- Introduction: A Top-Level Look at the Future of Federal Medicine
- Military Health System in Time of Transition as Conflicts End
- Army Medicine: Redefining Its Role in the Generation of a Ready and Resilient Force
- Air Force Medicine: Averting an Identity Crisis
- Moving Forward with Reforming the Indian Health Service
- The Clinical Pharmacy Specialist's Growing Provider Role in VA
- Public Health Service Pharmacy: Accelerating Transformation
- Military Pain Management’s Future: Less Invasive, More Data-Driven Techniques
- Navy Medicine: Strong, Agile and Ready
- Telemental Health in VA: A New Source of Support for Veterans
Quality Improvement: A Team Approach
Carolyn M Clancy, MD
Director, Agency for Healthcare Research and Quality
As the nation’s lead federal agency charged with improving the quality, safety, efficiency, and effectiveness of healthcare for all Americans, the Agency for Healthcare Research and Quality (AHRQ) has a broad mission that puts AHRQ squarely in the middle of all efforts to meet challenges and take advantage of the opportunities facing the American healthcare system.
To achieve its mission, AHRQ strives to develop evidence on how to improve patient safety and quality, and then transform that evidence into useful programs, interventions, and innovations that can be implemented across the country by providers and patients. AHRQ has fostered long-term collaborative relationships with the academic research community and other federal agencies. We are committed to enhancing these relationships, because we believe they will lead to more information and innovations that will improve the quality of care delivered to all Americans.
A ‘Team’ Approach to Quality
AHRQ embraces these partnerships because, as a federal agency, we know the importance of working together in teams. We believe that improving quality is a “team sport.”
One example of AHRQ’s commitment to collaboration is TeamSTEPPS™, an evidence-based teamwork system originally released in 2006. TeamSTEPPS, developed by the Department of Defense (DoD) in collaboration with AHRQ, is aimed at optimizing patient outcomes by improving health professionals’ communication and teamwork skills. Together, AHRQ and DoD have teamed with the American Institutes for Research to build a national training and support network, the National Implementation of TeamSTEPPS Project.
This network is currently conducting training sessions throughout the country. At the core of national implementation are five team resource centers, in North Carolina, Virginia, Minnesota, Nebraska, and Washington state. These centers conduct three day master trainer training courses that will create a national network of master trainers. In turn, master trainers offer TeamSTEPPS training to frontline providers in hospitals and other healthcare settings throughout the country.
Supporting Patient Centered Outcomes Research
Patient centered outcomes research, also known as comparative effectiveness research, addresses the gap between what is known and what typically is done. This research remains a major priority for AHRQ. The agency continues to work with its federal partners, the National Institutes of Health and the Office of the Secretary of Health and Human Services, to invest the $1.1 billion directed toward this research from the American Recovery and Reinvestment Act of 2009.
The Recovery Act funding, which included $300 million for this research explicitly to AHRQ, represents an unprecedented level of federal investment in patient centered outcomes research. This work is foundational to healthcare system transformation because it helps clarify for patients and doctors—at the point and time of treatment—the optimal approaches for their specific conditions.
AHRQ’s Effective Healthcare Program, which has been conducting this research since it was created in 2003, develops reports that draw on published studies to make head-to-head comparisons of treatments and generates new evidence. Additionally, the program also develops summary guides—condensed plain-language translations of comparative effectiveness reviews.
The dissemination of this research—which is so important because this research must be relevant and accessible to its users, including the general public—is an important component of a network of complementary contracts and grants funded under the Recovery Act. Each project is designed to work in parallel with other projects, to reinforce messages to key audiences, and to take advantage of allotted resources. Reinforcement of messages is crucial to changing clinician and consumer behavior and thus to achieve the ultimate goal of improving healthcare quality. Information on the investments under the Recovery Act is available on our website.1
AHRQ’s work in disseminating patient centered outcomes research was explicitly recognized in the Patient Protection and Affordable Care Act. The law creates an independent, non-profit Patient Centered Outcomes Research Institute that will set federal research priorities, establish a research project agenda, support research, and ensure peer review and public comment. Under the Affordable Care Act, a portion of the institute’s funding is directed to AHRQ for broad dissemination of research findings published by the institute.
Study of Implantable Defibrillators
A third example of AHRQ’s cooperative work is a $3.5 million, 3½-year research project that will study the long-term benefits and risks of implantable cardioverter defibrillators (ICDs). This study is being supported by AHRQ and the American College of Cardiology and is being conducted in conjunction with NIH’s National Heart, Lung, and Blood Institute (NHLBI). ICDs, which are similar to pacemakers, are small devices placed in the chest or abdomen. They use electrical shocks to help control irregular heartbeats, especially those that could cause sudden cardiac arrest. The study will follow 3,500 patients with ICDs to determine how often the devices deliver shocks, whether the shocks are appropriate, and to identify those patients who are most likely to require ICD shocks.
The study is being conducted by members of the AHRQ-supported HMO Research Network, a consortium of 15 healthcare delivery systems that conduct research on various topics. The systems are also part of NHLBI’s Cardiovascular Research Network. The results will be helpful to the Centers for Medicare & Medicaid Services, which covers ICDs for certain patients.
Affordable Care Act-related Challenges
Every year, AHRQ documents whether key measures of patient safety and quality have improved or declined in the National Healthcare Quality Report and National Healthcare Disparities Report. The 2009 reports, published in March 2010, reveal that while the quality of healthcare in the United States is improving, it is doing so at a pace far too slow, and that inequities based on race, gender, age, and multiple other factors remain pervasive.
These deficiencies demonstrate the need for focused quality improvement initiatives. The Patient Protection and Affordable Care Act of 2010 offers many opportunities to improve the quality of healthcare delivered to Americans. These opportunities include:
- the creation of an Interagency Working Group on Healthcare Quality;
- increased quality measure development;
- implementation of a National Pilot Program on Payment Bundling; and
- support for the expansion of quality-focused entities such as accountable care organizations and patient centered medical homes.
Another significant initiative called for in the Affordable Care Act is the development of a national strategy to improve healthcare quality. Recognizing multiple efforts under way by the public and private sectors to improve quality, the act calls on HHS to identify priorities to improve the delivery of healthcare services, patient health outcomes, and population health. The National Quality Strategy also should include provisions to align efforts of public and private payers and reflect the “meaningful use” requirements for health information technology, according to the new act.
Related areas of significant concern are medical liability and patient safety. For the first time, President Obama has directly linked these two issues, envisioning a healthcare system that advances safety first by allowing doctors to focus on practicing medicine. AHRQ has undertaken to test methods to achieve this vision. In June, AHRQ announced grants totaling $25 million to support efforts by states and health systems to implement and evaluate patient safety approaches and medical liability reforms.
Some of the reforms that are being planned and tested under this initiative address limitations of the current medical liability system—such as costs, timeliness, patient safety, and administrative burden for doctors. Grants support the creation of a judge-directed negotiation program, planning grants to explore the feasibility of developing “safe harbors” for state-endorsed evidence-based care guidelines, and early disclosure and offers of prompt compensation. The ultimate goal is to help states and healthcare systems test models that emphasize patient safety and work to reduce preventable injuries; foster better communication between doctors and their patients; ensure that patients are compensated in a fair and timely manner for medical injuries, while also reducing the incidence of frivolous lawsuits; and reduce liability premiums.
Putting Theory Into Practice
AHRQ has long been dedicated to the pursuit of evidence. But this pursuit, in and of itself, is not enough. The ultimate goal of AHRQ-conducted and AHRQ-supported research is to discover and develop quality improvement interventions that work, and then to implement them on a broad scale.
AHRQ performs this in a variety of ways. One is the aforementioned publication of the findings of patient centered outcomes research, which are directed at consumers, clinicians, and other key audiences. Another is direct consumer-focused outreach, such as the “Questions Are the Answer” and “Superheroes” campaigns, which are ongoing.
A third is targeted, condition-specific outreach, such as AHRQ’s outreach on blood thinner medications; AHRQ has developed a free booklet and a video about these medicines. Staying Active and Healthy with Blood Thinners, a 10-minute video, features easy-to-understand explanations of how blood thinners work and why it’s important to take them correctly. Blood Thinner Pills: Your Guide to Using Them Safely, a 24-page booklet, explains how these pills can help prevent blood clots from forming and what to expect when taking these medicines.
AHRQ also is committed to bringing the latest innovations to healthcare providers to ensure that care delivered to patients is based on the best evidence possible. Examples of these innovations include the Project RED (Re-Engineered Hospital Discharge); intervention, a set of 11 discrete, mutually reinforcing components that re-engineers the workflow process and improves patient safety; a nationwide expansion of a landmark project to combat healthcare-associated infections; developing an evidence base to support patient centered medical homes; and the advancement of health information technology, particularly electronic health records and clinical decision support systems.
Conclusion: One Size Does Not Fit All
The American healthcare system is as diverse as it is vast—ranging from solo physician practices to large integrated delivery networks spanning many states. Yet wherever they practice, no matter the setting, healthcare practitioners are united in their goal of providing high-quality, affordable care for their patients.
AHRQ-supported research is intended to further that goal. The challenges and opportunities confronting American healthcare today fit squarely within the agency’s mission to support research designed to improve the quality, safety, efficiency, and effectiveness of healthcare for all Americans.
AHRQ embraces its role in helping develop the evidence to inform the healthcare system’s quest to achieve its goal of providing high-quality care. We remain committed to working with partners within and outside the federal government, always striving to achieve a healthcare system that is safe, timely, effective, efficient, equitable, and patient centered.