AHRQ director: 'We are not doing enough' on quality

Notes slowdown in improvement, while costs soar

Carolyn M. Clancy, MD, director of the Agency for Healthcare Research and Quality (AHRQ), did not pull any punches when she gave the keynote plenary address on Sept. 8 at the 2008 AHRQ Annual Meeting — nor did she hold back in a follow-up interview with Healthcare Benchmarks and Quality Improvement.

"The rate of improvement in quality — which has been consistently slow anyway — has gone down," she reported in her address, citing the National Healthcare Quality Report, which indicated that quality improved by 3.1% in 2006, but only by 2.3% in 2007.

Why is the rate of improvement slowing down? "There are a couple of reasons," says Clancy. "One is that the science of measuring quality has evolved and improved, and there is more public reporting. I think we can expect the data will show a slight decline at first because we are getting better at defining the problem."

However, she continues, "It also shows we are not doing enough to reverse important trends. In our annual report on the quality of care we send to Congress each year we saw improvements in patient safety had slowed way down." This is not a recent trend, she adds. "We can look back to the mid-90s; things improve until about 2000 and then slowed down," she notes.

In addition, she says, "There's a disconnect between the way the overall rate of quality improvement is slowing and the rate at which costs are increasing (6.7%).

"We are spending money a lot faster without improving, and we have to find a way to link the quality bottom line to the financial bottom line."

The third factor says Clancy, is that "we have done the easy stuff, and now we're getting to the harder parts," among them transitioning to patient-focused care. "Also, most public reporting efforts have been incremental, starting with small measures and then adding more," Clancy notes. "When we have a small list of things to report, the natural tendency is to deploy a team to the ED, for example, and make sure patients get their antibiotics within the designated time. As there are more and more things to measure, it's clear we have to step back and make the right thing the easy thing, with system changes."

For example, she notes, top leadership engagement is imperative. "There are cutting-edge hospitals where the CEO walks around with the staff," she notes. "And those hospital boards that have subgroups getting regular quality reports tend to do better."

This is a new skill set for board members, and it will be even more important in the future, says Clancy, who notes that this can be a key role for the quality manager to play."I think they are in the best position to help make the business case for quality, because they have the data," Clancy explains. "They also have a clearer view into how people provide care, and the impact of what they do, which will be a very, very critical role. "

Some of the 'hard' things

The transition from provider-focused care to more patient-focused care "is high on my list," Clancy told the attendees at the AHRQ meeting, and AHRQ is doing its part to help make that transition. "We have promoted the 'Five Steps to Safer Health Care' for several years," she says. "We launched a campaign with the American Hospital Association and the American Medical Association, but I do not think it's hard-wired yet, though it is a big first step." (To access the "Five Steps to Safer Health Care," go to: www.ahrq.gov/consumer/5steps.htm.)

This shift in focus does not occur in a vacuum, Clancy notes. "You hear from people who have worked on specific improvement initiatives all the time," she relates. "They get all the team members together, decide on a list of things they all agree are critically important, and make them routine. It could be standing orders or flexibility for nurses. When those steps have been put on the wall of the patient's room, the patient becomes part of the team. They may say, for example, 'Oh, I'm getting out of bed today.' When patients are better informed, they will be more equipped to ask all the right questions at discharge, know what to do when they go home, and so forth."

Collaboration 'is huge'

As indicated in the example above, Clancy believes that collaboration "is huge." Clancy says that "if you pick up a hospital chart today, you could see notes from the nurse, the doctor, the pharmacist, the nutritionist, and the physical therapist. Oftentimes you will think these people are talking about different patients."

It's often evident, she continues, that these people are not reading each other's notes. "The bottom line," she says, "is that getting to great care is a team sport."

Again, she notes, the role of the quality manager is pivotal because they have the data. "They can bring the players together and say, 'Look, you have dropped the ball and we need to work together,' because they don't have a dog in the fight," Clancy explains.

Clancy notes three other major areas of emphasis that can help boost the rate of quality improvement:

  • Greater focus on outcomes: Clancy cites an article published recently by two AHRQ colleagues that said preventable surgical errors cost employers $1.5 billion a year. "In some cases they increase the cost of care by 100%," she notes. Much of the solution lies in better discharge instructions and better follow-up.

    "I think what we will see in the very near future is increased pressure from the public and private payers to [penalize] avoidable readmissions," Clancy predicts. She notes this is easier said than done, but again AHRQ is providing tools through its "Health Innovations Exchange" (www.innovations.ahrq.gov). "It lets people know what works and, frankly, what doesn't," notes Clancy.
  • Greater focus on health literacy: "Everyone has got to be more attentive to health literacy; even if you have the best instructions in the world, if the patient does not understand them, you can drop the ball in a big way," says Clancy. Quality managers, she says, can work with those who create the discharge instructions to make sure they are "more meaningful than check-off boxes." The AHRQ web site also has tools to use with patients who have limited health literacy (www.ahrq.gov/browse/hlitix.htm).
  • Greater focus on multiple chronic conditions: "This is a huge, huge challenge of unbelievable importance," says Clancy. "These are the groups we provide the worst care and spend the most money on." There is a great deal known about the individual diseases, such as heart disease, arthritis, diabetes, and so forth, she says, "but unfortunately, the patient could have all of those."

Here again, she says, the "team sport" approach becomes critical. "The quality manager might be in a position to coordinate with the multiple specialists and ask who the 'quarterback' is going to be," she suggests. "Who's going to be following the patient when they are discharged?" They may literally need to physically bring them together in person, or by phone, Clancy suggests, "This is much harder than it should be," she says.

The good news, Clancy says, is that every provider and all health care organizations want to do the right thing. "However," she concludes, "we still have a long way to go to make the right thing the easy thing to do."

[For more information, contact:

Carolyn M. Clancy, MD, Director, Agency for Healthcare Research and Quality, 540 Gaither Road Rockville, MD 20850. Phone: (301) 427-1364.]