Health System Reform: Health System Reform: Doing Doing the Right Thing the Right Thing AND AND Doing Things Doing Things Right Right Carolyn M. Clancy, MD Carolyn M. Clancy, MD Director Director Agency for Healthcare Research and Agency for Healthcare Research and Quality Quality Alliance for Health Care Reform Alliance for Health Care Reform Washington, DC – March 27, 2009 Washington, DC – March 27, 2009
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Health System Reform: Doing the Right Thing AND Doing Things Right Carolyn M. Clancy, MD Director Agency for Healthcare Research and Quality Alliance for.
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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
““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
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
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”