Evidence-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
What We Think We Know
“The truth is that for a
large part of medical
practice, we don’t 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
Health 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)
And 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?
CHANGE
AHEAD
So, 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 patientcentered 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)
Evidence-Based System
Transformation
 AHRQ’s 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
AHRQ Priorities
Patient Safety
 Health IT
 Patient Safety
Ambulatory
Patient Safety
 Safety & Quality Measures,


Organizations
 Patient Safety
Grants (incl.
simulation)
Drug Management, &
Patient-Centered Care
Survey of Patient Safety Culture
Diagnostic Error Research
Effective Health
Care Program
 Comparative
Effectiveness Reviews
 Patient-Centered
Outcomes Research
 Clear Findings for
Multiple Audiences
Medical Expenditure Other Research &
Dissemination Activities
Panel Surveys
 Visit-Level Information on  Quality & Cost-Effectiveness, e.g.,
Medical Expenditures
 Annual Quality &
Disparities Reports
Prevention & Pharmaceutical
Outcomes
 U.S. Preventive Services
Task Force
 MRSA/HAIs
AHRQ’s TOP 3 Focus Areas
Patient Safety
• Build a “trustworthy” delivery system,
minimize the impact of adverse events
Quality
• Focus on the National Quality Strategy and
collaboration (HHS, private sector)
“Getting to HOW”
• Practical, evidence-based process
improvements
National Quality Strategy:
Three 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
Healthy People/
Healthy Communities
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
Affordable Care
Reduce the cost of quality health care for
individuals, families, employers and
government
www.healthcare.gov/center/reports/quality03212011a.html
With 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
Partnership for Patients:
HHS Public-Private Initiative
By end of 2013:

40% decrease in instances of hospital
patients acquiring preventable conditions,
including:
–
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–
–
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–
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–
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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
Funded by the
Affordable Care Act
20% decrease in preventable readmissions due to
complications during a transition from one care
setting to another
www.healthcare.gov/center/programs/partnership/index.html
On The CUSP: Stop BSI
Part of HHS Action Plan
 As part of Action Plan,
AHRQ funded $18
million national effort
 Goal: Reduce CLABSI
rates to < 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
On 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
CUSP Cuts CLABSIs by 40
Percent in 1,100 Hospital Units
 Nationwide patient safety
project
–
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Developed at Johns Hopkins,
tested in Michigan
Implemented in more than 1,100
hospital units
 Results:
–
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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
Evidence-Based System
Transformation
 AHRQ’s 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
2012 National Healthcare Quality and
Disparities Reports: New Features
 AHRQ’s 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
2011 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
Quality 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
Quality 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 shortterm complications of diabetes
per 100,000 population
Hospital patients with heart attack Maternal deaths per 100,00 live
who received percutaneous
births
coronary intervention w/in 90
minutes of arrival
AHRQ 2011 National Healthcare Quality Report
Making 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
Virginia Snapshot: Overall
Health Care Quality Measures
Measure
Performance
% of adults age 18 and over who have Better than
average
had their blood cholesterol checked
within the last 5 years
Average
Adult surgery patients who received
prophylactic antibiotics within 1 hour
prior to surgical incision
Worse than
All cancer deaths per 100,000
average
population
National Healthcare Quality Report, State Snapshots
Evidence-Based System
Transformation
 AHRQ’s 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
Medical 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:
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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
Reforming 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
Improving 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
Optimizing 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
Evidence-Based System
Transformation
 AHRQ’s 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
Research 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
Implementing EvidenceBased 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
AHRQ’s Effective
Health Care Program
 AHRQ’s 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
EHC Products Developed
By the Eisenberg Center
www.effectivehealthcare.ahrq.gov
Recently Released
Translation Products
 ADHD in Children
 ANA and RF tests for
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Musculoskeletal Complaints in
Children
Chronic Pelvic Pain
Mechanical Thrombectomy
Pain Management in Hip Fracture
Preventing Fractures in Low Bone Density
Urinary Incontinence in Women
AHRQ’s 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.
AHRQ’s 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
AHRQ’s 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
/
Innovations 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
Patient Centered Outcomes
Research Dissemination Framework
Example:
New Diabetes CER
• Media campaign
• Outreach to national orgs (i.e.
ADA, AADE, Endocrine Society,
AACE)
• Outreach to consumers
• 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
Regional Offices
Individual clinician
education and practicelevel implementation
Academic Detailing
&
Online CE
Evaluation
• Integrate message into
Diabetes package
• Promote via regional/State
chapters of national orgs, local
advocacy orgs, and regional
health systems
Prioritization and Message Development
The 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
www.pcori.org
– Up to 20% of Patient-Centered
Outcomes Research Trust Fund can
be used to support research
capacity building and dissemination
activities
Closing 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:
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Bundled Payment
Health Disparities
Patient-Centered Medical Home
Public Reporting
Medication Adherence
http://www.ahrq.gov/clinic/tp/gapbundtp.htm
Prioritizing Future Research Needs
Identifying Research Needs for Improving Health Care *

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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
Cycle and Effect of New Research*
New Research
Studies
Systematic
Reviews
Future Research
Needs
Chang S, Carey T. Ann Inter Med. 2012;157:439-445
Uptake and Use
of Evidence by
Decision Makers
A 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
What 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
The Journey from Patient Safety
Knowledge to Practice
 What we know:
– It’s 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
Traveling 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
Thank 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