Next Steps, Parting Remarks
Expanding Research and Evaluation Designs to Improve the Science Base
Dr. Orleans summarized that the organizations that sponsored this symposium are collaborating so we can think about how to do a better job of accelerating quality improvement (QI) research. We also are examining how to best disseminate the results of this meeting. She and others from the Robert Wood Johnson Foundation (RWJF) were very pleased to see their grantees in attendance. The grantees are doing leading work and RWJF will be making an effort to synthesize their findings in order to contribute to the cumulative evidence from the field. RWJF also is applying quality improvement to reduce disparities in health care and soon will launch a number of new initiatives in this area. Lori Melichar of RWJF has been leading an effort to improve the quality of quality improvement research. RWJF is considering sponsoring a network among its grantees and perhaps among a larger group. Finding a common taxonomy will be critical to this effort, and it must be embedded in the larger forces of health care QI and pay-for-performance initiatives, as well as performance measurement and reporting initiatives. The use of a common measure of system-level supports for quality care is needed to introduce QI into the health care improvement "machinery." RWJF has funded the National Committee for Quality Assurance (NCQA) to adapt the ACIC (Assessing Chronic Illness Care) measure developed by Edward Wagner, Russell Glasgow, and colleagues into a Health Plan Employer Data and Information Set (HEDIS)-type measure. This measure assesses the presence of system supports for Chronic Care Model-based care for a range of chronic conditions. The most recent version of this NCQA measure is being validated for use in practices of varying sizes, ranging from small one-to-two physician office practices to larger health plans and preferred provider organizations. Ideally, such a measure could be adopted into the National Quality Forum's core performance measurement set, as well as into other national "pay for performance" measurement sets. RWJF also is funding a new effort led by the Association of American Medical Colleges, with significant input from the Improving Chronic Illness Care national program to build continuous quality improvement (CQI) into the core medical curriculum. Finally, Dr. Orleans noted that federal agencies must work to better address the needs of end-users. She suggested that funders should spend more time with operations personnel and study end-users in their own environments. HealthPartners is planning a meeting that will bring an operations system perspective into sharper focus—this meeting may be a starting point for such efforts.
Dr. Mercer noted that the Centers for Disease Control and Prevention (CDC) has been involved in conferences such as these because the agency is interested in projects related to translational research. CDC's vision statement is "healthy people in a healthy world" and it seeks to attain this through all of its research portfolio, its direct support of public health services, and through surveillance. As CDC works with state and local health departments, it is able to observe and determine their needs from the front lines. She mentioned the importance of partnerships and the need to have a seamless interface between public health and the health care system. The issue of external validity is very important to CDC. At this point, quality improvement as a term does not resonate at CDC as much as the concept of translation of research into practice, but it is recognized that the terms have areas of commonality. The issue of disparities also is important to CDC. Quality improvement terminology is creeping into the vernacular of some parts of CDC, such as those involved in developing business case models. And there are some opportunities for QI funding at CDC in areas such as obesity and diabetes where there is close networking between the public health and health care systems.
Dr. Francis pointed out that the Department of Veterans Affairs (VA) has a new chief research and development officer, Dr. Joel Kupersmith, who has written a position paper29 proposing an expansion of effectiveness and implementation research through the creation of a public-private partnership. Employers, health plans, pharmaceutical and device companies, and provider organizations all stand to benefit from the implementation of evidence-based practice, and the support of such work would constitute a very small percentage of their total expenditures. Interagency collaboration is also important, although many structural barriers exist (e.g., coordinating funds transfer and funding cycles is difficult).
Dr. DeVoto stated that the National Institutes of Health (NIH) is actively involved in research and funding of health care QI, mostly within the context of individual institutes. But, also there are cross-NIH efforts, such as a special interest group that includes individuals at AHRQ, CDC, and other Federal Agencies as well. The special interest group was formed to pool resources and to learn from one another and work together on health care quality improvement. The National Library of Medicine dedicates a lot of resources to health services research, and the Health Services Research Interest Group is working with the library to compile a list of the requests for applications (RFAs) and program announcements from across NIH related to health services research and this will be posted on the Web.
Dr. Dougherty thanked everyone for their contributions during the symposium, noted that it had been a great success, and adjourned the meeting.