FY 2004: Research on Health Care Costs, Quality and Outcomes (HCQO) (continued)

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Goal 3. Identifying Strategies to Improve Access, Foster Appropriate Use, and Reduce Unnecessary Expenditures

Patient Safety and Reducing Errors

The November, 1999, report of the Institute of Medicine (IOM), To Err is Human: Building a Safer Health System, galvanized attention on the unacceptable number of medical errors occurring in the United States every day. This report brought patient safety to the forefront of our attention and led to unprecedented efforts to find solutions. The report showed that a wide gap exists in the quality of care people receive and the quality of care that we as a Nation are capable of providing.

According to the IOM, as many as 44,000 to 98,000 people die in hospitals each year as a result of medical errors. Even using the lower estimate, this would make medical errors the eighth leading cause of death in this country. Medical errors cause more deaths annually than automobile accidents (43,458), breast cancer (42,297), or AIDS (16,516). It is estimated that about 7,000 people each year die from medication errors alone—about 16 percent more deaths than the number attributable to work-related injuries.

Research on medical errors and other patient safety issues is not new to AHRQ. We have recognized for some time that reducing medical errors is critically important for improving the quality of health care. In 1993, the agency published one of the first reports focused on medical errors. This landmark report noted that 78 percent of adverse drug reactions were due to system failures, such as the misreading of handwritten prescriptions. Subsequent studies sponsored by AHFQ have focused on the detection of medical errors, investigation of diagnostic inaccuracies, the relationship between nurse staffing and adverse events, computerized adverse drug event monitoring, and tools for computer-assisted decisionmaking that can reduce the potential for errors and improve safety.

In FY 2001, AHRQ invested $50 million in new research grants, contracts, and other projects to reduce medical errors and improve patient safety. These projects will address key unanswered questions about when and how errors occur and provide science-based information on what patients, clinicians, hospital leaders, policymakers, and others can do to make the health care system safer. The results of this research will identify improvement strategies that work in hospitals, doctors' offices, nursing homes, and other health care settings across the Nation.

The results of investment in patient safety research are now being incorporated into practice. Below are examples of how this research is being used:

• AHRQ's Center for Education and Research in Therapeutics (CERTs) in the University of Arizona Health Sciences Center developed a unique educational and research tool at www.qtdrugs.org. This Web site contains a list of 72 drugs that can cause life-threatening abnormalities in heartbeats, or arrhythmia (abnormal heartbeat). Caregivers around the world can use this online resource to research specific drugs that might pose a risk to their patients, and they can submit clinical cases of drug-induced arrhythmias to the registry. Researchers are using the information submitted to develop profiles of people most at risk for drug-induced arrhythmia and to develop a genetic test that can identify them in advance of treatment.
• Patients and their families can use a new consumer tip sheet, available in English and Spanish, to help them play a more active role in ensuring that they get the best health care possible. The tips also help consumers prevent medical errors.
• AHRQ research has given about 73 proven patient safety practices to health care administrators, medical directors, health professionals, and others who are responsible for patient safety programs. AHRQ research has also identified 11 other patient safety practices proven to work but not used routinely in the Nation's hospitals and nursing homes. Voluntary Hospitals of America and Premier, Inc. use the information to guide their member hospitals in selecting projects to improve safety. Many chief executive officers, medical directors, and hospital safety officers have reported that they use the information to help them initiate project to improve patient safety.
• To help patients assess the safety of their care, AHRQ, CMS, and other organizations supported the National Quality Forum (NQF), a not-for-profit membership organization created to develop and implement a national strategy for health care quality measurement and reporting. The NQF developed a list of serious, avoidable, adverse events that are so significant and so preventable that their occurrence should trigger an investigation of the organization in which they occurred. An example of such an event would be surgery on the wrong site. This list is now completed and available to the public. For information on how to obtain a copy of Serious Reportable Events in Healthcare, go to the NQF's Web site (www.qualityforum.org) and click on "Activities/Consensus Reports" to find a description of the report, an executive summary, and ordering information for the full report.
• AHRQ supported the NQF's effort to develop a list of safe practices proven to be effective in reducing harm to patients. The list, which soon will be available to the public, is a tool to identify and encourage practices to reduce errors and improve care. Hospitals will be encouraged to report on their use of these practices so that patients can determine what hospitals have done to improve safety of care.

AHRQ's $50 million dollar investment in patient safety research for FY 2001 went to fund a variety of projects, including many new research initiatives. Many of these new projects are expected to take three years to compete. For 2001, AHRQ funding went to the following categories of patient safety research:

Identifying Methods for Reporting Medical Errors Data. This involves 24 demonstration projects to study different methods of collecting data on errors or analyzing data that are already collected to identify factors that put patients at risk for medical errors. Projects include determining how best to identify hazards to patients, by collecting and analyzing data, and identifying ways to use the data to reduce risk.

Using Computers and IT To Prevent Medical Errors. This group of 22 projects will develop and test the use of computers and information technology to reduce medical errors, improve patient safety, and enhance quality of care. Projects include:

• Developing an Internet based training tool to help physicians and other providers learn from "close calls." A prototype Web site has been developed and will be fully functional in early 2003.
• Examining how to effectively use computers, personal digital assistants (PDAs), and other information technologies to support decision making and communication in health care to reduce harm to patients.

Understanding the Impact of Working Conditions on Patient Safety. These eight projects will examine how staffing, fatigue, stress, sleep deprivation, and other factors can lead to errors. Projects include studying the impact of working conditions such as long work hours and noisy environments on patient safety.

Developing Innovative Approaches to Improving Patient Safety. This involves 23 projects that will research and develop innovative approaches to improving patient safety at health care facilities and organizations in geographically diverse locations across the country. Projects include developing and supporting Centers of Excellence to conduct research on a variety of topics such as:

• Methods of decreasing medication errors.
• Options for changing organizational cultures to increase support of patient safety improvement.
• Techniques for reducing harm to patients in nursing homes, home health care, physician offices, and hospitals.

Disseminating Research Results. This group of seven projects will focus on educating clinicians and others about the results of patient safety research. This work will help develop, demonstrate, and evaluate new approaches to improving provider education in order to reduce errors, such as applying new knowledge on patient safety to curricula development, continuing education, simulation models, and other provider training strategies.

Additional Patient Safety Research Initiatives. AHRQ funded 10 additional projects covering other patient safety research activities, including supporting meetings of State and local officials to advance local patient safety initiatives and assessing the feasibility of implementing a patient safety improvement corps. Projects include developing methods for increasing the adoption of proven safety enhancing practices.

In addition, in FY 2001 and 2002 AHRQ funded research on implementation research in patient safety. This includes an implementation planning study for the AHRQ, CDC, CMS, FDA Patient Safety Task Force and development of a training program to provide on-site patient safety experts to State health departments and health care delivery systems. Funding for these projects is included in the FY 2003 President's budget request.

National Healthcare Quality Report

AHRQ is developing the first annual report on the quality of health care in the United States, as called for in the agency's reauthorization legislation, which became law in 1999. The goal of the report, now in development and due out in 2003, is to provide a clear, easily understandable picture of the quality of health care in America. The development of a national report on health care quality is an important step in improving the quality the Nation's health care system and addressing the health care needs of priority populations.

The report project is being led by AHRQ in collaboration from Center for Disease Control and Prevention's National Center for Health Statistics. An interagency work group is guiding the development of this landmark first report. Other members of the work group include the Department's Office of the Assistant Secretary for Planning and Evaluation, the Centers for Medicare and Medicaid Services, the Food and Drug Administration, the Indian Health Service, the National Institutes of Health, the Health Resources and Services Administration, and the Substance Abuse and Mental Health Services Administration.

Work on the NHQR has proceeded in five areas:

Developing a Conceptual Framework for Reporting. AHRQ commissioned the Institute of Medicine (IOM) to develop the conceptual framework for the NHQR. The IOM formed a 14-member committee of leading experts in quality. They committee commissioned papers, held multiple meetings to discuss alternative conceptual recommended a conceptual framework that includes both dimensions of care (e.g., safety, effectiveness, timeliness, patient centeredness, equity) and patient needs (e.g., staying healthy, getting better, living with illness or disability, coping with the end of life). The quality measurement system for the NHQR is organized around this framework.

Identifying Potential Measures to Populate the Framework. AHRQ formed an interagency work group to identify candidate measures for the report. The work group developed a call for measures that was sent to all relevant Federal agencies, and the IOM issued a similar call to the private sector. About 600 measures were submitted for consideration in response to these calls. The interagency workgroup mapped the candidate measures into the conceptual framework. The measures within each conceptual category were then evaluated for inclusion. There were two parts to the evaluation. First, measures were selected to maintain consistency with existing consensus-based measure sets where possible. Second, the workgroup assessed candidate measures using criteria recommended by the IOM in the Envisioning report, which include: importance, scientific soundness, and feasibility.

Based on these assessments the workgroup identified a preliminary set of about 140 measures for the first NHQR. The workgroup is currently seeking input on the preliminary measure set from potential stakeholders and other interested parties. They are seeking input on the individual measures and the overall balance, comprehensiveness, and robustness of the measure set. The workgroup held a public hearing through the National Committee for Vital and Health Statistics and made the measure set available for comment on AHRQ's web site for anyone who could not attend the hearing. Public comments were accepted through the Web site until mid-September 2002.

Identifying Data Sources for Potential Measures. Existing data sources to support measurement for the first NHQR have been identified and include population-based data collection efforts, establishment/provider-based data collection efforts, administrative/regulatory data collection efforts, vital statistics, and surveillance activities. Measurement specifications have been completed, data processing support procurements have been completed, and data analysis has begun. Analyses are being conducted throughout the Department including AHRQ, NCHS, CMS, and NIH. Final decisions on which measures to include in the first report will be based on the results of these analyses, the public input we receive and guidance from the NHQR Interagency Workgroup, Department technical experts and AHRQ senior leadership.

Research on Report Design. AHRQ formed interagency workgroup to develop the design of the report. The workgroup has conducted research to identify the needs of potential audiences for the report and to develop a report design to meet those needs. There have been several rounds of audience research, including testing on general design, report organization, and presentation format. Another AHRQ project reviewed existing reporting systems and conducted a comprehensive literature search of information on quality reporting programs in the United States and internationally. The information was analyzed to identify common themes and best practices among other reporting entities. Based on these activities, the workgroup has developed a preliminary design for the report. When data analyses are completed and the final measures are selected, the design will be finalized and the report will be drafted. We anticipate sending the draft of the first report into clearance in early Spring 2003.

Longer Term Development. The development of an effort to monitor the Nation's progress in health care quality is an evolutionary process. Measurement systems need to continue to improve to better capture the multidimensional nature of quality. As we are preparing the first report we are simultaneously initiating efforts to enhance the data and measurement infrastructure to support future reports. For example, AHRQ has enhanced the Medical Expenditure Panel Survey by increasing the size and geographic dispersion of the sample and adding quality-related content. A current research project is looking at the pros and cons of private sector data sources that may be appropriate for future reports. We are working with the National Association of Health Data Organizations to coordinate quality measurement and reporting at the national and state levels. We are working with international partners to identify a common set of indicators that can be used to facilitate international comparisons. We are also working to enhance our future reporting capabilities. Ultimately we want to develop a Web-based product that will allow users to drill down from national-level data to obtain detail on quality performance measures for population subgroups and smaller geographic areas. Users would then have the capability to link to evidence-based information and tools on how to improve quality in areas related to the measurements.

Working Conditions and the Quality of Health Care

Understanding how working conditions affect health care workers, the risks for errors, and the quality of services provided to patients is of major importance to the health care industry. Recent efforts to reduce costs and streamline the delivery of care have led to significant changes in the health care workplace. The experiences of other industries demonstrate that differences in the equipment and physical characteristics of the workspace, changes in work responsibility and process, and changes in staffing levels can affect the quality of the products or services provided. For example, research on working conditions in the aviation industry demonstrates the relationship between aviation safety and work hours, including the effect of factors such as fatigue, lack of sleep, and shift work. Despite the importance of the issue, there has been scant research on the importance of quality of the workplace environment—not only for worker satisfaction, worker health, the avoidance of disability, but also for the quality and productivity of the work performed. Workplace factors, including the way work is organized and staffed, may pose a threat, not only to the health and well-being of workers, but also to the quality of care they provide to patients and the safety of patients.

Over the last 2 years, AHRQ has funded more than 30 projects to examine the effects of working conditions on health care workers' ability to provide safe, high-quality care in ambulatory, in-patient (both hospital and long-term care institutions), and home care settings. Examples of the critical issues now being addressed by these researchers include:

• Effects of extended work hours, sleep deprivation, fatigue, and stress on residents and nurses working in hospital-based settings.
• Relationship between working conditions—such as nurse-to-patient ratios, workload, and skill mix—and the occurrence or near occurrence of medical errors or adverse events.
• Impact of workplace characteristics, organizational culture, and teamwork on the safety, quality, and outcomes of care in inpatient settings, specifically intensive care units and surgical settings.
• Relationship between nursing home working conditions—such as staffing levels, job design, and job satisfaction—and worker outcomes, patient outcomes, and quality of care.
• Impact of financial incentives and the work environment on the quality of care in both ambulatory and inpatient settings.
• Effects of employee training, satisfaction, and understanding of patient safety on patient outcomes and quality of care.

AHRQ Research Study: Nursing Staff Levels and Patient Outcomes Major Finding: Direct link between nurse staffing levels and patient complications and deaths in hospitals. Low RN staffing associated with rates of serious complications: Pneumonia, Shock, Cardiac arrest, Gastrointestinal bleeding. Ongoing partnership with AHRQ, HRSA, CMS, and National Institute for Nursing Research. J Needleman, P Buerhaus, et al., NEJM, May 30, 2002.

Tools for Patients and Health Care Consumers

Americans are demanding greater value and quality in their health care. To achieve these goals in today's rapidly changing health care environment, consumers need reliable, evidence-based information to help them choose among health care plans, practitioners and facilities. They also need information to help them participate more actively and effectively in their personal health care decisions. AHRQ is committed to providing the information consumers need and want to get the best possible health care.

Consumer Assessment of Health Plans (CAHPS®). CAHPS® is an easy-to-use kit of survey and reporting tools that provides reliable information to help consumers and purchasers assess and choose among health plans. CAHPS® will also allow health plans and purchasers to assess and track areas for quality improvement. Information from CAHPS® surveys was available to help more than 120 million Americans with their 2002 health care benefits decisions.

The CAHPS® team and AHRQ work closely with the health care industry and consumers to ensure that the CAHPS® tools are useful to both individual consumers and to employers and other institutional purchasers of health plans. Collaborations include the following:

• Beneficiaries enrolled in 280 Medicare managed care plans assessed their plans and this information was made available to nearly 40 million Medicare beneficiaries. This information is also available on the Medicare.gov Web site.
• AHRQ and CMS collaborated with the CAHPS® consortium to develop a Medicare CAHPS® Disenrollee Survey. This survey of beneficiaries who had recently left a Medicare managed care plan was fielded by CMS in FY 2000. Approximately 80 percent of this survey related to quality. Survey data allows users to distinguish between disenrollment decisions that are unrelated to quality (e.g., enrollee moving out of the area that the plan serves) and disenrollment that is related to quality (e.g., limited access to specialists).
• A version of CAHPS® to assess care at the group practice level was developed in collaboration with the California Health Care Foundation and the Pacific Group on Health. The survey was developed in response to strong consumer interest in information on the ability of physicians in group practices to provide high-quality care. In CAHPS® II, the team will develop ways of reporting CAHPS® data to consumers as well as to group practices. An additional goal is to develop strategies for working with physicians to improve areas that consumers identified as troublesome.
• The CAHPS® consortium and the Foundation for Accountability, with support from the David and Lucille Packard Foundation, developed a CAHPS® survey to identify children with special health care needs and collect information on how well health plans are meeting those needs. This tool is used by numerous State Medicaid and other agencies involved in managing children's health insurance programs to meet the requirements set forth in the 1997 Balanced budget Act. The National Committee for Quality Assurance has included this survey as a requirement in the HEDIS reporting set.
• AHRQ and CMS are collaborating in the development of a CAHPS® survey to obtain consumers' assessments of health care and services received in nursing homes. Survey development and sampling and data collection procedures were completed in FY 2001. Additional testing was carried out in FY 2002. Data collected from nursing home residents and next of kin will be used to help people choose a nursing home.

Blue Cross of California and CAHPS® Shifting the focus from cost savings to improving quality, Blue Cross of California changed its method of rewarding HMO physicians. As of January 1, 2002, the health plan awards bonuses to its HMO physicians and medical groups based on quality of care and patient satisfaction. Satisfaction is determined through the use of Consumer Assessment of Satisfaction (CAS) survey data, derived from the HMO CAHPS® survey.

In 2002, AHRQ funded three grants submitted under the CAHPS® II Request for Applications (RFA) for $2.5 million. CAHPS® II will focus on development and testing of new and more effective ways to report quality data to consumers, patients, caregivers, and purchasers. It will also permit translation of the questionnaires and reports into Spanish and other languages. This initiative includes the development of assessment instruments for people with mobility impairments and more refined questionnaire items for people who receive care through preferred provider organizations. The team will also work with caregivers and plans to use CAHPS® data for the purpose of quality improvement.

CAHPS® and Small Business Innovation Research Award The State of Washington's Health Care Authority is using a decision support tool originally developed through an AHRQ SBIR grant that incorporates CAHPS® to help State employees and retirees choose among health plans. The tool was developed as "Health Plan Select", but, as customized by Washington State, is called "Compare-A-Plan." Because the volume of information about health plans can be confusing, the tool is designed to help consumers learn about their health plan choices, then compare and choose a plan. To accomplish this, the Web-based tool integrates price, benefits, physician choice and health plan performance measures such as CAHPS® and HEDIS®. "Compare-A-Plan" is on the Washington State government's Web site.

Partnerships for Quality (Translating Research into Practice)

Research and experience have taught that new scientific knowledge does not automatically translate into practice and improve patient care. For research findings to make their way into everyday clinical practice, the new knowledge must be linked with supportive environments and incentives for change. Systematic approaches are required for change to take place and services to be implemented that have the potential to improve care.

To close the gap between the level of quality that is possible and that which is achieved, AHRQ is supporting a newly funded initiative called Partnerships for Quality. This initiative supports projects that are designed to accelerate the pace with which research findings can be translated into improved quality of care and improvements in the health care system's ability to deliver that care. In response to AHRQ's call for research proposals, the agency funded 18 grants in FY 2002 for a total of $1.8 million that are primarily focused on improvements in the delivery and outcomes of health care, with a focus on priority health conditions, such as diabetes and heart disease, and priority health issues, such as long-term care, bioterrorism, and children's mental health.

Although no specific matching requirements are included in this RFA, these grants are seen as partnerships and as furthering and facilitating efforts already underway or in advanced stages of planning. Therefore, it is expected that grantee organizations and consortia will devote substantial amounts of their own resources to this effort. Examples of three Partnerships for Quality grants are provided below:

• Partnership To Improve Children's Health Care Quality. The partners for this project are the National Initiative for Children's Healthcare Quality (NICHQ), the American Academy of Pediatrics (AAP), a certifying body (the American Board of Pediatrics, ABP), and Children and Adults with Attention Deficit Disorder (CHADD). The project will build on NICHQ's success in improving care for children with ADHD by engaging five State AAP chapters in systems- and evidence-based collaborative learning sessions along with an interactive Web-based CME quality improvement tool (eQUIPP). ABP will collaborate by including eQUIPP as a vehicle for satisfaction of new certification requirements. Efforts in subsequent years will focus on supporting these local improvement networks, spreading these efforts to additional AAP chapters, and beginning work with pediatric residency training programs.

• Partnership for Achieving Quality Home Care. This project, awarded to the Visiting Nurse Service of New York, will launch a national partnership among home health care providers to improve care for a priority population, elderly home care recipients, by creating a model and establishing an infrastructure through which collaborating organizations can identify and prioritize goals for improvement and gain access to methods, tools, and materials that will enable them to reach beyond what they could do as individual organizations to conduct more sophisticated, evidence-based quality improvement activities. A learning collaborative model, adapted from the successful Breakthrough Series approach developed by the Institute for Healthcare Improvement (IHI), will be created to serve as a central mechanism of the partnership. Activities will include 14 home health agencies, up to two national home health industry associations, two accrediting bodies, and the National Academy of Home Health Physicians.

• Measurement of Quality and Bioterrorism Preparedness: An Impact Study. This project, which was awarded to the Joint Commission on Accreditation of Healthcare Organizations, consists of two distinct but complementary entities. The first element relates to performance measurement using an indicator-based approach to measuring quality of care that will demonstrate the impact of evidence-based measurement on health care quality across U.S. hospitals. Areas of focus will be congestive heart failure, acute myocardial infarction, community-acquired pneumonia, and pregnancy. The second element will address an essential element of overall preparedness of health care organizations for a bioterrorism event. The goal is to assess improvements in linkages between health care organizations, the public health infrastructure, and emergency response in the wake of multiple influences such as implementation of the revised Joint Commission emergency management standards, occurrence of national events, and availability of Federal funding for bioterrorism preparedness.

A PART assessment was conducted for this program and helped inform the FY 2004 budget policy. Select for a summary of the PART for Translating Research into Practice.

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