AHRQ Summit--Improving Health Care Quality for All Americans (continued)

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AHRQ Summit—Improving Health Care Quality for All Americans

The Quality Challenge

Carolyn Clancy, M.D., Director
Agency for Healthcare Research and Quality (AHRQ)
U.S. Department of Health and Human Services

At AHRQ, quality is more than just a part of our name. It identifies the role we play within the U.S. Department of Health and Human Services and is at the heart of everything we do to:

Further our understanding of quality gaps and health disparities.
Uncover the evidence-based strategies to address them.
Disseminate that knowledge as broadly as possible.

Huge Gaps and Variations in Quality Remain

In so many cases, we know in detail the kind of care we should be delivering, including the science-based evidence and measures needed to assure quality. Yet the gaps in quality are glaring—not only the gaps between high-performing States and low-performing ones, but more fundamentally, the gaps between what we know about improving quality and what we actually achieve. We do have evidence of rapid positive changes, for example, in nursing home quality. However, it is the exception, not the rule—especially in the area of health care disparities.

What Can Be Measured Can Be Improved

Today we are measuring health care quality as never before—and these measures provide a critical baseline that is pointing the public spotlight on important quality gaps and disparities across the Nation.

Both consumers and clinicians experience health care on a one-by-one basis, based on personal stories or individual patients. Quality measures show us general patterns that cannot be seen at the individual level. They show what is really at stake in terms of quality, gaps, and disparities—and the stakes are huge.

If we do not improve quality more rapidly, our health care system will hardly be prepared to deliver the health care of the future.

The second annual National Healthcare Quality Report and National Healthcare Disparities Report, issued by AHRQ in February 2005, present the most extensive ongoing examination of quality and disparities. These reports indicate that a large gap remains between high-quality and low-quality care and that disparities remain entrenched. For example:

State-by-State comparisons indicate that the percentages of women receiving prenatal care in the first trimester vary from 91 to 69 percent from the lowest performing States to the highest performing States.
Rates of colon cancer screening for adults over age 50 range from 38 to 66 percent.
Prompt administration of antibiotics for older patients with pneumonia ranges from 46 to 77 percent.

The data also indicate that even in States where the rates are higher, they often remain well below the standard of quality. Thus, there is need for improvement everywhere.

We Must Step Up the Rate of Progress

Of 98 measures with trend data tracked in the National Healthcare Quality Report, the median rate of change was only 2.8 percent compared to the first report issued last year. Of these 98 measures:

67 measures saw some improvement.
30 indicators were worse this year than last.
1 measure remained unchanged.

At this rate of progress, it will take 20 years to achieve the desired levels of quality improvements.

Awareness of the Importance of Quality Improvements Is Gaining Attention

Here are just a few examples of recent national initiatives:

The Centers for Medicare & Medicaid Services just released strong, comparative hospital quality data.
AHRQ released its second annual report on health care quality and disparities.
The Institute for Healthcare Improvement, led by Don Berwick, has launched a new 100K Lives Campaign—with specific goals to improve health care quality and reduce unnecessary deaths across the country.
Policymakers in Congress are beginning to understand the association between quality and cost-effectiveness in health care. The Medicare Modernization Act includes many provisions that build on quality measurements—including the charge to AHRQ to study the comparative effectiveness of treatments for 10 key medical conditions.

These comparisons are critical. What athlete ever broke a performance record without knowing what the record was? Comparison is part of the process of turning information into action.

Measurement Is Critical, But It Is Not Enough

We must translate information into action. The challenge is to disseminate knowledge and best practices broadly and in formats that are easy to access and use.

We know that the closer we come to the source of care, the more actionable our information becomes. We need to help clinicians and health care systems learn the evidence-based facts about best practices. And they need to make the system changes that put knowledge into practice.

At AHRQ, we are trying to make our data more useful to States, communities, and practitioners—especially by making them more targeted. We are offering a new presentation of our data for 14 key health indicators which are now broken down by State. (Go to http://statesnapshots.ahrq.gov or select for additional AHRQ resources to facilitate quality improvement efforts.)

This is meant to be a tool (not a grade) that States can use to clarify areas of strength and weakness. In addition, AHRQ is interested in hearing from States regarding what other types of technical assistance would help them.

Much is happening at the local level. Islands of innovation are everywhere. Hospitals, doctors, nurses, and other clinicians are developing novel solutions. By focusing on their own priority areas in their own communities and clinics, they are finding creative, real-world solutions that work.

In response, AHRQ is launching a new million-dollar initiative called AHRQ QualityConnect to help shine the light on what works and share lessons learned with those on the front lines of improvement. This is critical. We need to build bridges. We need to find where successful innovations have been made and share these new approaches widely.

Our goal is to share information on innovations and promising practices, on leaders in the field, and on useful tools and ideas through multiple communications methods such as meetings, the Web, research networks, and other forms of outreach.

A Critical Quality Challenge Lies Before Us

This requires a new attitude toward our mission and our profession. What is the Quality Challenge?

It is a challenge that is being carried out in the Medicare program, which is tracking and publishing quality data to drive improvements in health care facilities. It is the challenge that was launched by the Institute of Medicine report on medical errors that called for openness regarding quality issues and shared accountability for improvements.

The Quality Challenge can be described using five Cs:

Candor—We must find the data on quality and disparities and share them openly.
Comparison—Both patients and clinicians need to be able to compare providers and facilities to find and spur quality services.
Consequences—The consequence of consumer and payer choice is that when quality shortcomings become known, it drives demand for improvement, forcing providers to find the energy and knowhow to correct problems.
Courage—The Quality Challenge is not easy. Incorporating the features of candor, comparison, and consequences will require a culture change among health care providers. Courage is perhaps what is most needed to make the rest possible. Let's acknowledge that all over this country, health care professionals are demonstrating that they have the courage to improve.
Cooperation—We must build bridges that connect successful innovations with those on the front lines of improvement, who are looking for creative models and lessons learned.

The Challenge Is Great and Raises the Question, "Where Do We Go From Here?"

We need to maintain constant focus, not only nationally but also in our community and clinical settings.
We need to acknowledge the power of the metrics. We have built a new vocabulary of quality measurement and must incorporate the language of quality comparison and improvement into every health care setting.
We need to use the power of health information technology to measure performance, make treatment information available, and make available complete patient information.
We need the leadership of health care settings to be directly and visibly committed to health care improvement.
We need to understand the central importance of health care disparities and the importance of improving provider communications to help tackle this problem.
We need to keep improving our knowledge of what works best in health care, incorporating effectiveness research and ensuring that quality measures are kept up to date to reflect the latest findings.
We need to understand the complexity of quality improvement; the major transformations it requires, and the importance of maintaining consistent scorecards, such as AHRQ's quality reports.
We need to appreciate the full meaning of patient-centeredness, which goes beyond patient needs and incorporates what patients themselves see as quality of care.
We need to recognize the importance of professional pride among everyone in our health care system. In the end, it is personal vision, professionalism, and courage that will drive quality improvement.

This meeting is an important beginning. It has brought individuals who focus on quality together with those that focus on disparities. At AHRQ, we plan to follow up this conference with a series of town hall meetings to continue the discussion and information sharing. Our hope is that the dialog, research, promising practices, and exchange of information on lessons learned will continue.

Only by meeting the Quality Challenge can we ensure that every dollar we invest in health care buys a dollar's worth of value and that Americans actually receive the best quality health care.

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