimes even dismal, ranging from less than respectful care to abusive
behavior on the part of providers. The world’s poor are particularly vulner-
able to this kind of disrespect, but the problems are global.
In sum, defects in the quality of health care deny patients and commu-
nities the potential benefits of effective care. The currently prevailing forms,
habits, and models of care worldwide are incapable of bridging this global
quality chasm. Beyond the consequences for people’s health, costs rise
when defects in care—such as errors; failure to use effective care; overuse
of ineffective care; disregard of a person’s values and resources; and waste
of equipment, supplies, time, and spirit—are common. The committee has
attempted to quantify roughly the cost of poor quality in at least some low-
and middle-income settings, and found it to be enormous. Across LMICs,

4 CROSSING THE GLOBAL QUALITY CHASM
the costs of lost productivity alone due to poor-quality care amount to

between $1.4 trillion and $1.6 trillion each year. And this figure does not
include the immense costs incurred in health care systems as the result of
wasted resources and of having to deal with the downstream consequences
of errors and harms attributable to poor quality. Arguably, countries or
regions with the fewest resources can least afford this economic toll. Given
these costs, improving the quality of care may be one of the most powerful
strategies available for achieving affordable care and ensuring UHC.
The committee does not offer this dramatically worrisome picture of
the quality of global health care lightly. We understand fully that millions
of health care workers, managers, executives, and policy makers are strug-
gling daily to offer patients better care and better health, often in the face
of great obstacles. We also understand that, especially in the dire conditions
of extreme poverty or adversity, our calls for redesign, bold improvement,
and modernization may sound unrealistic. When there is no clean water or
when the supply chain for essential medicines is broken, it may seem unreal-
istic for us to suggest imagining a perfect patient journey or fully integrated,
seamless care. We intend nothing about this report or our recommenda-
tions to gainsay the basic, humanitarian agenda of ensuring essentials for
the people who lack them or to undercut the vast, unmet social needs for
justice, human rights, equity, and physical security. Nor do we wish in any
way to slow the long-overdue momentum toward UHC. Instead, we hope
to build on the lessons that have been learned worldwide, to call attention
to the gaps that remain for every country seeking higher-quality health care,
and to suggest how to bridge that chasm.
BUILDING ON HISTORY
In 2001, the Institute of Medicine (IOM) published a seminal report
on the state of quality in health care in the United States. The report’s title,
Crossing the Quality Chasm: A New Health System for the 21st Century,
heralds its conclusions. Speaking of Americans, it states: “Between the
health care that we have and the health care that we could have lies not just
a gap, but a chasm.” The report parses the concept of “quality of care” into
six basic dimensions. The committee charged with conducting the present
study, initiated in 2017, examined these six dimensions in reviewing the evi-
dence for the quality of health care globally and developing recommenda-
tions and a research agenda for its improvement. The committee concluded
that these six dimensions remain germane to the current global context
and that, with some modifications, they are thoroughly applicable to low-
resource settings and modern times. The committee’s modifications to the
six dimensions of the 2001 IOM report include changing the wording for
the “patient-centered” domain to “person-centered,” reflecting sensibilities

Another random document with
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drilled the counterpoise and the column for the governor spindle. I
suppose the twist-drill had its origin in these Hartford works.
I never saw any twist-drills in England except at Mr. Whitworth’s,
and these I thought were the funniest things I ever did see. They
were twisted by the blacksmith out of square bars and with a uniform
quick twist, were left rough, and did not fill the hole, and the ends
were flattened out in the form of the common drill to scrape, and not
to cut.
When I returned from England in 1868 twist-drills were coming into
general use in this country. After 1876 the firm of Smith & Coventry
introduced them in England.
At that time almost everything in machine-shops was done in the
old-fashioned way, and accuracy depended entirely on the skill of the
workman. The tool work left much to be done by the fitter.
Interchangeability was unknown, even in screw-threads. For
example, when nuts were removed from a cylinder head, pains had
always to be taken that each nut was replaced on its own bolt, as no
two were exactly of a size. This condition developed a class of very
skillful all-round workmen; but my earliest observation showed me
that in manufacturing it was important that so far as possible the
personal factor should be eliminated. I adopted the rule that in
mechanical work there was only one way to insure that anything
should always be done right, and that was to make it impossible that
it should be done wrong. For example, in my governor gears their
true running required that the bore should be absolutely correct, both
in position and in direction. I had seen many gears bored. They were
held in the jaws of a chuck and trued by marking their projecting side
when running with a piece of chalk. It was evident that absolute truth
could hardly ever be reached in this way, and the approximation to it
depended wholly on the skill and pains of the workman. Besides,
much time was lost in setting each wheel. These objections were
much aggravated in the case of bevel-gears.
I met these difficulties in this way. In standardizing my governors I
found it necessary to make eight sizes, but managed to use only
three different pairs of gears. I made a separate chuck for each of
these six wheels, the faces of which were turned to fit the top and
inner ends of the teeth, the same surfaces to which I had seen the
chalk applied. When the castings were received from the foundry the
first operation on them was to bed them to their chucks, which were
covered with a thin coating of red lead for this purpose. The
workman was careful to remove only projecting imperfections without
touching the true surfaces of the teeth. After this the gears, being
held firmly to their chucks by means of a yoke, were bored rapidly
and always with absolute truth. Result: their running was practically
noiseless.
Mr. Freeland taught me the secret of producing true cylindrical
surfaces by grinding with a wheel. It was to let the swiftly revolving
wheel traverse the surface as it rotated, touching only the highest
points, and these very lightly. This avoided the danger of errors from
the springing of either the piece or the wheel, which under strong
pressure is sure to take place to some extent, even in the best
grinding-machines. I have found this delicacy of touch to be a most
difficult thing to teach the ordinary workmen. They often manage to
produce by grinding a surface more imperfect than it was before.
I took extreme pains to insure that the axes of the joint pins should
intersect the axis of the governor spindle and those of the governor
balls, and should be equidistant from the center of the counterpoise,
these parts of the joints having been turned to true spherical forms
by means of a circular tool-rest. For this purpose I employed a
feeling-gauge, consisting of a cylindrical stem fitting the hole as
drilled, with a curved arm projecting from this stem and terminating in
a point that would rub on the external surface of the balls. By this
means we almost always detected some slight inaccuracy, which
was remedied by the use of a round file. The joint holes were
afterwards finished with long reamers, the cutting portion of which
was in the middle of their length. The front end of the reamer fitted
the drilled hole and extended quite through the joint, so guiding the
cutting edges as they entered, and the back end of the reamer filled
the hole that had been reamed.
I finally tested their alignment by bringing the last of the five joints
together after the others had been united, when the forked link
should swing freely to the ball without the least tendency in either
direction from its exact place. This it always did.
Some time afterwards I adopted the plan of dispensing with heads
and washers on the joint pins, reaming the holes in the central
portions of the joint slightly smaller than those in the arms and
making the pin a hard fit in the former. There was never any
tendency for a pin to get loose in the running of the governor. I also
at a later date cut the counterpoise in two a short distance above the
joints, so that the mass of its weight did not need to be started and
stopped when the speed of the governor changed. I could not see,
however, that this was of any advantage, although when the
governor balls were pulled around by hand no motion was imparted
to the mass of the counterpoise. The action was apparently quite
perfect before.
CHAPTER III
Invention and Application of my Marine Governor.
was anxious from the first to produce a governor

capable of being used on marine engines—which the
governor already described could not be, as it needed
to stand in a vertical position—and also one that
should be free from the limitations of the conical
pendulum. I gave a great deal of study to the subject,
and after worrying about it—I am ashamed to say how long, for the
principle when once seen is found to be exceedingly simple, being
merely maintaining a constant ratio between the compression of the
spring and the radius of the circle of revolution of the balls—I finally
perfected my marine governor and tried it in my shop, running it from
a hand-driven pulley, and found it perfectly isochronous. It was
capable of being adjusted to be as nearly isochronous as we thought
expedient consistent with stability of position.
This governor is represented in the cut that follows. The motion
imparted was small, from ³⁄₄ to 1¹⁄₂ inches in the different sizes, but
the governor was very strong. The balls are shown half expanded.
Before expansion their circle of revolution is 10 inches diameter;
when fully expanded it is 15 inches diameter; increase in diameter,
and so in centrifugal force, 50 per cent. The spring has an initial
compression given by the nut of 2 inches; additional compression
imparted by the expansion of the balls, 1 inch, giving an increase of
50 per cent. in the resistance. So in every position of the balls the
two forces are in equilibrium, at a constant number of revolutions per
minute.
My friend Mr. McLaren had the job of making repairs on the
vessels of the newly started North German Lloyd Line, and feeling
confident that my governor was what that line needed very much, he
obtained from the agents in New York an order for me to put one on
the steamer “New York” on a guarantee of perfect performance. This
was the first steamship of this line. The chief engineer of the vessel,
an Englishman, Mr. Sparks, told me in conversation that I could have
no idea how anxious they were in the engineering department for my
governor to be a success, because they had to throttle the ship by
hand, and it seemed sometimes as though their arms would drop off
before the end of their watch; but he was sorry to say that I could not
do it, and he would tell me why. “We know when the screw is coming
out of the water by the rising of the stern of the vessel, and we shut
the steam off beforehand, and so when the stern goes down we
know that it is going down into the sea and admit the steam to the
engine beforehand. Now, your governor cannot tell what is going to
happen. It cannot act until a change of motion has taken place which
will be too late, and so I am sorry to say that you cannot succeed.”
But in spite of his want of faith I obtained authority to attach the
governor.
On returning from his first voyage with it, Mr. Sparks said to me: “I
have nothing to say, Mr. Porter, except that we have sat quietly in our
chairs all the voyage, which has been a very stormy one, and
watched the engine moving as regularly as a clock, while the
governor has been in a state of incessant activity.”
The captain joined with him in giving me the following testimonials:
“Steamship ‘New York,’
“Pier 30, North River.
“To Mr. Chas. T. Porter:
“Sir: It affords me sincere pleasure to acknowledge the perfect success of your
patent marine governor, as applied to the engines of the above ship.
“On our passage from Southampton we had an excellent opportunity of testing
its merits fully, and I can assure you it had complete control over the engines at all
times. Not the slightest racing occurred, nor any of those sudden shocks that
happen with the best hand-throttling. It closed the valve at the right moment, and
as freely opened it again, thus maintaining a uniform speed throughout.
“To the proprietors of steamships, or engineers having charge of marine
engines, I can confidently recommend this most valuable invention, wishing it the
success so perfect a governor deserves.
“I am
“Respectfully yours,
“H. Sparks,
“Chief Engineer.
“May 30, 1861.”
“I cordially concur in the approbation of Mr. Porter’s governor, contained in the
foregoing letter of the chief engineer. We had several days of bad weather on the
last passage, and the ship, being very lightly laden, pitched excessively, so as to
throw the screw at times entirely out of the water.
“The motion of the engines and ship was at all times perfectly steady; scarcely a
jar was felt in the ship more than in calm weather.
“I would strongly recommend to all masters and engineers of screw steamships
to use this governor.
“G. Wenke,
“Master of the S. S. ‘New York.’
“New York, June 1, 1861.”
It may be supposed that with such an unqualified endorsement we

would have no difficulty in obtaining many orders. In fact, so long as
simple engines were used a good business was done in the
manufacture of these governors, but when compounding came into
use it was found that they regulated no more. The intermediate
receiver held steam enough when admitted to the low-pressure
cylinder to run the engine away when the screw came out of the
water, and the use of marine governors entirely ceased, and the
engines have ever since been allowed to race without any attempt to
control them.
This governor was not, however, to vanish like the stone-dressing
machine. About the time when the patent on it expired, its principle
came to be utilized in shaft governors. I do not know by whom this
application of it, which afterwards became so extensive, was first
made.
The Porter Marine Governor.
On the “New York” I made my first and only observation on the

subject of electrolysis. I was required to put in a special valve to be
operated by the governor. I put in a throttle valve of steam metal in a
cast-iron chamber. The spindle was of steel, 2 inches diameter, and
the valve was secured on it by three steel taper pins ⁵⁄₈ inch diameter
at one end and ¹⁄₂ inch at the other. For some reason, what it was I
have now no idea, on the return of the ship I took this valve chamber
out of the pipe, and found something I was not looking for. The
projecting ends of these pins, fully ¹⁄₂ inch long, had been completely
eaten away in one round trip. I had to replace them with composition
pins, which I always used afterwards.
Directly after the success of my marine governor on the “New
York” I went West to attempt its introduction on propellers running on
the Great Lakes. This journey resulted in the same financial success
that I had achieved at Pittsburg; but some incidents make it
interesting to me.
On taking my seat in a car for Albany I found my companion to be
Mr. Hiram Sibley, afterwards the founder of Sibley College of the
Mechanic Arts in Cornell University. When I lived in Rochester Mr.
Sibley was sheriff of Monroe County, of which Rochester is the
capital or shire town, and as a lawyer I was occasionally brought into
some relations with him. We had not met in eleven years, but we
instantly recognized each other. He was then enjoying the
triumphant outcome of his amazing foresight and boldness, and he
loved to talk about his experience, especially with an old Rochester
man who had known his associates there. In fact, he entertained me
all the way to Albany.
On the first burst of enthusiasm over the invention of the
telegraph, companies had been incorporated in many of the States
for the establishment of lines. These companies, it was found
directly, could not even pay their running expenses, because their
operations were confined to their respective States. Mr. Sibley was
the man for the hour. He conceived the plan of buying up the stock of
all these companies, which could be got for very little, and after this
had been secured incorporating a company to operate throughout
the United States. It is difficult now to put ourselves back to that time,
when the vastness of such a scheme would take men’s breath away.
Mr. Sibley succeeded in interesting the financial men of Rochester in
the enterprise, and the Western Union Telegraph Company was
formed. The story of his struggles to hold his subscribers, resisting
the appeals of some of them for the sake of their families to be
released from their obligations, was very amusing. He was obdurate
and enriched them all.
A few years later Mr. Sibley conceived a plan for a telegraph line
to San Francisco, and at his request a meeting was held of parties
holding large interests in the Western Union Telegraph Company to
consider the proposition. This was referred to a committee, who in
their report pronounced the scheme utterly visionary, and indulged in
considerable merriment over its absurdity, and the proposal was
unanimously rejected. Mr. Sibley then got up and said, “Gentlemen,
if I were not so old a man I would build the line myself.” This
declaration was received with peals of laughter. Then he got mad
and shouted over the din, “Damn it, gentlemen, I’ll bar the years and
do it”; and now he had done it. “And this very day,” said he, “I have
been solicited by merchants in New York to let them have shares in
California telegraph stock at the rate of five dollars for one, men
whom I had almost on my knees begged in vain for help to build the
line; but they could not get the stock.” I asked him, “Don’t you have
trouble from the Indians?” to which he replied: “The Indians are the
best friends we have got. They believe the Great Spirit is in that wire;
in fact, they know it, for they have seen him. The linemen had shown
them the electric sparks. The only trouble we have had has been
from the border ruffians of Missouri. We are now building a line
through Iowa, around the State of Missouri.”
On arriving at Buffalo I called first upon the firm of Shepard &
Company, who were the largest builders of engines for the lake
steamers. I did not succeed in persuading them that it would be for
their advantage to add to the cost of the engines they were building,
but they were very courteous and advised me to apply to the
companies owning the boats. I did not make much progress with
them, but the matter was left open for further consideration on my
return from Chicago. An official of one of the transportation
companies showed me over a new boat. I saw a valve in the steam-
pipe at some little distance from the engine, and asked him what it
was. He told me that was the cut-off. I asked him, “Why not place it
on the boiler?” He did not see the humor of the question, but replied
to me quite seriously, “Because it is a part of the engine.”
At the Shepard Works I said to the gentleman who conducted me
over the works, “I see you use the Corliss valve.” “Corliss valve,
indeed!” said he. “Come with me.” He then showed me their own
engine driving the shop, and fitted with the same valve, cutting off, of
course, at a fixed point. He said to me: “That engine has been
running in that very spot more than twenty years. Mr. Corliss once
visited these works, and I showed him around just as I am showing
you around. He was very much interested in the valves we were
making, and asked me a great many questions about them. It was
not very long afterwards that we began to hear from Providence
about the Corliss valve.”
I went on to Chicago, arriving on a Saturday afternoon. I went to
the house of an uncle, the Rev. Jeremiah Porter, who was a man of
some local prominence, having been the first missionary sent by the
American Home Missionary Society to Fort Dearborn, which stood
where Chicago is before Chicago was. I expected to set out Monday
morning to look for customers, but I changed my mind, for that
morning the telegraph brought the news of the battle of Bull Run,
which had been fought the day before, while I was in church hearing
my uncle preach. I did not think any one would have much heart for
business for some time to come, so hurried back home as fast as
steam could take me, not stopping in Buffalo.
Some years afterwards I had an amusing experience in attempting
to introduce my governor into the British navy. I called upon Mr. John
Penn, to whom I had sold one of my stationary governors for his own
works and who had become very much interested in the Richards
indicator, and I thought he would surely adopt my marine governor.
He told me, however, that he must set his face against it like a flint,
and explained as follows: “I do business entirely with governments,
principally the English government, and I come in contact with the
official mind, and I have to adapt myself to it. Should I put one of
your governors on an engine, my competitors would say: ‘Mr. Penn
is afraid to send his engines to sea without a governor, they are
made so delicately. Our engines, gentlemen, do not require any
governor,’ and they would take all the orders.”
Marine-engine builders generally did not seem to appreciate this
governor. While in Manchester I had an inquiry from Caird & Co. of
Greenock, the builders of the engines for the “New York,” and indeed
of the entire ship. They asked the price of my smallest marine
governor. I inquired the size of the vessel for which it was wanted.
Their reply was brief. “None of your business. We would like an
answer to our question.”
Some months after I received a letter from my foreman in New
York: “Mr. Porter, what in the name of common sense did you put
such a little governor on the ‘America’ for?” Caird & Co. had
performed their contract to supply a Porter governor, and had left a
suitable one to be ordered from my shop in New York.
Soon after the first arrival of the steamer “Kaiser Wilhelm der
Grosse,” about 1900 (I forget the year), I obtained a letter of
introduction to the chief engineer of that vessel, and called upon him
for the purpose of asking him to favor me with indicator diagrams
from its engines. In the course of conversation I said to him: “I have
rather a partiality for this line, for I put my first marine governor on its
first vessel, the old ‘New York,’ in ’61.” He replied to me: “I remember
that very well, Mr. Porter; I was an oiler on that ship.” He had risen
from that position to be chief engineer of the line. At that time the
Germans were commencing to form a steam marine. They had not
only to procure their vessels abroad, but also engineers to run the
machinery. They set in earnest about this development, and took out
of their polytechnic schools the brightest young men to put them on
foreign-built vessels and in foreign shops to learn the business, with
the wonderful results we are now witnessing, and the chief engineer
was one of those lads. He said to me: “I have an acquaintance in
your town, Montclair—Mr. Clemens Herschel,” a prominent civil
engineer. “He was an old friend and fellow student of mine in the
polytechnic.” About the diagrams, he said he would take a set for me
on their next voyage. He kept his promise. I have the diagrams now,
and very instructive ones they are.
CHAPTER IV
Engineering conditions in 1860. I meet Mr. Allen. Mr. Allen’s inventions. Analysis of
the Allen link.
efore resuming my narrative, it seems desirable to

present a brief sketch of steam engineering conditions
forty years ago.
The science of thermodynamics had been
established on the foundation laid in the experiments
of Joule, determining with precision the rate at which,
through the medium of water, heat is converted into dynamical force.
This science was, however, as yet without practical results. The
condensation of steam in the cylinder from the conversion of its heat
into mechanical energy was unregarded. The same was true also
respecting the far greater loss from the changing temperatures of the
surfaces with which the steam comes in contact in alternately
entering and leaving the cylinder. The action of these surfaces in
transmitting heat from the entering to the exhaust steam without its
doing any work was imagined by very few.
In the United States economy of steam was sought only by
mechanical means—by cutting off the admission of the steam at an
early point of the stroke in a single cylinder and permitting the
confined steam to complete the stroke by its expansion. By this
means a large saving of steam over that consumed in earlier
practice was effected, and with this gain the universal disposition
was to rest content.
America was eminently the land of the cut-off system, an early
application of which was on steamboats. The earliest device for this
purpose was the elegant Stevens cut-off, which still keeps its
position on the class of boats to which it was first applied, though
commonly modified by the Sickles improvement. In this system the
exhaust and the admission valves are operated by separate
eccentrics on opposite sides of the engine, and all the valves have
the amount and rapidity of their opening and closing movements
increased by the intervention of wiper cams, those for the admission
valves being very long and giving a correspondingly greater
enlargement of opening. The valves were double poppet valves,
moving nearly in equilibrium in directions vertical to their seats. This
cut-off was found to be capable of improvement in one important
respect. The closing motion of the valve grew slower as the valve
approached its seat, and while the piston was moving most rapidly
much steam passed through the ports at a lower pressure, and so a
great part of its expansive value was lost. This was technically
termed “wire-drawing.” To remedy this defect Mr. Sickels invented his
celebrated trip cut-off. The valve, lifted by the Stevens wiper, was
liberated by tripping the mechanism, and fell quickly to its seat,
which it was prevented from striking forcibly, being caught by water
in a dash-pot. The steam was thus cut off sharply and the economy
was much improved. The pressure used in this system was only
about 25 pounds, the vacuum being relied upon for the larger portion
of the power.
On the Great Lakes a pressure of 60 pounds was commonly
employed, and the valves were the four cylindrical rotating slide
valves afterwards adopted by Mr. Corliss. What was called the cut-
off was made by a separate valve located in the steam-pipe
somewhere between the engine and the boiler.
On the Mississippi and its tributaries, much higher pressures were
carried, condensers were not used, and the admission and release
of the steam were generally effected by four single poppet valves,
lifted by cams against the pressure of the steam.
On land engines Mr. Sickels’ invention of the trip cut-off stimulated
inventors to a multitude of devices for working steam expansively. Of
these the one of enduring excellence proved to be that of Mr. Corliss.
He applied the trip cut-off to the rotating slide valve, and arrested the
motion of the liberated valve by an air-cushion. This proved a
satisfactory method, as the valve, moving in directions parallel to its
seat, did not need to be stopped at a determinate point. Mr. Corliss
applied the governor to vary the point of liberation of the valve, and
so produced a variable cut-off, which effected a large saving of
steam and regulated the motion of the engine more closely than
could be done by a throttle valve outside the steam-chest. This was
by far the most prominent of the numerous forms of automatic
variable cut-offs, to all of which it was supposed that the liberating
feature was essential.
In England, when the steam was worked expansively, it was cut off
by a separately driven valve on the back of the main slide valve, the
point of cut-off being fixed; and the regulation was effected by means
of the throttle. This system was also largely employed in this country.
The compound engine was unknown in the United States. I once
saw at some place in New York City, now forgotten, a Wolff engine—
a small beam-engine, which had been imported from England. It was
visited as a curiosity by several engineers, and I remember Mr.
Horatio Allen, then president of the Novelty Iron Works, remarking,
“It is only a cut-off.”
In the south of England the Wolff system was used to a limited
extent. I was much interested in the McNaught system, devised, I
think, by the same Scotchman who first applied a rotating paper
drum to the Watt indicator. The cotton and woolen mills, as their
business grew, felt the need of additional power, but dared not
employ higher steam pressures in their cylinders, because the beam
centers of their engines would not stand the additional stress.
McNaught provided an additional cylinder to carry a higher pressure,
and applied this pressure directly to the connecting-rod end of the
beam. The exhaust from this cylinder was taken into the old cylinder
at the old pressure. This latter cylinder then exerted the same power
it always had done. The stresses on the beam centers were not
increased, but the power of the engine was doubled, and only a little
more steam was used than before. This method of compounding
was known as McNaughting, and became common in the
manufacturing districts of England and Scotland.
There was one feature which was common to all engines in
America and Europe, both ashore and afloat, and of whatever make
or name, except locomotives. That was the piston speed, which
varied only from 200 to 300 feet per minute. This last was the
maximum speed, to which every new engine, however novel in other
respects, was made to conform.
I come now to the turning-point in my career, and the reflection
forces itself upon me, how often in the course of my life incidents
trivial in themselves have proved afterwards to have been big with
consequences; and how events, sometimes chains of events,
beyond my control, of which indeed I had no knowledge, have
determined my course. The same must be the case in the lives of
many persons, and the thoughtful mind cannot look back on them
without being impressed by the mysterious interrelations of our
being.
One morning in the winter of 1860-61, Mr. Henry A. Hurlbut, of the
firm of Swift, Hurlbut & Co., wholesale dealers in hats at No. 65
Broadway, and who was interested in my governor manufacture,
called upon me to tell me that a friend of his, Mr. Henry A. Burr,
manufacturer of felt hat bodies at the corner of Frankfort and Cliff
streets in New York, had been having trouble with his engine. He
thought my governor was just what he needed, and asked me to
accompany him to Mr. Burr’s office, where he would give me the
advantage of his personal introduction. In the interview with Mr. Burr
which followed, I did not have an opportunity to say a word. After Mr.
Hurlbut had explained the object of our visit, Mr. Burr replied that he
had had a great deal of trouble with the regulation of his engine, and
had thought seriously of getting a Corliss engine in the place of it;
but two or three weeks before the builders of the engine had sent
him a very skillful engineer, and since he came there had been no
further trouble, so he should not need my governor. He invited us to
see his engine, in which—since it had been taught to behave itself—
he evidently took much pride. We found a pair of beam-engines of 5
feet stroke, running at 25 revolutions per minute, made by Thurston
& Gardiner of Providence. They had the usual poppet valves and the
Sickels cut-off. This was made adjustable, and was regulated by the
governor. At the time of our entrance, Mr. Allen, the new engineer,
was engaged on the scaffold. Mr. Burr called him and he came
down, and at Mr. Burr’s request explained to us the variable
liberating mechanism and what he had done to make it work
satisfactorily. The regulation did not appear to me to be very close,
and I made a determined effort to induce Mr. Burr to substitute one
of my governors. I showed him a cut of the governor, and pointed out
its combination of power and sensitiveness, but all in vain. He was
satisfied with things as they were, and I went away crestfallen,
having lost not only the sale of a governor, but also an opportunity
for a triumph in a very important place. But I did not know to whom I
had in fact been talking.
As we were leaving, Mr. Allen asked me if I would call some time
and see him—he had something he thought I would be interested in.
I called soon after. He told me he had a plan for a variable cut-off
with positive movements, which he thought would avoid defects in
the liberating gear. He had had it in his mind a good while, but did
not think it could be used, because the governor could not handle
the block in his link so as to maintain uniform motion, and he had
been inclined to abandon the idea; but when he heard me describing
my governor to Mr. Burr, it occurred to him that that governor would
do it, and he would like to explain his plan to me. He had no drawing,
not a line; the design existed only in his mind. He put down his ideas,
as he fitly expressed it, with chalk on the engine-room floor, and that
rude sketch represented the perfect system.
When his plan came to be analyzed, it was found that everything
had been thought out and provided for, with a single exception
afterwards provided by Mr. Allen, as will be described. But the
wonder did not stop there. Mr. Allen had remedied the defect in the
link motion of making a narrow opening for admission when cutting
off early, by employing a four-opening admission valve of unique
design at each end of the cylinder, and also by greatly enlarging the
opening movements.
The four-opening valve required four seats in one plane, and it
was important that these should be as narrow as possible. For this
purpose Mr. Allen employed the Corliss wrist-plate movement to
reduce the lap of the valve, and, by an elegant improvement on this
movement, he made it available also to enlarge the openings. This
improvement consisted in the employment of two rockers having a
common axis and separate driving-arms, as well as driven arms, for
each valve. The driving-arms were made to vibrate a long way
towards their dead points, and the increased opening movement in
arc thus obtained was imparted directly to the valve. This
combination of an enlarged opening with a reduced lap was perhaps
the most surprising feature of Mr. Allen’s system.
The four-opening equilibrium valve, afterwards invented by Mr.
Allen and since 1876 always employed, requires but two seats in
one plane. These could therefore be made wider. The division of the
driving-arm was then dispensed with, and the enlarged openings
were obtained by increasing the length of the driven arms.
That this remarkable system of ports and movements should have
been elaborated in the mind of a man who had no knowledge of
mechanics except what he had absorbed in engine-rooms must
stand among the marvels of inventive power.
The accompanying diagram represents the lines put down by Mr.
Allen on his engine-room floor and since retained, except that it is
now adapted to the more simple movement, with a single driving-arm
on the rocker, as previously described.
The eccentric is formed on the shaft coincident with the crank of
the engine, so that the two arrive at their dead points simultaneously.
The angular vibration of the line connecting the center of the
eccentric with the trunnions of the link is the same as that of the
connecting-rod.
The connecting-rod of the length always used by me, namely, six
cranks, makes the piston velocity at the head end of the cylinder 40
per cent. greater than at the crank end. By this construction the valve
velocities were made to vary in the same ratio.
A connecting-rod five cranks in length would increase this
difference in piston velocities to 50 per cent., and one four cranks in
length would increase it to 66 per cent.
After Mr. Allen had explained his plan to me, I expressed my
confidence that my governor would meet its requirements, and
observed that it would enable a variable cut-off engine to be run as
fast as a locomotive. Somewhat to my surprise, he replied that he
wanted his cut-off compared with the liberating cut-off turn for turn;
that it had an advantage which he thought would cause it to be
generally preferred at the same speed.
RELEASE AND
COMPRESSION
¹⁵⁄₁₆ OF THE STROKE
PORTER-ALLEN ENGINE.
DIAGRAM OF ADMISSION-VALVE
MOVEMENTS.
¹⁄₂ CUT OFF ¹⁄₂ CUT OFF
³⁄₈ CUT OFF ³⁄₈ CUT OFF
MEAN POSITION OF ROD ¹⁄₄ CUT ¹⁄₄ CUT OFF
TO VALVE
AT OFF ¹⁄₈ CUT OFF
CRANK ¹⁄₈ CUT
END OFF
RADIUS OF LINK
TO VALVE
AT
HEAD END
A. POINTS OF ADMISSION AND CUT-OFF.
FOR DISTINCTNESS OF REPRESENTATION, THE THROW
OF THE ECCENTRIC IS SHOWN ¹⁄₄ THAT OF THE CRANK.
IN PRACTICE IT IS ONLY ¹⁄₁₂ THAT OF THE CRANK.
The Diagram Drawn by Mr. Allen on his Engine-room Floor.

John F. Allen
I was then ignorant of his state of mind on that subject, or of what
had produced it. I learned these afterwards, and will state them here.
In one of our interviews, in reply to my question as to what had led
him to make this invention, he told me it was his experience when he
was engineer of the propeller “Curlew,” a freight-boat running on
Long Island Sound, between New York and Providence, which had a
Corliss engine. He became impressed with what he thought to be a
serious defect in the liberating system. The governor did not control
the point of cut-off, but the point of release; this point being at the
beginning of the closing movement of the valve, while the cut-off
took place near the end of that movement. When the engine was
worked up to nearly its capacity, as was the case in a ship, the port
was opened wide, and quite an appreciable time elapsed between
the release and the cut-off. During this interval the piston advanced
considerably, and if the engine ran fast enough it might get to the
very end of the stroke before the cut-off took place. He said that in
smooth water they had no trouble, but in the open ocean, going
around Point Judith, it was always rough, and sometimes in stormy
weather the screw would be thrown quite out of the water, and the
engine, having no fly-wheel, would race most furiously. The faster it
ran the further the steam would follow, and was pumped out of the
boiler very rapidly. Springs were employed to accelerate the closing
movement of the valves, but in these cases they seemed to be of
little use, and were continually breaking. He saw that this difficulty
could be avoided only by a positive motion gear which would enable
the governor to control the point of cut-off itself; and, accordingly, he
set himself to work to devise such a system. We know now that this
judgment, formed from observations made under very exceptional
conditions, was not well founded. The difficulty in question does not
practically exist in engines having fly-wheels and the present
improved liberating gear, and running at moderate speeds; but the
experience naturally made a deep impression upon Mr. Allen’s mind,
and led to the invention of the positive motion system.
This he did not tell me at the time, so that I was at a loss to
understand his reluctance to admit what was really the great value of
his invention. However, I told him I would be willing to attempt its
introduction, provided he would allow me to apply it at once to a

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Crossing the Global Quality Chasm:

Improving Health Care Worldwide The

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National Academies of Sciences, Engineering, and Medicine 2018. Crossing the

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Committee on Improving the Quality of Health Care Globally

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Health and Medicine Division

A Consensus Study Report of

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The National Academy of Sciences was established in 1863 by an Act of

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Consensus Study Reports published by the National Academies of Sciences,

Proceedings published by the National Academies of Sciences, Engineering, and

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COMITTEE ON IMPROVING THE QUALITY

DONALD M. BERWICK (Co-Chair), Institute for Healthcare

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This Consensus Study Report was reviewed in draft form by individuals

JEFFREY BRAITHWAITE, Macquarie University

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AZIZ SHEIKH, The University of Edinburgh

Although the reviewers listed above provided many constructive com-

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Donald M. Berwick, Co-Chair

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ACRONYMS AND ABBREVIATIONS xxi

PART I: THE IDEAL VISION FOR FUTURE HEALTH CARE

2 THE PATH TO A HIGH-QUALITY FUTURE:

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3 OPTIMIZING THE PATIENT JOURNEY BY

PART II: THE CURRENT STATE OF QUALITY IN HEALTH CARE

4 THE CURRENT STATE OF GLOBAL HEALTH CARE

5 HIGH-QUALITY CARE FOR EVERYONE: MAKING

6 THE CRITICAL HEALTH IMPACTS OF CORRUPTION 203