Carolyn M. Clancy

Transforming healthcare: a safety imperative

Ten years ago, the Institute of Medicine reported alarming data on the scope and impact of medical errors in the US and called for national efforts to address this problem. While efforts to improve patient safety have proliferated during the past decade, progress toward improvement has been frustratingly slow. Some of this lack of progress may be attributable to the persistence of a medical ethos, institutionalized in the hierarchical structure of academic medicine and healthcare organizations, that discourages teamwork and transparency and undermines the establishment of clear systems of accountability for safe care. The Lucian Leape Institute, established by the US National Patient Safety Foundation to provide vision and strategic direction for the patient safety work, has identified five concepts as fundamental to the endeavor of achieving meaningful improvement in healthcare system safety. These five concepts are transparency, care integration, patient/consumer engagement, restoration of joy and meaning in work, and medical education reform. This paper introduces the five concepts and illustrates the meaning and implications of each as a component of a vision for healthcare safety improvement. In future roundtable sessions, the Institute will further elaborate on the meaning of each concept, identify the challenges to implementation, and issue recommendations for policy makers, organizations, and healthcare professionals.

Gatekeeping Revisited — Protecting Patients from Overtreatment

Over 90 percent of health maintenance organizations (HMOs) use primary care physicians as gatekeepers,1 whose role is to authorize access to specialty, emergency, and hospital care and to diagnosti...

TeamSTEPPS: assuring optimal teamwork in clinical settings

delivery of health care in virtually every setting, effective teamwork is not a given but a goal that requires training and cultivation. Paul M. Schyve, MD, senior vice president of The Joint Commission (formerly JCAHO, the Joint Commission on Accreditation of Healthcare Organizations), has observed, “Our challenge . . . is not whether we will deliver care in teams but rather how well we will deliver care in teams.” In a recent article, Frankel and colleagues noted, “Currently, we can assure our patients that their care is always provided by a team of experts, but we cannot assure our patients that their care is always provided by expert teams.” For more than 20 years, the Agency for Healthcare Research and Quality (AHRQ) has collaborated with the Department of Defense (DoD), which encompasses one of the largest health care delivery systems in the world, to explore the field of medical teamwork. Recently, the 2 agencies announced the availability of an outstanding new resource for training health care providers in better teamwork practices: TeamSTEPPS, which stands for Team Strategies and Tools to Enhance Performance and Patient Safety. The new training package capitalizes on the DoD’s expertise in medical and nonmedical team performance and AHRQ’s extensive research in the fields of patient safety and health care quality. Following extensive field testing in the military health system (MHS) and several civilian organizations, a multimedia TeamSTEPPS toolkit was recently made available, via the public domain, to civilian health care facilities and medical practices. (Details on how to obtain the toolkit appear at the conclusion of this commentary.)

Skepticism Toward Medical Care and Health Care Utilization

OBJECTIVES As health care moves toward systems that assume accountability for defined populations, there has been increasing emphasis on developing performance measures for those systems and their providers, with little attention given to patient demand or attitudinal factors. The impact of skepticism toward health care providers on health behavior and health care utilization was assessed using a cross-sectional analysis of data from the 1987 National Medical Expenditure Survey (NMES). METHODS A nationally representative sample from the United States comprising 18,240 persons 25 years and older was surveyed. Skepticism, defined as doubts about the ability of conventional medical care to appreciably alter ones health status, was assessed through a 4-item scale. Outcome measures included health behavior, access (health care insurance, having a regular source of care, and physician type), utilization (annual number of physician or emergency department visits and hospitalizations), total annual health care expenditures, and preventive health care behavior (having had a Pap smear within 3 years or ever having had a mammogram). RESULTS In multivariate analyses, skepticism was associated with younger age, white race, lower income, less education, and higher health perceptions. After adjusting for these variables, skepticism was associated with less healthy behavior, with not having health insurance, not having ones own physician, choice of a physician, fewer physician and emergency department visits, less frequent hospitalizations, lower annual health care expenditures, and less prevention compliance. CONCLUSIONS Medical skepticism represents a relevant patient demand factor that demonstrates significant associations with a variety of health care access and utilization measures with important policy implications.

Current Guidelines Have Limited Applicability to Patients with Comorbid Conditions: A Systematic Analysis of Evidence-Based Guidelines

Background Guidelines traditionally focus on the diagnosis and treatment of single diseases. As almost half of the patients with a chronic disease have more than one disease, the applicability of guidelines may be limited. The aim of this study was to assess the extent that guidelines address comorbidity and to assess the supporting evidence of recommendations related to comorbidity. Methodology/Principal Findings We conducted a systematic analysis of evidence-based guidelines focusing on four highly prevalent chronic conditions with a high impact on quality of life: chronic obstructive pulmonary disease, depressive disorder, diabetes mellitus type 2, and osteoarthritis. Data were abstracted from each guideline on the extent that comorbidity was addressed (general comments, specific recommendations), the type of comorbidity discussed (concordant, discordant), and the supporting evidence of the comorbidity-related recommendations (level of evidence, translation of evidence). Of the 20 guidelines, 17 (85%) addressed the issue of comorbidity and 14 (70%) provided specific recommendations on comorbidity. In general, the guidelines included few recommendations on patients with comorbidity (mean 3 recommendations per guideline, range 0 to 26). Of the 59 comorbidity-related recommendations provided, 46 (78%) addressed concordant comorbidities, 8 (14%) discordant comorbidities, and for 5 (8%) the type of comorbidity was not specified. The strength of the supporting evidence was moderate for 25% (15/59) and low for 37% (22/59) of the recommendations. In addition, for 73% (43/59) of the recommendations the evidence was not adequately translated into the guidelines. Conclusions/Significance Our study showed that the applicability of current evidence-based guidelines to patients with comorbid conditions is limited. Most guidelines do not provide explicit guidance on treatment of patients with comorbidity, particularly for discordant combinations. Guidelines should be more explicit about the applicability of their recommendations to patients with comorbidity. Future clinical trials should also include patients with the most prevalent combinations of chronic conditions.

The national healthcare quality and disparities reports: an overview.

Background:Congress directed the Agency for Healthcare Research and Quality (AHRQ) to lead an effort for the US Department of Health and Human Services (DHHS) to develop 2 annual reports: a National Healthcare Quality Report (NHQR) and a National Healthcare Disparities Report (NHDR). Objectives:This article lays out key concepts, definitions, statistical methods, and findings from these first ever national reports on quality and disparities. We also summarize some possible future directions for the reports. Research Design:The NHQR and NHDR rely on secondary analysis of available data from over 40 established, national databases. The NHQR presents data at the national level, by sociodemographic characteristics, and at the state level. The NHDR presents data broken out by race/ethnicity and by socioeconomic status. Measures:The 2003 NHQR presented data on approximately 140 quality measures and the NHDR presented data on these same measures plus approximately 100 measures of access to care. Results:The reports found that high healthcare quality is not a given and that disparities are pervasive throughout the US healthcare system. In addition, they found the quality and disparities issues are particularly apparent in preventive care, but that greater improvement is possible. Conclusions:As these reports evolve for the 2004 version and beyond, they will be a vital step in the effort to improve healthcare quality for all populations in the United States.

The Future of Quality Measurement for Improvement and Accountability

Patrick H. Conway, MD, MSc Farzad Mostashari, MD, MPH Carolyn Clancy, MD THE AFFORDABLE CARE ACT EXPANDS ACCESS TO HEALTH insuranceand includesnumerousprovisions focused ondeliveringcare that ishighquality, safe, andaffordable.Reliableandmeaningfulqualitymeasurementthat focuses on important outcomes, including patient experience throughout the health care system, is an essential prerequisite forachieving thisgoal. In thisViewpoint,wedescribe thecharacteristicsof thequalitymeasuremententerpriseof the future, outline a potential roadmap for the transition, and identify a setofopportunities forpublic-andprivate-sectorcollaboration.

Transformation of Health Care at the Front Line

CONCERN ABOUT ESCALATING COSTS AND THE quality of health care delivered in the United States continues to mount. This has led to an increasing focus on pay-for-performance, valuedriven health care and public reporting of quality and cost information. However, several authors have questioned the effectiveness of pay for performance and public reporting to improve patients’ outcomes and have highlighted the potential for unintended negative consequences. Currently, frontline clinicians are exposed to disparate pay-for-performance programs that are often uncoordinated and not clearly aligned with producing better outcomes for patients. Evidence is produced at an astonishing rate, but its incorporation into clinical practice is difficult. For patients, the current transparency efforts often have little useful information for decisions regarding a specific disease and selection of clinician or treatment option. However, policy makers and purchasers are faced with an underperforming health care system and untenable cost estimates, so maintaining the status quo is not an option. Recently, 82% of Americans indicated that the health system needs fundamental change or complete restructuring. Health care is now at a critical fork in the road. One option is to continue down a path that too often frustrates clinicians, confuses patients, and fails to align incentives with improving quality and value. The other is to take the path that aligns quality and value efforts with care where it matters, at the front line with clinicians and patients. The Agency for Healthcare Research and Quality (AHRQ) has a role to play in developing the science of measurement, research on quality improvement, and informing how to transform the system successfully, but leadership and collaboration from all stakeholders and a clear vision are needed. The approach described in this Commentary is by no means exhaustive. Each key driver to engage and enable frontline clinicians and their patients to transform care and achieve better outcomes could be the subject of multiple articles, but at the least, a vision must be outlined, the best path and methods to make progress debated, and the focus shifted to the front line of care. Quality Measurement and Payment The multitude of quality organizations (eg, National Quality Forum, National Committee for Quality Assurance, Ambulatory Care Quality Alliance) have each made contributions to the quality enterprise, but there is a need to move beyond simply developing more measures and to focus on developing high-priority measures such as those that influence outcomes on high-prevalence diseases, demonstrate baseline performance variability, and have potential mechanisms to improve results. A mix of process and outcome measures is needed, but measures should increasingly focus on patient-centered outcomes, including appropriate risk adjustment that is improved over time. Occasionally, a given measure may not be appropriate because of patient preference or clinician knowledge of information not captured in claims or electronic data. In these cases, exception reporting should be allowed to minimize “unfair penalization” and the potential unintended consequence of clinicians avoiding complicated cases. However, exception reporting will need to be monitored so it is truly the exception and provides information for requisite refinements. The measurement enterprise needs to be linked to a strategy for capturing high-priority data with minimal workflow disruption. Instead of chart review–based measurement, functional electronic health records (EHRs) are needed, along with patient registries that capture quality measurement data, such as monthly reports, to provide feedback to clinicians. Measurement is the first step in clinicianand practice-based improvement. Current measures often focus on individual patientclinician interactions at a single point in time and, therefore, undervalue teamwork and patient outcomes over time. Measures focused on adherence to process in single interactions, when implemented widely, may have unintended negative consequences for patients. Measures need to focus more on the patients’ outcomes over an episode of care, such as from hip fracture through recovery. If a patient with

Use of information technology to improve the quality of health care in the United States.

In 1969, when the Internet was known as the DARPAnet and the World Wide Web was nothing more than a glint in a creative students mind, the Agency for Healthcare Research and Quality funded its first project in medical informatics.1 Since then, the Agency has continued to support research and development projects in the use of information technology to improve health care, awarding

Creating A Framework For Getting Quality Into The Public Health System

250 million dollars to fund more than 150 projects in medical informatics. Today, the Agency is still blazing this technology trail with projects that seek to develop the knowledge and tools needed to improve the quality of care in the U.S. health care system.