Federal Government Initiatives to Improve Healthcare Quality

Federal Government Initiatives Federal Government Initiatives to Improve Healthcare Qualityto Improve Healthcare Quality

Carolyn M. Clancy, MDCarolyn M. Clancy, MDDirectorDirector

Agency for Healthcare Research and QualityAgency for Healthcare Research and QualityQuality ColloquiumQuality ColloquiumAugust 22, 2005August 22, 2005

AHRQ’s MissionAHRQ’s Mission

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

HHS Organizational FocusHHS Organizational Focus

NIH

Biomedical research to prevent, diagnose and treat diseases


NIH


CDC

Population health and the role of community-based interventions to improve health


NIH


CDC

Population health and the role of community-based interventions to improve health

AHRQ

Long-term and system-wide improvement of health care quality and effectiveness

InitiativesInitiatives

National Healthcare Quality National Healthcare Quality and Disparities Reportsand Disparities Reports

Quality, safety and health Quality, safety and health information technologyinformation technology

New patient safety legislationNew patient safety legislation Effective Health Care ProgramEffective Health Care Program Educating consumers about Educating consumers about

healthcare choiceshealthcare choices

Congressionally mandated annual reports focus Congressionally mandated annual reports focus on quality of and disparities in U.S. health careon quality of and disparities in U.S. health care

–Quality ReportQuality Report finds finds that quality is improving that quality is improving and identifies areas and identifies areas which are in need of which are in need of major improvementsmajor improvements

–Disparities ReportDisparities Report indicates that there are indicates that there are pervasive disparities pervasive disparities related to race, related to race, ethnicity, and ethnicity, and socioeconomic statussocioeconomic status

National Healthcare Quality and National Healthcare Quality and Disparities ReportsDisparities Reports

First national comprehensive efforts to measure the First national comprehensive efforts to measure the quality of health care in America and differences in quality of health care in America and differences in access to health care services for priority populationsaccess to health care services for priority populations

– Presents data for clinical conditions, including cancer, Presents data for clinical conditions, including cancer, diabetes, end-stage renal disease, heart disease, HIV diabetes, end-stage renal disease, heart disease, HIV and AIDS, mental health, and respiratory diseaseand AIDS, mental health, and respiratory disease

– Includes data on maternal and child health, nursing Includes data on maternal and child health, nursing home and home health care, and patient safetyhome and home health care, and patient safety

Reports available at: http://www.qualitytools.ahrq.govReports available at: http://www.qualitytools.ahrq.gov


How Reports Are RelatedHow Reports Are Related

NHQRNHQR

NHDRNHDR

NHQR is foundation -- NHQR is foundation -- analyzes quality across analyzes quality across components of quality components of quality and priority conditionsand priority conditions

NHDR examines NHDR examines quality and access for quality and access for priority populationspriority populations

Disparities in Quality of Care Disparities in Quality of Care for Medicare Enrolleesfor Medicare Enrollees

0

10

20

30

40

50

60

70

80

Eye Exam inDiabetics

Beta Blockerpost MI

Follow uppost-hosp

WhiteBlack

Schneider et al. JAMA 2002

Take Home PointsTake Home Points

Poorer quality care consistently observed for racial Poorer quality care consistently observed for racial and ethnic minorities, worse if combined with low and ethnic minorities, worse if combined with low income and educationincome and education

Patterns vary by condition, service and by communityPatterns vary by condition, service and by community Improvement is possibleImprovement is possible National Healthcare Disparities Report provides National Healthcare Disparities Report provides

roadmap for improvementsroadmap for improvements

Recent disparities researchRecent disparities research

3 new studies, including an AHRQ-3 new studies, including an AHRQ-supported study, suggest some supported study, suggest some improvements in health care equality improvements in health care equality among black and white U.S. residentsamong black and white U.S. residents

Significant disparities remain for black Significant disparities remain for black patients, including less access to patients, including less access to operations tests, medications and operations tests, medications and other treatmentsother treatments

National Health Plan Learning National Health Plan Learning Collaborative to Reduce DisparitiesCollaborative to Reduce Disparities

Public/private partnership to reduce disparities in health care Public/private partnership to reduce disparities in health care for people with diabetes and other conditions (AHRQ and for people with diabetes and other conditions (AHRQ and RWJ)RWJ)

Over next 3 years, collaborative will test ways to improve Over next 3 years, collaborative will test ways to improve collection and analysis of data on race and ethnicity and collection and analysis of data on race and ethnicity and match data to existing quality measures to close gap in carematch data to existing quality measures to close gap in care

9 National Health Plans Sponsored by nine of Nation’s 9 National Health Plans Sponsored by nine of Nation’s largest health insurance plans, and other organizations largest health insurance plans, and other organizations (serving commercial, Medicare, and Medicaid).(serving commercial, Medicare, and Medicaid).

Participating Health PlansParticipating Health Plans

AETNAAETNA*Anthem BCBS*Anthem BCBSCigna HealthCareCigna HealthCareHarvard PilgrimHarvard PilgrimHealth PartnersHealth PartnersHighmark Blue Highmark Blue

Cross Blue ShieldCross Blue ShieldKaiser PermanenteKaiser Permanente

Molina HealthcareMolina HealthcareUnited Healthcare United Healthcare

(UnitedHealth (UnitedHealth Group and Group and Ovations, Senior Ovations, Senior and Retiree and Retiree Services)Services)

*Wellpoint *Wellpoint

TOTAL ENROLLEES = 76,748,227

*Anthem and Wellpoint have merged to form Wellpoint, Inc.

Quality Quality isis improving, improving, slowly slowly

Most measures have shown some improvementMost measures have shown some improvement– Nearly twice as many measures have improved as have Nearly twice as many measures have improved as have

deteriorated deteriorated Some specific examples:Some specific examples:

– 37% decrease in percentage of nursing home patients 37% decrease in percentage of nursing home patients who have moderate to severe pain who have moderate to severe pain

– 34% decrease in the hospital admission rate for 34% decrease in the hospital admission rate for uncontrolled diabetes uncontrolled diabetes

– 32% increase in the percentage of persons living in long-32% increase in the percentage of persons living in long-term care or nursing home facilities who were given term care or nursing home facilities who were given pneumococcal vaccinations pneumococcal vaccinations

Pace of Change VariesPace of Change VariesAcross Care SettingsAcross Care Settings

Of 98 measures Of 98 measures with trend data, with trend data, 88 can be 88 can be mapped to care mapped to care settingssettings

Some Some improvement improvement seen in all seen in all settingssettings

However, change However, change in performance in performance varies across varies across settingssettings

5.4%

1.4%3.0%

14.7%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

Hospital care Ambulatorycare

Home healthcare

Nursing homecare

Setting

Med

ian

per

cen

t ch

ang

e

(24 measures) (5 measures)( 12 measures)(49 measures)

AHRQ Quality Connect AHRQ Quality Connect

Help States Help States identify where they need to improveidentify where they need to improve health health care quality care quality

Assist states in Assist states in developing and implementing action plansdeveloping and implementing action plans to improve health care qualityto improve health care quality

Provide Provide technical assistancetechnical assistance for new and existing quality for new and existing quality improvement efforts at the State and local levelimprovement efforts at the State and local level

Facilitate Facilitate more rapid adoptionmore rapid adoption of promising quality of promising quality improvement practices through communication among states improvement practices through communication among states and local communities, peer based learning networks, and and local communities, peer based learning networks, and facilitation of State teams facilitation of State teams

Bridging the Quality ChasmBridging the Quality Chasm

Where Where weWhere Where wewe are want to bewe are want to be

InnovationInnovation

AdoptioAdoptionn

Health IT

Diffusion

Intersection of Safety, Quality Intersection of Safety, Quality and Health Information Technologyand Health Information Technology

Support diffusion of HITSupport diffusion of HIT – 38 states38 states– 40 million Americans40 million Americans

Improve medication safetyImprove medication safety– CMS e-prescribing CMS e-prescribing

demosdemos Provide HIT technical Provide HIT technical

support to the safety netsupport to the safety net– Community health Community health

centers centers – Critical access hospitalsCritical access hospitals– Public hospitals (HHC)Public hospitals (HHC)

AHRQ

Health IT: A Means to An EndHealth IT: A Means to An End

AHRQ’s Role: Prove Health IT works AHRQ’s Role: Prove Health IT works

in real-life clinical settingsin real-life clinical settings How does Health IT drive safety and How does Health IT drive safety and

quality improvement?quality improvement? How can we ensure that doing the right How can we ensure that doing the right

thing is the easy thing to do? thing is the easy thing to do? How can we use the power of Health IT How can we use the power of Health IT

to provide better quality measures to provide better quality measures faster? faster?

Lappé, J. M. et. al. Ann Intern Med 2004;141:446-453

Proportions of patients receiving the appropriate discharge prescriptions

Systems + Measurement + HIT Systems + Measurement + HIT Improved QualityImproved Quality

Intermountain Intermountain Health Care QI Health Care QI effort on CVD effort on CVD

Results:Results:– 90% 90%

prescription prescription ratesrates

– 27% decrease 27% decrease in unadjusted in unadjusted absolute death absolute death rates rates

How AHRQ Is HelpingHow AHRQ Is Helping

We fund grants and contracts We fund grants and contracts to to promotepromote Health IT investment, especially Health IT investment, especially in rural and underserved areasin rural and underserved areas

We evaluate We evaluate what works best, where what works best, where barriers exist, and how Health IT can be barriers exist, and how Health IT can be successfully implementedsuccessfully implemented

We offer technical assistance We offer technical assistance through through ourour National Resource Center on Health National Resource Center on Health Information Technology to help clinicians Information Technology to help clinicians make the leap from pencils to PDAsmake the leap from pencils to PDAs

National Resource Centerfor Health IT

AHRQ Health IT Portfolio AHRQ Health IT Portfolio

Planning1 yr

Implementation3 yr

DemonstratingValue

3 yr

State and Regional Demonstrations5 yr

Health IT GrantsHealth IT Grants

Promote access to Health ITPromote access to Health IT $139 million $139 million investment over 5 yearsinvestment over 5 years OverOver 100100 grantsgrants to communities, to communities,

hospitals, providers, and health care hospitals, providers, and health care systems to help in all phases of the systems to help in all phases of the development and use of Health ITdevelopment and use of Health IT

The grants spread across The grants spread across 40 states40 states Special focus on Special focus on small and ruralsmall and rural

hospitals and communities. hospitals and communities.

HIT, Quality and SafetyHIT, Quality and Safety

Outpatient Advanced CPOE and EMROutpatient Advanced CPOE and EMR

Avoid 2.1 million adverse drug eventsAvoid 2.1 million adverse drug events Inpatient CPOE and EMRInpatient CPOE and EMR

Decrease serious medication errors by 55%Decrease serious medication errors by 55% Healthcare information exchange and Healthcare information exchange and

interoperability between settingsinteroperability between settings Improve decision-making at the point-of- Improve decision-making at the point-of-

care through complete information access care through complete information access

Source: CITL

Building HIT Evidence BaseBuilding HIT Evidence Base

Electronic Health RecordsElectronic Health Records Clinical Decision SupportClinical Decision Support Electronic PrescribingElectronic Prescribing Use of hand-held devicesUse of hand-held devices Consumer-directed IT Consumer-directed IT

AHRQ Research Study: CPOEAHRQ Research Study: CPOE

Major Finding:Major Finding: While computerized While computerized physician order entry (CPOE) is expected physician order entry (CPOE) is expected to significantly reduce medication errors, to significantly reduce medication errors, systems must be implemented thoughtfully systems must be implemented thoughtfully to avoid facilitating certain types of errorsto avoid facilitating certain types of errors

Study looked at clinicians’ experience in using one Study looked at clinicians’ experience in using one CPOE system at a major urban teaching hospitalCPOE system at a major urban teaching hospital

Implementation problems can be minimized Implementation problems can be minimized through testing before products are marketed and through testing before products are marketed and through adaptation to meet the needs of individual through adaptation to meet the needs of individual clinical settingsclinical settings

R. Koppel, J. Metlay, A. Cohen, et al., Role of computerized physician order entry R. Koppel, J. Metlay, A. Cohen, et al., Role of computerized physician order entry systems in facilitating medication errors,systems in facilitating medication errors, Journal of the American Medical Journal of the American Medical AssociationAssociation, March 9, 2005, March 9, 2005

Health IT and Patient SafetyHealth IT and Patient Safety

Tap and collect ongoing resources

Convince providers to buy in

Understand existing workflow

Understand HIT impact on workflow

Data standards/integration

Get vendors to make needed changes

Key challenges

Health IT OpportunitiesHealth IT Opportunities

Reengineer processes to Reengineer processes to improve patient safetyimprove patient safety As we migrate to a health IT As we migrate to a health IT

infrastructure, put effective processes in infrastructure, put effective processes in place as the same timeplace as the same time

Augment health IT applications for error Augment health IT applications for error reduction, CPOE and other decision reduction, CPOE and other decision support toolssupport tools

Build in the necessary disciplines and Build in the necessary disciplines and team approachesteam approaches


Remove barriersRemove barriers Build interoperable systemsBuild interoperable systems Standardize medical nomenclatureStandardize medical nomenclature Examine privacy issuesExamine privacy issues Prepare the health care sector and Prepare the health care sector and

clinicians to use full potential of health ITclinicians to use full potential of health IT Learn and share best practices through Learn and share best practices through

the AHRQ Resource Center and other the AHRQ Resource Center and other channelschannels


Develop/disseminate evidence Develop/disseminate evidence Assess effectiveness of different Assess effectiveness of different

treatment options for high-priority treatment options for high-priority conditions (MMA)conditions (MMA)

Use health IT channels to deliver Use health IT channels to deliver important information faster and more important information faster and more effectively, especially in patient safety effectively, especially in patient safety

Identify new research neededIdentify new research needed

S. 544 -- PATIENT SAFETY & S. 544 -- PATIENT SAFETY & QUALITY IMPROVEMENT ACTQUALITY IMPROVEMENT ACT

Major provisions of Act:Major provisions of Act:

– Creates “Patient Safety Organizations (PSOs)Creates “Patient Safety Organizations (PSOs)

– Establishes “Network of Patient Safety Databases”Establishes “Network of Patient Safety Databases”

– Mandates Comptroller General to study Mandates Comptroller General to study effectiveness of Act (by 2010)effectiveness of Act (by 2010)

– Is a completely voluntary systemIs a completely voluntary system

GoalsGoals

To encourage providers to identify & correct medical To encourage providers to identify & correct medical errors & threats to patient safety by ensuring that their errors & threats to patient safety by ensuring that their work with PSOs cannot be used against them in work with PSOs cannot be used against them in courts or in disciplinary proceedingscourts or in disciplinary proceedings

To encourage aggregation of cases by & among To encourage aggregation of cases by & among PSOs, creating a network of patient safety databasesPSOs, creating a network of patient safety databases

Patient Safety OrganizationPatient Safety Organization

Private or public entityPrivate or public entity Meets PSO criteria & complies with Meets PSO criteria & complies with

policies/procedurespolicies/procedures Self-certifies initially & every 3 years thereafterSelf-certifies initially & every 3 years thereafter Certification is accepted by Secretary or not; Certification is accepted by Secretary or not;

may be revokedmay be revoked

PSO CriteriaPSO Criteria

Mission to improve quality & safetyMission to improve quality & safety Has appropriately qualified staffHas appropriately qualified staff Within 24 months of listing, has contracts with more than 1 Within 24 months of listing, has contracts with more than 1

providerprovider Is not (component of) health insurerIs not (component of) health insurer Collects data in standardized mannerCollects data in standardized manner Uses work product to provide feedback & assistance & Uses work product to provide feedback & assistance &

minimize patient riskminimize patient risk

PSO ActivitiesPSO Activities

Conducts efforts to improve patient safety & qualityConducts efforts to improve patient safety & quality Collects & analyzes data, reports, records, root cause Collects & analyzes data, reports, records, root cause

analysesanalyses Develops/disseminates information to improve patient Develops/disseminates information to improve patient

safety; provides feedbacksafety; provides feedback Encourages culture of patient safetyEncourages culture of patient safety Maintains procedures to preserve confidentiality of all work Maintains procedures to preserve confidentiality of all work

productproduct

Network of Patient Safety Network of Patient Safety DatabasesDatabases

Interactive evidence-based management resourceInteractive evidence-based management resource Capacity to accept, aggregate, & analyze non-identifiable Capacity to accept, aggregate, & analyze non-identifiable

data voluntarily reported by PSOs, providers, & othersdata voluntarily reported by PSOs, providers, & others Data to be used to analyze national & regional statistics, Data to be used to analyze national & regional statistics,

including trends & patterns of health care errorsincluding trends & patterns of health care errors Information to be made public & reported annually (in Information to be made public & reported annually (in

AHRQ’s AHRQ’s National Healthcare Quality ReportNational Healthcare Quality Report))

Likely Role of AHRQLikely Role of AHRQ

Bill vests all authority in Secretary but law is in AHRQ statute. Likely Bill vests all authority in Secretary but law is in AHRQ statute. Likely AHRQ duties:AHRQ duties:

Elaborate criteria for PSO certificationElaborate criteria for PSO certification Provide technical assistance to PSOs to ensure common definitions to Provide technical assistance to PSOs to ensure common definitions to

permit valid comparisons & analyses, develop & improve methodology, permit valid comparisons & analyses, develop & improve methodology, etc. (annual meeting required)etc. (annual meeting required)

Create Patient Safety Database to aggregate non-identifiable data Create Patient Safety Database to aggregate non-identifiable data shared by PSOs for analyses by AHRQ & othersshared by PSOs for analyses by AHRQ & others

Incorporate analyses of trends/patterns/findings in AHRQ’s Incorporate analyses of trends/patterns/findings in AHRQ’s National National Healthcare Quality ReportHealthcare Quality Report




New patient safety legislation New patient safety legislation Effective Health Care ProgramEffective Health Care Program Educating consumers about Educating consumers about


Evidence Report: Episiotomy Evidence Report: Episiotomy

Major Finding:Major Finding: Routine use of episiotomy for Routine use of episiotomy for uncomplicated vaginal births does not provide uncomplicated vaginal births does not provide immediate or longer term benefits for the immediate or longer term benefits for the mothermother– Without episiotomy, women were more likely to give Without episiotomy, women were more likely to give

birth without perineal damage, less likely to need birth without perineal damage, less likely to need suturing, and more likely to resume intercourse suturing, and more likely to resume intercourse earlierearlier

AHRQ Evidence Report No. 112, Episiotomy Use in Obstetrical Care, May 2005AHRQ Evidence Report No. 112, Episiotomy Use in Obstetrical Care, May 2005

Evidence Report: Post-Evidence Report: Post-Myocardial Infarction DepressionMyocardial Infarction Depression

Major Finding:Major Finding: One in five patients hospitalized for One in five patients hospitalized for heart attack suffers from major depressionheart attack suffers from major depression– These patients may be more likely than other heart attack These patients may be more likely than other heart attack

patients to need hospital care again within a year patients to need hospital care again within a year for a cardiac problem for a cardiac problem

– May be 3x more likely to die from a future attack or May be 3x more likely to die from a future attack or other heart problemsother heart problems

Certain antidepressants may reduce symptoms of Certain antidepressants may reduce symptoms of depressiondepression

AHRQ Evidence Report No. 123, Post-Myocardial Infarction Depression, May 2005AHRQ Evidence Report No. 123, Post-Myocardial Infarction Depression, May 2005

Effective Health Care ProgramEffective Health Care Program

Designed to support the new Medicare Designed to support the new Medicare prescription drug benefit in 2006prescription drug benefit in 2006

Mandated by Section 1013 of the Medicare Mandated by Section 1013 of the Medicare Modernization Act to improve the quality, Modernization Act to improve the quality, effectiveness and efficiency of health care effectiveness and efficiency of health care delivered through Medicare, Medicaid and the delivered through Medicare, Medicaid and the S-CHIP programsS-CHIP programs

Will help patients, clinicians and payers Will help patients, clinicians and payers choose the best treatments for their needschoose the best treatments for their needs

Builds on years of experience gained through Builds on years of experience gained through AHRQ’s Evidence Based Practice CentersAHRQ’s Evidence Based Practice Centers

Legs of the ProgramLegs of the Program

Evidence Evidence SynthesisSynthesis

Evidence Evidence CommunicationCommunication

Evidence Evidence GenerationGeneration

Stroke, including control of hypertensionPneumoniaPeptic ulcer/dyspepsiaIschemic heart diseaseDiabetes mellitusDepression and other mood disordersDementia, including Alzheimer’s diseaseChronic obstructive pulmonary disease/asthmaCancerArthritis and non-traumatic joint disorders

Top 10 Conditions Affecting Top 10 Conditions Affecting Medicare BeneficiariesMedicare Beneficiaries

$15 million initiative, authorized by MMA Section $15 million initiative, authorized by MMA Section 1013, to develop state-of-the-art information 1013, to develop state-of-the-art information about effectiveness of interventions, including about effectiveness of interventions, including prescription drugs, for top 10 conditions affecting prescription drugs, for top 10 conditions affecting Medicare beneficiaries:Medicare beneficiaries:

August 16, 2005 story Includes findings from AHRQ, Kaiser Family Foundation and Harvard School of Public Health survey published Fall, 2004

In the Hospital, a Degrading Shift from Person to PatientBy Benedict Carey

Awash in Information, Patients Face a Lonely, Uncertain RoadBy Jan Hoffman

August 14, 2005 story

Outreach and educationOutreach and education

Town hall meetings in Chapel Hill, Town hall meetings in Chapel Hill, Oklahoma City and PhiladelphiaOklahoma City and Philadelphia

Expanded dissemination of consumer Expanded dissemination of consumer healthcare information through healthcare information through publications such as “Next Steps After publications such as “Next Steps After Your Diagnosis”Your Diagnosis”

More information on the InternetMore information on the Internet HHS radio and TVHHS radio and TV PSA collaboration with the Ad CouncilPSA collaboration with the Ad Council Consulting with Hollywood writers and Consulting with Hollywood writers and

producersproducers

Making stridesMaking strides

“I’m running as fast as I can, but my legs still need to grow!”

Your questionsYour questions??

Federal Government Initiatives to Improve Healthcare Quality

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