Health System Reform: Health System Reform: Doing the Doing the Right Thing Right Thing ANDAND Doing Things Right Doing Things Right

Carolyn M. Clancy, MDCarolyn M. Clancy, MDDirectorDirector

Agency for Healthcare Research and QualityAgency for Healthcare Research and Quality

Alliance for Health Care ReformAlliance for Health Care ReformWashington, DC – March 27, 2009Washington, DC – March 27, 2009

Treating Cardiac PatientsTreating Cardiac Patients

““In the current, long-overdue In the current, long-overdue debate about health care, the debate about health care, the focus is almost entirely on health focus is almost entirely on health insurance. And there is no insurance. And there is no question that the country would be question that the country would be better off if everyone were better off if everyone were covered. But the gaps in insurance covered. But the gaps in insurance aren’t the only problem with the aren’t the only problem with the medical system. They are not even medical system. They are not even the biggest problem.”the biggest problem.”

New York TimesNew York TimesMarch 7, 2007March 7, 2007

The Importance of Reforming The Importance of Reforming Health Care DeliveryHealth Care Delivery

Making Reform of the Making Reform of the Health Care Delivery Health Care Delivery System a Part of System a Part of Health Care ReformHealth Care Reform

Success StoriesSuccess Stories

2121stst Century Health Century Health CareCare

AHRQ’s MissionAHRQ’s Mission

Improve the quality, safety, Improve the quality, safety, efficiency and effectiveness of efficiency and effectiveness of health care for all Americanshealth care for all Americans

AHRQ PrioritiesAHRQ Priorities

Effective HealthEffective HealthCare ProgramCare Program

Medical ExpenditureMedical ExpenditurePanel SurveysPanel Surveys

AmbulatoryAmbulatoryPatient SafetyPatient Safety

PatientPatient Safety Safety

Health IT Patient Safety

Organizations New Patient

Safety Grants Comparative Effectiveness Reviews

Comparative Effectiveness Research

Clear Findings for Multiple Audiences

Quality & Cost-Effectiveness, e.g.Prevention and PharmaceuticalOutcomes

U.S. Preventive ServicesTask Force

MRSA/HAIs

Visit-Level Information on Medical Expenditures

Annual Quality & Disparities Reports

Safety & Quality Measures,Drug Management andPatient-Centered Care

Patient Safety ImprovementCorps

Other Research & Other Research & Dissemination ActivitiesDissemination Activities

Key ChallengeKey Challenge

We’re not going to get to high-quality We’re not going to get to high-quality high-value health care until we put a lot high-value health care until we put a lot more focus on doing things rightmore focus on doing things right– Comparative effectiveness research is Comparative effectiveness research is

about doing the right thingabout doing the right thing

– System reform is about doing things rightSystem reform is about doing things right

Pronovost StudyPronovost Study

Settings: Volunteer MI hospital Settings: Volunteer MI hospital ICUs for adults (108 intention to ICUs for adults (108 intention to treat)treat)

Primary hypothesis: Rate of Primary hypothesis: Rate of CABSIs would be reduced during CABSIs would be reduced during first 3 months of intervention v first 3 months of intervention v baselinebaseline

Multiple interventions (sequential Multiple interventions (sequential and parallel)and parallel)

Outcome measure: Incidence-Outcome measure: Incidence-rate ratios for CABSIs rate ratios for CABSIs

Pronovost et al., NEJM 355(26); Dec. 28, 2006Pronovost et al., NEJM 355(26); Dec. 28, 2006

Analytic approach: Generalized linear latent and mixed Analytic approach: Generalized linear latent and mixed model with robust variance estimation and random effects model with robust variance estimation and random effects to account for clustering within hospitals and hospitals to account for clustering within hospitals and hospitals within regions, adjusted for hospital teaching status and within regions, adjusted for hospital teaching status and number of bedsnumber of beds

New Yorker, December 2007New Yorker, December 2007

CLBSI-Reduction Program:CLBSI-Reduction Program:10 State Pilot10 State Pilot

 

10 States10 States Experts will help Experts will help hospital ICUs in hospital ICUs in these states:these states:• CaliforniaCalifornia• ColoradoColorado• FloridaFlorida• MassachusettsMassachusetts• NebraskaNebraska• North Carolina North Carolina • Ohio Ohio • PennsylvaniaPennsylvania• Texas Texas • Washington Washington

Builds on the Keystone ProjectBuilds on the Keystone Project

AHRQ Health IT AHRQ Health IT Research FundingResearch Funding

Long-term agency priorityLong-term agency priority– More than 200 projects More than 200 projects

and demonstrations to and demonstrations to improve the safety, improve the safety, quality and efficiency of quality and efficiency of health care in virtually health care in virtually every stateevery state

– Focus on the adoption Focus on the adoption of health ITof health IT

– Projects in 43 statesProjects in 43 states

AHRQ Health IT AHRQ Health IT Investment: $260 Investment: $260

MillionMillion

AHRQ-Sponsored Interactive AHRQ-Sponsored Interactive Preventive Health Record Preventive Health Record

(IPHR)(IPHR)

Virginia Commonwealth University IPHR Virginia Commonwealth University IPHR called My Preventive Health Care designed to called My Preventive Health Care designed to increase the delivery of health care servicesincrease the delivery of health care services

Goals include determining whether the IPHR Goals include determining whether the IPHR increases delivery and patients use it, and increases delivery and patients use it, and whether it increases shared decision making whether it increases shared decision making and improves communicationand improves communication

Involves seven primary care practices in the Involves seven primary care practices in the Virginia Ambulatory Care Outcomes Network Virginia Ambulatory Care Outcomes Network (ACORN)(ACORN)

Project End – August 31, 2010

Promoting Patient-Centered CarePromoting Patient-Centered Care

Communication is a Communication is a Core Component of HROsCore Component of HROs

TeamSTEPPSTeamSTEPPS Toolkit Toolkit

Team Strategies & Tools to Enhance Team Strategies & Tools to Enhance Performance & Patient Safety Performance & Patient Safety

– Improves communication & Improves communication & teamwork skills among health teamwork skills among health care professionals care professionals

– Collaboration between AHRQ Collaboration between AHRQ and the Department of and the Department of Defense’s military health systemDefense’s military health system

– Adopted in the U.S. and Adopted in the U.S. and internationally, in places including internationally, in places including Singapore and Southern Australia Singapore and Southern Australia

Evidence-Based Team Training and ImplementationEvidence-Based Team Training and Implementation

AHRQ/DoD InitiativesAHRQ/DoD Initiatives

Activities began in 2002Activities began in 2002 AHRQ issued PSO Task Order AHRQ issued PSO Task Order

Contract to American Institutes of Contract to American Institutes of Research (AIR)Research (AIR)

Expert PanelExpert Panel Comprehensive Literature ReviewComprehensive Literature Review Case Study AnalysisCase Study Analysis Journals/ArticlesJournals/Articles PresentationsPresentations Clinical Measures of Teamness Clinical Measures of Teamness

(RAND evaluation contract Mod)(RAND evaluation contract Mod) Medical Team Training Curriculum Medical Team Training Curriculum

TeamSTEPPSTeamSTEPPS

Edited HandbookEdited Handbook

Evidence-Based

Methods

Tools forTraining and

Measurement

Principles andGuidelines

Collaboration ProductsCollaboration Products

Teamwork in Teamwork in Professional Professional

EducationEducation

Relevant Evidence Relevant Evidence Teamwork in Teamwork in HealthcareHealthcare

Teamwork Teamwork & &

SimulationSimulation

National Implementation TeamNational Implementation Team

Carilion TRC

Duke TRC

Creighton TRC

Minnesota -TRC

AIR

Lumetra

Delmarva

Booz | Allen | Hamilton

Trained more than 1,000 Master Trainers who have trained 8,000 traineesTrained more than 1,000 Master Trainers who have trained 8,000 trainees

New Book on New Book on Evidence-Based NursingEvidence-Based Nursing

More than 90 experts, 51 peer-More than 90 experts, 51 peer-reviewed chapters reviewed chapters

Intended for all nurses, especially Intended for all nurses, especially those in universities and hospitalsthose in universities and hospitals

Provides practice implications for Provides practice implications for nurses and sets forth a research nurses and sets forth a research agendaagenda

Links with curriculum on patient safety Links with curriculum on patient safety & quality improvement – developed by & quality improvement – developed by UNCUNC

Patient Safety & Quality: An Evidence-Based Handbook for Nurses

www.ahrq.gov/qual/nurseshdbkwww.ahrq.gov/qual/nurseshdbk

Co-sponsored by RWJFCo-sponsored by RWJF

Re-Engineered Hospital Re-Engineered Hospital Discharge Program (RED)Discharge Program (RED)

AHRQ-funded research AHRQ-funded research program at Boston University program at Boston University Medical Center, Department Medical Center, Department of Family Medicineof Family Medicine

– RED patients had 30 percent RED patients had 30 percent fewer subsequent emergency fewer subsequent emergency visits and readmissionsvisits and readmissions

RCT-tested, designed to RCT-tested, designed to educate patients about their educate patients about their post-hospital care planspost-hospital care plans

Ongoing research is testing Ongoing research is testing the automation of discharge the automation of discharge principles in RED principles in RED

More than 1,400 hospitals have signed up to dateMore than 1,400 hospitals have signed up to date

Delivery of Health Care Delivery of Health Care is a Team Sport is a Team Sport

Having a common Having a common understanding and a understanding and a common strategy for common strategy for addressing the issuesaddressing the issues

Collecting enough data Collecting enough data to monitor progressto monitor progress

Adapting based on the Adapting based on the specific circumstances specific circumstances involvedinvolved

2121stst Century Health Care Century Health Care

Improving quality by promoting a culture of safety Improving quality by promoting a culture of safety through Value-Driven Health Carethrough Value-Driven Health Care

21st Century Health Care

Information-rich, patient-Information-rich, patient-focused enterprisesfocused enterprises

Information and Information and evidence transform evidence transform

interactions from interactions from reactive to reactive to

proactive (benefits proactive (benefits and harms)and harms)

Evidence is Evidence is continually refined continually refined as a by-product of as a by-product of

care deliverycare delivery

Actionable information available – to Actionable information available – to clinicians AND patients – “just in time”clinicians AND patients – “just in time”

Your questionsYour questions??