Title: Evidence-Based System Transformation: Research, Physician Education and New Models of Care
1Evidence-Based System Transformation Research,
Physician Education and New Models of Care
Carolyn M. Clancy, MD Director Agency for
Healthcare Research and Quality First Annual
Jewell and Carl Emswiller Interprofessional
Symposium Virginia Commonwealth
University Richmond, VA March 9, 2013
2What We Think We Know
- The truth is that for a large part of medical
practice, we dont know what works. But we pay
for it anyway. - H. Gilbert Welch, MD
- Geisel School of Medicine
- at Dartmouth
Testing What We Think We Know. New York Times -
August 19, 2012
3Health System Transformation Current and Future
Current Future
Variable quality expensive, wasteful Consistently better quality lower cost, more efficient
Pay for volume Pay for quality
Pay for transactions Care-based episodes
Quality assessment based on provider and setting (process) Quality assessment based on patient experience (outcomes)
4And Big Questions Still
Need Answers
- Although health care reform has begun, these
questions remain - How is evidence on safety and quality improvement
integrated into the new environment? - How has the nature of evidence changed?
- How do these changes affect patients, providers,
payers? - How do we ensure that these changes are
beneficial? - How are improvements put into practice?
5So, Where Does That Leave Us?
Making progress, but our destination is in the
distance
- Progress in quality improvement and patient
safety is taking place, but at a slow and uneven
pace - Payment based on quality and safety performance
is not a passing fad role of teamwork is now
valued - Movement to patient-centered care also an
evolving process
Institute of Medicine proposed 6 aims for the
health care system safe, effective,
patient-centered, timely, efficient, and
equitable. (Crossing the Quality Chasm, 2001)
6Evidence-Based System Transformation
- AHRQs New and Ongoing Priorities
- Why System Transformation is Needed in Quality
and Safety Improvement - Evidence-Based Interventions
- Patient-Centered Care in an Era of Transformation
- Q A
7AHRQ Priorities
Patient Safety
- Health IT
- Patient SafetyOrganizations
- Patient Safety Grants (incl. simulation)
Effective HealthCare Program
AmbulatoryPatient Safety
- Comparative Effectiveness Reviews
- Patient-Centered Outcomes Research
- Clear Findings for Multiple Audiences
- Safety Quality Measures,Drug Management,
Patient-Centered Care - Survey of Patient Safety Culture
- Diagnostic Error Research
Other Research Dissemination Activities
Medical ExpenditurePanel Surveys
- Quality Cost-Effectiveness, e.g.,Prevention
PharmaceuticalOutcomes - U.S. Preventive ServicesTask Force
- MRSA/HAIs
- Visit-Level Information on Medical Expenditures
- Annual Quality Disparities Reports
8AHRQs TOP 3 Focus Areas
9National Quality StrategyThree Broad Aims
Created Under the Affordable Care Act
Better Care
Improve the overall quality, by making health
care more patient-centered, reliable, accessible
and safe
Improve the health of the U.S. population by
supporting proven interventions to address
behavioral, social and environmental determinants
of health, in addition to delivering
higher-quality care
Healthy People/ Healthy Communities
Affordable Care
Reduce the cost of quality health care for
individuals, families, employers and government
www.healthcare.gov/center/reports/quality03212011a
.html
10With a Focus on Six Priorities
Making care safer by reducing harm caused in the
delivery of care
Ensuring that each person and family are engaged
as partners in their care
Promoting effective communication and
coordination of care
Promoting the most effective prevention and
treatment practices for the leading causes of
mortality, starting with cardiovascular disease
Working with communities to promote wide use of
best practices to enable healthy living
Making quality care more affordable for
individuals, families, employers, and governments
by developing and spreading new health care
delivery models
11Partnership for Patients HHS Public-Private
Initiative
- By end of 2013
- 40 decrease in instances of hospital
patients acquiring preventable
conditions, including - Central line-associated bloodstream infections
- Catheter-associated urinary tract infections
- Surgical site infections
- Ventilator-associated pneumonia
- Pressure ulcers
- Adverse drug events
- Venous thromboembolisms
- Injuries from falls
- Injuries from obstetrical adverse events
- 20 decrease in preventable readmissions due to
complications during a transition from one care
setting to another
Funded by the Affordable Care Act
www.healthcare.gov/center/programs/partnership/ind
ex.html
12On The CUSP Stop BSIPart of HHS Action Plan
- As part of Action Plan, AHRQ funded 18 million
national effort - Goal Reduce CLABSI rates to lt 1 per 1,000
central line days across all hospitals in project - Partnership with JHU Quality and Safety Group,
Health Research and Educational Trust (AHA
affiliate), and Michigan Hospital Assn.s
Keystone Center
13On the CUSP
Stop BSI Project Update
- To date, 45 state hospital associations and 1
other umbrella group have committed to leading
project in their states - Groups have recruited more than 1,100 hospitals
and 1,800 hospital teams to participate - Twenty-three states began project in 2009, 14
states and District of Columbia began during
2010, and 9 States and Puerto Rico began efforts
in 2011
14CUSP Cuts CLABSIs by 40 Percent in 1,100 Hospital
Units
- Nationwide patient safety project
- Developed at Johns Hopkins, tested in Michigan
- Implemented in more than 1,100 hospital units
- Results
- CLABSIs reduced from 1.903 infections per 1,000
central line days to 1.137 per 1,000 days - Savings more than 500 lives, 34 million in
costs - New toolkit for implementation
AHRQ Patient Safety Project Reduces Bloodstream
Infections by 40 Percent. Press Release,
September 10, 2012. www.ahrq.gov/news/press/pr2012
/pspclabsipr.htm
15Evidence-Based System Transformation
- AHRQs New and Ongoing Priorities
- Why System Transformation is Needed in Quality
and Safety Improvement - Evidence-Based Interventions
- Patient-Centered Care in an Era of Transformation
- Q A
162012 National Healthcare Quality and Disparities
Reports New Features
- AHRQs National Quality and National Disparities
Reports - 2012 will be 10th in series
- Addition of more NQS measures reflecting
population need - Focus on long-term trends
- Focus on new HHS race/ethnicity standards
- NHQRDRnet
- Addition of function to generate customized
graphics
172011 National Healthcare Quality and Disparities
Reports
- Overall health care quality in the US is
improving slowly - Access to health care not improving for most
racial and ethnic groups - On average, Americans receive appropriate
- Acute care services 80 of the time
- Recommended chronic disease management services
70 of the time - Preventive care services 60 of the time
18Quality is Improving Slowly
Quality measures that are improving, not changing
or worsening, overall and for select populations
- Across all measures of health care quality
tracked in the reports, almost 60 showed
improvement - However, median rate of change was only 2.5 per
year - Improvement included all groups defined by age,
race, ethnicity, and income
AHRQ 2011 National Healthcare Quality and
Disparities Reports
19Quality Measures Most Rapidly Improving or
Worsening
Quality Improving Quality Worsening
Adult surgery patients who received prophylactic antibiotics w/in 1 hr before surgical incision Postoperative pulmonary embolism or DVT per 1,000 surgical hospital discharges, adults 18 or over
Adult surgery patients who had prophylactic antibiotics discontinued w/in 24 hours after surgery end time Hospital admissions for short-term complications of diabetes per 100,000 population
Hospital patients with heart attack who received percutaneous coronary intervention w/in 90 minutes of arrival Maternal deaths per 100,00 live births
AHRQ 2011 National Healthcare Quality Report
20Making Care Safer
- Improvements in safety are lagging
- The reports track 26 safety measures related to
HAIs and other hospital-related adverse events - Of these measures, 38 showed improvement
- By comparison, among 16 hospital quality measures
not related to safety, almost all showed
improvement over time
2011 AHRQ National Health Care Quality and
Disparities Reports
21Virginia Snapshot Overall Health Care Quality
Measures
Measure Performance
of adults age 18 and over who have had their blood cholesterol checked within the last 5 years Better than average
Adult surgery patients who received prophylactic antibiotics within 1 hour prior to surgical incision Average
All cancer deaths per 100,000 population Worse than average
National Healthcare Quality Report, State
Snapshots
22Evidence-Based System Transformation
- AHRQs New and Ongoing Priorities
- Why System Transformation is Needed in Quality
and Safety Improvement - Evidence-Based Interventions
- Patient-Centered Care in an Era of Transformation
- Q A
23Medical Liability and Patient Safety
Initiative
- Part of Affordable Care Act
- Supports implementation and evaluation of
evidence-based patient safety and medical
liability projects - Seven AHRQ-funded demonstration grants have been
awarded to test models that - Reduce preventable harm
- Inform injured patients promptly and making
efforts to provide prompt compensation - Promote early disclosures and settlements,
through court-directed alternate dispute
resolution model
24Reforming Medical Liability Seven Pillars
Project
- Launched in 2006 at University of
Illinois-Chicago by Dr. Timothy McDonald focuses
on transparency and disclosure to eliminate
patient harms and learn from safety events. - Seven Pillars components
- Patient safety incident reporting
- Investigation
- Communication and disclosure
- Apology and remediation, including waiver of
hospital and professional fees - System process and performance improvement
- Data tracking and performance evaluation
- Education and training
25Improving Hospital Safety Culture TeamSTEPPS
- TeamSTEPPS
- Evidence-based teamwork system to improve
communications and teamwork among health care
professionals - Provides higher-quality, safer care by
- Increasing team awareness and clarifying team
roles and responsibilities - Resolving conflicts and improving information
sharing - Eliminating barriers to quality and safety
- Rooted in more than 25 years of research and
lessons from application of teamwork principles - Developed by Department of Defense and AHRQ
www.teamstepps.ahrq.gov
26Optimizing TeamSTEPPS for Simulation Training
and Rapid Response Systems
- TeamSTEPPS includes instruction modules applied
to simulation-based training rapid response
systems - Simulation modules integrate critical teamwork,
interpersonal, and communication skills into
simulation-based training - Rapid response modules provide insight into
teamwork concepts applied to rapid response
protocols
http//ahrq.gov/teamsteppstools
27Evidence-Based System Transformation
- AHRQs New and Ongoing Priorities
- Why System Transformation is Needed in Quality
and Safety Improvement - Evidence-Based Interventions
- Patient-Centered Care in an Era of Transformation
- Q A
28Research that Addresses Patient Outcomes
Patient-Centeredness The final frontier?
- Patient-centeredness may be the most challenging
of all 6 domains of quality, because it is so
difficult to define and measure - But, it is also likely the most important,
because it includes elements of all other domains
29Implementing Evidence-Based Treatment Decisions
- Which treatments work, for which patients, and
what are the trade-offs? - Patient-centered outcomes research informs
decisions by providing evidence and information
on effectiveness, benefits and harms - How can evidence-based improvements be translated
and shared with providers, patients? - Effective Health Care Clinician and Consumer
Summaries - Continuing Medical Education
- Center for Medicare and Medicaid Innovation AHRQ
Health Care Innovations Exchange
30AHRQs Effective Health Care Program
- AHRQs Effective Health Care Program, created by
the Medicare Modernization Act of 2003 - Program has published more than 100 products,
including summaries for clinicians, consumers and
policymakers, with plans for at least 75 more
over two-year period - Emphasis on synthesis of existing evidence and
creation of new evidence
31EHC Products Developed By the Eisenberg
Center
www.effectivehealthcare.ahrq.gov
32Recently Released Translation Products
- ADHD in Children
- ANA and RF tests for
Musculoskeletal
Complaints in
Children - Chronic Pelvic Pain
- Mechanical Thrombectomy
- Pain Management in Hip Fracture
- Preventing Fractures in Low Bone Density
- Urinary Incontinence in Women
33AHRQs Guide to Patient and Family Engagement
Environmental Scan
- AHRQ-funded environmental scan conducted to serve
as evidence-based foundation for development of
Guide to Patient and Family Engagement. - Highlights
- Quality and Safety Both patients and providers
think that the quality of care they receive or
give is generally good they do not share same
views on what constitutes quality or safety - Engagement In theory, patients and providers
support patient and family involvement and
recognize it can lead to better patient
experience and outcomes. Support is more
uncertain when patient engagement includes higher
level of involvement, i.e. making diagnosis or
treatment decisions.
34AHRQs Guide to Patient and Family Engagement
Environmental Scan
- Highlights
- Engagement Patients more likely to engage when
goals relate to obtaining specific information
about their care (asking questions about
condition), but less likely to engage when faced
with behaviors that seem new or confrontational
(asking providers to mark surgical sites) - Barriers and facilitators to engagement
- Patients and family members Fear, uncertainty,
low health literacy and provider reactions.
Facilitators include self-efficacy, information,
invitations to engage, and other provider
support. - Health providers Professional norms and
experiences, fear of litigation, perceived level
of effort. Facilitators include leadership,
occurrence of sentinel event, business case for
quality and safety, patient stories, altruism
35AHRQs Guide to Patient and Family Engagement
Environmental Scan
- Key Findings to Inform Future Development of
Patient and Family Engagement Guide - Existing approaches to and resources for patient
and family engagement lack strong evidence base
of efficacy or effectiveness - Gaps in content and topic areas include
- Strategies not attuned to patient and family
member experience of hospitalization - Lack of individual tools to support
hospital-level strategies - Lack of concrete, actionable support for
individual users to engage in behaviors - Dearth of materials for nurses on how to better
communicate with patients
http//www.ahrq.gov/qual/ptfamilyscan/
36Innovations and Tools To Improve Quality, Reduce
Disparities
- AHRQ Health Care Innovations Exchange
- Find evidence-based innovations and quality tools
- View new innovations and tools
- Learn from experts through events and articles
http//Innovations.ahrq.gov
37Patient Centered Outcomes Research Dissemination
Framework
Prioritization and Message Development
- Example
- New Diabetes CER
- Media campaign
- Outreach to national orgs (i.e. ADA, AADE,
Endocrine Society, AACE) - Outreach to consumers
- Integrate message into Diabetes package
- Promote via regional/State chapters of national
orgs, local advocacy orgs, and regional health
systems - Integrate clinical message into Diabetes AD
package - Promote/discuss in individual practice settings
- Create and promote CE modules based on individual
findings
National awareness of CER and specific findings
Publicity Center
Deeper awareness of CER and findings at regional,
local, or system level
Evaluation
Regional Offices
Individual clinician education and practice-level
implementation
Academic Detailing Online CE
38The Patient-Centered Outcomes Research Trust Fund
and AHRQ
- Provides funding for AHRQ to disseminate research
findings of the Institute and other
government-funded research, train and build
capacity for research - Up to 20 of Patient-Centered Outcomes Research
Trust Fund can be used to support research
capacity building and dissemination activities
www.pcori.org
39Closing the Quality Gap Revisiting the State
of the Science
- Series of reports summarizing the evidence on
quality improvement strategies for chronic
conditions and other priorities - Bundled Payment
- Health Disparities
- Patient-Centered Medical Home
- Public Reporting
- Medication Adherence
http//www.ahrq.gov/clinic/tp/gapbundtp.htm
40Prioritizing Future Research Needs
Identifying Research Needs for Improving Health
Care
- Article describes challenges and lessons learned
in developing a systematic approach to
identifying and prioritizing future research
needs (FRN) - Based on the approach initiated by EPCs in 2010
to better define patient-centered research needs
from selected systematic reviews - Focuses on stakeholder involvement as an
essential tenet in the process
Chang S, Carey T. Ann Inter Med. 2012157439-445
41A Decent Meal,Or a New Model of Care?
- The challenge
- Serving millions of people
- Delivering a range of services
- Keeping costs reasonable
- Attaining a consistently high level of quality
- Can care be mechanized? Should it be?
- Are there models we can use?
- Gawande A. Big Med Restaurant chains have
managed to combine quality control, cost control,
and innovation. Can health care? New Yorker.
August 13, 2012
42What Should the New Model
Look Like?
- That remains to be determined, although overall
factors to consider include - Engaging stakeholders at the point when strategic
decisions are being made - Making evidence available earlier and during
different intervals of a project - Thinking of publication as one step in the
continuing process to get results into the hands
of those who need it rather than the end of the
research cycle - Testing multiple conclusions in the field rather
than waiting until there is a right answer
43The Journey from Patient Safety Knowledge to
Practice
- What we know
- Its a long journey
- Holds unexpected surprises
- Not just one way to get there
- Bottom line Improving safety requires that we
understand how patients and families perceive
their care, recognize different degrees of
engagement, and be willing to form partnerships
to provide safer care
44Traveling Fast or Traveling to Get Somewhere?
- If you want to travel fast, you travel alone. If
you want to go far, travel with others.
African Proverb
45Thank You
AHRQ Mission To improve the quality, safety,
efficiency, and effectiveness of health care for
all Americans AHRQ Vision As a result of AHRQ's
efforts, American health care will provide
services of the highest quality, with the best
possible outcomes, at the lowest cost
www.ahrq.gov