What is Quality? Quality Literacy and Current Initiatives

1. What is Quality?Quality Literacy and Current Initiatives Carolyn Clancy, M.D. Director Agency for Healthcare Research and Quality Quality at the Leading Edge The Leapfrog Conference on the Future of Hospital Governance Santa Monica, CA – January 28, 2008

2. Excellence & Mediocrity “A society which scorns excellence in plumbing simply because it is plumbing, but rewards mediocre philosophy simply because it is philosophy will soon become a society in which neither its pipes nor its theories will hold water.” John W. Gardner (1961)

3. Attaining Quality Literacy • Understanding Quality and Disparities • Culture’s Role in Patient Safety • Measuring Patient Safety • Patient Safety and Value-Based Health Care • Q&A

4. The Right Care For The Right Patient At The Right Time What Is Quality?

5. What is Quality? IOM defines quality as care that is: • Safe • Timely • Effective • Efficient • Equitable • Patient-Centered

6. Health Care Quality • Varies – A LOT; NOT clearly related to $$ spent • Matters – can be measured and improved • Measurement science is evolving: • Structure, process and outcomes • Broad recognition that patient experience is essential component* • Strong focus on public reporting is good • Motivates providers to improve • Not yet ‘consumer friendly’

7. AHRQ’s Mission Improve the quality, safety, efficiency and effectiveness of health care for all Americans

8. FY 2008 Funding • $334.6 million • FY 2008 Request – $329.6 million • FY 2007 Appropriation – $318.7 million • Appropriation includes: • $30 million for comparative effectiveness research, double the $15 million designated in FY 2007 • $5 million for research and activities to reduce Methicillin Resistant Staphylococcus aureus (MRSA) and related infections • Congress also encouraged AHRQ to: • Consider proposals to detect medical errors and preemptively control injury via compact medical devices • Investigate the feasibility of an open-source, no-cost license computer model capable of predicting the effects of health care policy alternatives to improve quality and cost-effectiveness

9. FY 2008 Priorities Patient Safety • Health IT • Patient SafetyOrganizations • New PatientSafety Grants Effective HealthCare Program AmbulatoryPatient Safety • Comparative Effectiveness • Network of Research Centers • Clear Findings for Multiple Audiences • Safety & Quality Measures,Drug Management andPatient-Centered Care • Patient Safety ImprovementCorps Other Research & Dissemination Activities Medical ExpenditurePanel Surveys • Visit-Level Information on Medical Expenditures • Annual Quality & Disparities Reports • Quality & Cost-Effectiveness, e.g.Prevention and PharmaceuticalOutcomes • U.S. Preventive ServicesTask Force • MRSA/HAIs

10. AHRQ’s National Reports on Quality and Disparities • 2007 editions pending • New efficiency chapter • Disability data added • More on health literacy

11. What Do We Know About Disparities? • Most areas of health care quality are improving, but only very slowly • 38 of 40 core measures improved compared with 2005 reports • Overall improvement rate: 3.1% • Use of proven prevention strategies lags significantly behind other gains in health care • Only 52% of adults reported receiving recommended colorectal cancer screenings • Only 58% of obese adults given advice about exercise from their doctor • Only 48% of adults with diabetes receive all their recommended screenings

12. 2006 National Reports – The Good News • Good (but not perfect) news • 6% of patients reported communication problems with doctors* • 7% of patients reported communication problems with nurses *CAHPS Hospital Survey, 2006 National Healthcare Disparities Report

13. 2006 National Reports – Communication Issues Remain • Room for improvement • 26% of hospitalized patients reported problems with communication about medications • 21% reported problems with discharge information Source: CAHPS Hospital Survey, 2006 National Healthcare Disparities Report

14. Quality of Hospital Care for Heart Attack and Heart Failure: Poor Counties, Rich Counties Source: Gannett News Service, Rating Hospital Heart Care, 2006.

15. AHRQ Quality Tools State Snapshots • Web-based tool • Designed to help State officials and their public- and private-sector partners understand health care quality and disparities in their State • Provides State-specific information on health care quality measures for each State using user-friendly graphs and customized tables

16. Health Literacy Evidence Report “The nation’s estimated 90 million adults with lower-than-average reading skills are less likely than other Americans to get potentially life-saving screening tests such as mammograms and Pap smears, to get flu and pneumonia vaccines and to take their children for well child care visits.” AHRQ Health Literacy Evidence Report April 2004

17. Transforming Hospitals: Designing for Safety and Quality • A DVD that demonstrates how evidence-based design can improve the quality and safety of hospital services while improving staff satisfaction and retention. • Case studies of three hospitals illustrate the benefit of incorporating evidence-based design principles into new construction or renovation projects. http://www.ahrq.gov/qual/transform.htm

18. Patient Involvement Campaign • AHRQ’s campaign with The Advertising Council uses a series of TV, radio, and print public service announcements • Web site features a “Question Builder” for patients to enhance their medical appointments • http://www.ahrq.gov/questionsaretheanswer/index.html

19. Attaining Quality Literacy • Understanding Quality and Disparities • Culture’s Role in Patient Safety • Measuring Patient Safety • Patient Safety and Value-Based Health Care • Q&A

20. How Powerful is Culture? “When it comes to changing an organization, culture eats strategy’s lunch each time.” - Unknown

21. How Powerful is Culture? • Best plans by smartest experts are merely an academic exercise without support of everyone (nurses, medical staff, administration) in the organization • Changing culture is our biggest challenge

22. A Culture of Blame… and Other Barriers • “Culture of blame” one of the top 7 barriers to implementing a patient safety system. Others: • Competition for scarce resources in a system where patient safety not considered a top priority • Lack of resources: inadequate staffing and work overloads • Availability and cost of patient safety • Resistance to change • Lack of commitment at the executive level • Culture of health care workforce – perceptions, attitudes, and behaviors of error “cover up” Akins RB, Cole BR. “Barriers to Implementation of Patient Safety Systems in Healthcare Institutions”, Journal of Patient Safety, Vol.1, No. 1, March 2005, pp. 9-16.

23. Single Challenge, Multiple Variables • Weighing many factors: • Do gains in quality/safety reduce costs to patients, hospitals, and payers? • If costs increase, does value to patients justify the increase? • How do we get buy-in from providers, payers, and patients?

24. Leadership Essentials for a Culture of Safety • AHRQ Funding & Priorities • Culture’s Role in Patient Safety • Measuring Patient Safety • Patient Safety and Value-Based Health Care • Q&A

25. Hospital Survey on Patient Safety Culture • New tool helps hospitals and health systems evaluate employee attitudes about patient safety in their facilities or within specific units • Asses an organization’s patient safety culture • Track changes in patient safety over time • Evaluate the impact of patient safety interventions http://www.ahrq.gov/qual/hospculture

26. Hospital Survey on Patient Safety Culture • 2007 Comparative Database Report • Data from 382 participating hospitals, 108,621 hospital staff • Report developed for: • Comparison: Allow hospitals to compare their patient culture survey results with others • Assessment and learning: Provide data to hospitals to facilitate internal assessment and learning in patient safety process • Supplemental information: Provide information to help hospitals identify strengths and weaknesses with potential for improvement

27. 2007 Comparative Database Report – Findings • Respondents: • 36% nurses (both RN/LPN) • 23% other • 11% technician (EKG, lab, radiology) • 76% had direct interaction with patients • Work area in hospital: • 36% other • 10% surgery • 9% medicine • 9% many different hospital units/no specific unit

28. 2007 Comparative Database Report – Findings • Areas of Strength for Most Hospitals: • Teamwork within units: 85% positive response to: “When a lot of work needs to be done quickly, we work together as a team to get the work done.” • Patient safety grade: Majority (70%) of respondents within hospitals gave their hospitals grade of either “A-Excellent” (22%) or “B-Very Good (48%) • However, a wide range of responses in patient safety grades – at one hospital, no respondents provided unit with a grade of “A,” to another where 63% did so

29. 2007 Comparative Database Report – Findings • Areas for Improvement for Most Hospitals: • Non-punitive response to error: Only 35% disagreed/strongly disagreed with: “Staff worry that mistakes they make are kept in their personnel file.” • Number of events reported: Majority (53%) reported no events in their hospital over the past 12 months • Wide range of responses, from hospital where 96% had not reported an event, to a hospital where only 5% had not reported an event

30. 2008 Comparative Database Report • Year 2 of Hospital Survey on Patient Safety Culture Comparative Database • Eligible hospitals: Those that participated in patient safety culture survey by June, 2007 • Additional breakout data by hospital characteristics (bed size, teaching status, ownership, region) to be included • 2008 comparative database report to be available without cost on AHRQ Web site http://www.ahrq.gov/qual/hospculture

31. Web-Based CPOE Testing Tool • Evaluates how a hospital’s CPOE system responds to unsafe medication ordering and clinical situations • Rollout of inpatient version is scheduled for April, with a year before reporting of test results begin • Organizations using the tool include the Leapfrog Group and the National Quality Forum, and researchers have expressed an interest in using it as a benchmarking apparatus “View Results” window from Leapfrog CPOE Tool AHRQ is working with Leapfrog on updates and on the Outpatient version of the tool, which is aligned with the agency’s efforts in promoting the adoption of health IT to mitigate mistakes

32. Leapfrog P4P Decision Tool • Decision-support tool that guides users through the process of selecting pay-for-performance programs • Matches user preferences with programs listed in the Leapfrog Group’s Compendium, an online clearinghouse of incentive and reward programs • Based on Pay for Performance: A Decision Guide for Purchasers, by AHRQ

33. Leadership Essentials for a Culture of Safety • Understanding Quality and Disparities • Culture’s Role in Patient Safety • Measuring Patient Safety • Patient Safety and Value-Based Health Care • Q&A

34. ‘Never Events’: Never Paid? • Mandatory state reporting • CMS not covering care related to certain errors • Private insurers following suit (e.g., Aetna, WellPoint)

35. Getting to Value-Driven Health Care “The mantra of competition based on value is that there is no such thing as a national health care market. What we have is a network of local markets.” Michael O. Leavitt, Secretary Department of Health and Human Services

36. Quality Standards Design systems to collect quality of care information and define what constitutes quality health care Incentives Reward those who provide and purchase high-quality and competitively priced health care Price Standards Aggregate claims information to enable cost comparisons between specific doctors and hospitals Interoperability Set common technical standards for quick and secure communication and data exchange Cornerstones of Value-Driven Health Care

37. Value-Driven Health Care: Core Principles • All health care is local • Broad access to information will improve value by: • stimulating provider improvement • engaging consumers in provider selection, treatment choices • enabling purchasers to align consumer, provider incentives • Nationwide learning network will foster market-based health care reform

38. Patient Safety, Value-Driven Health Care and Health IT • How does health IT affect patient safety culture? • Adopting and using health IT remains a huge cultural change for many clinicians • Change requires commitment to achieving and sustaining evolution in culture

39. Patient Safety and Value • Need to “hard-wire” emerging value-based health care system to: • Design and build a system that takes advantage of the enormous clinical evidence to make better decisions about: • Treatments • Medications • Risks • Costs and benefits

40. Challenges in Patient Empowerment • Using measurement and reporting for quality improvement • Incorporating local initiatives into the national debate • Ensuring all Americans benefit from advances in medical science; “no patient left behind” • Leveraging technology

41. What’s Needed in Health Care • Delivery system design • Real-time information • Clinical effectiveness • Delivery to patients • Impact on patients • Evidence-based management • Shared attention to data • Shared strategies for improvement • Policy adjustments for improvement

42. The Social Case: Potential lives saved through quality improvement Woolf and Johnson,

43. 21st Century Health Care Improving quality by promoting a culture of safety through Value-Driven Health Care Information-rich, patient-focused enterprises Information and evidence transform interactions from reactive to proactive (benefits and harms) Evidence is continually refined as a by-product of care delivery 21st Century Health Care Actionable information available – to clinicians AND patients – “just in time”

44. Moving Forward • Community solutions are the key for improving care • Individuals can move mountains within their own institutions • Improving quality will require community based projects

45. We Face Frustrations • Health care is complex • Health care is plagued by conflicting demands, needs and incentives • Systems can impede our work • But…

46. Equitable, Safe Care Can Be Achieved We can create positive health care when: • We work in teams • We use evidence to provide appropriate services and treatments • We implement technology wisely • We apply evidence-based leadership practices • We work as partners with our patients

47. Getting to Best Possible Care • Moving the ball right now: • Public Reporting – AND transparency • Payment Reforms* • Common Measures for public and private sectors • Enhanced support for local collaboratives • Specific Policy Opportunities: • P4P: absolute performance – &/or improvement? • Rewarding the ‘leading edge’ and bringing others along • Support for unbiased consumer information – and for effective use of HIT • Insist on clear synthesis of results from public and private demonstrations

48. Call to Action • It’s time to rededicate ourselves to achieving high quality in all its forms, for all Americans, all the time • We need better tools to identify and analyze trends • We must increase the use of health education to eliminate disparities and drive other health care enhancements • Collaboration at all levels is critical • We need leadership, at both the national and local levels

49. Time to Take Charge Be a change agent in your own institution or community

50. Leadership Essentials for a Culture of Safety • Understanding Quality and Disparities • Culture’s Role in Patient Safety • Measuring Patient Safety • Patient Safety and Value-Based Health Care • Q&A