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The Quality Challenge

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Carolyn M. Clancy, M.D., Director of the Agency for Healthcare Research and Quality (AHRQ)

Health Care Quality Summit—Improving Health Care for All Americans, Washington, DC, April 4, 2005

Select to hear a video presentation of Dr. Clancy's speech.

We've come together at this Summit to look toward a "Quality" future for American health care—to take up the "Quality Challenge." We know we can do better. We know we can learn from each other. One thing is clear—none of us has all the answers.

And yet—let's state our predicament right up front:

When it comes to Quality in health care delivery, we actually do have many answers—answers about best practices... answers about what works... proven, science-based answers.

What we don't have yet is results.

  • In so many cases, we already know in detail the kind of care we should be delivering. We have the evidence. We have the measures.
  • And yet, we remain so far short of having the performance.

More than that—We still see such variation in quality, from one clinic to another and one State to another. In some measures, the quality of care can be many times lower in some States than in others.

This is doubly frustrating—because it makes clear to us what can be attained. It tells us what we could be achieving, if we all performed at the level that's already being achieved by some.

There's no getting off this hook. We can see what is possible—and we can see, in our own clinics and States, when we've failed to attain it.

So this is the state of health care quality in America today:

  • Stubbornly short of where we want it to be.
  • Agonizingly short of where we know it could be.
  • And still slow and sporadic in making improvement.

What should we feel about this? Impatience? Anger? Even outrage? I think we feel all of these—because health care quality is not about numbers. It's about lives... and health... and avoiding needless waste.

I hope that after today, we'll also feel energized and better enabled to help all Americans get the quality of care that we know can be delivered.

The "Quality Challenge" is a personal challenge to each of us—but it's one that none of us can accomplish alone. It requires not just new procedures but new attitudes—indeed, a new culture.

Let me take a moment and acknowledge what we have achieved—because I believe we're at a significant turning point. I think a fundamental change is occurring. And that change comes from what we've learned, and what we've done, to measure quality.

The saying goes: "What can be measured can be improved." Today, we are measuring health care quality as never before.

That is Step One—and I believe the rest will follow.

Look at what has happened, even recently:

  • Just this past Friday, we saw the release of strong, comparative hospital quality data by the Centers for Medicare & Medicaid Services. Just a few short years ago, who would have thought this would be possible so soon?
  • Just a few weeks earlier, AHRQ released its second annual national reports on quality of care and disparities in care. These reports are establishing a baseline expectation among Americans that our Nation's health care quality can and will be measured—and the results will be public. This represents a sea-change in our health care system.
  • Just last December, the Institute for Healthcare Improvement, led by Don Berwick, launched its "100,000 Lives" campaign—with specific goals and a strategic battle plan. That campaign is highly visible. But we also know that it joins many other campaigns and initiatives, large and small, all over our country.
  • Even on Capitol Hill... Congress is learning that "quality" and "cost effectiveness" are allies, not enemies. "Quality" means "the right treatment at the right time." And that is a prescription for getting your money's worth. The Medicare Modernization Act includes many provisions that build on quality measurement—including the charge to AHRQ to study the comparative effectiveness of treatments for 10 key medical conditions.

So we can take some pride that progress is being made. Quality measurement is taking root in health care. Consumers have access to more quality information. And new payment structures are being examined to reward quality care.

We can take some pride—but not satisfaction. Because, as we know, the real job is so far from being done.

Let's look at the data:

  • The National Healthcare Quality Report and the National Healthcare Disparities Report, which were issued by AHRQ in February, are an important new resource for the Nation.
  • The Quality Report gathers into one document an overview of many different national surveys. It looks at 179 different quality-related measures. It is the most extensive ongoing examination of quality of care ever undertaken.
  • The Disparities Report is a "twin" document with the Quality Report. They need to be read together. It would be difficult to understand the real dimensions of the quality measures without taking into account the pervasive differences in care associated with race, ethnicity, and income.

This year was the second annual issuance of our quality reports. They'll now provide a means for tracking the state of health care quality in America year after year.

The details they provide are complex—but the overall story is clear:

  • The gap between those delivering high quality care and low quality care remains very large.
  • In most instances, even those delivering the best care are still far short of what we can achieve.
  • Progress is very slow overall.
  • And disparities remain entrenched.

For the 98 measures where trend data were available, there was some progress. In fact, 67 of the measures improved while 30 deteriorated, with 1 unchanged. But the median rate of change was only 2.8 percent from our first-year report. We have to do much better.

Measure by measure, the Quality Report shows that patients in the leading States are getting care at a level of quality that is many times higher than the lowest performing States. For example, nursing home residents were physically restrained at a rate almost 10 times higher in the lowest performing State, compared with the highest performing State.

Let's look at a few specific measures:

Take the percentage of women who receive prenatal care in the first 3 months of pregnancy. In the leading State, it's more than 91 percent. In the trailing State, it's only 69 percent. This cries out for improvement.

Or take the percentage of Medicare patients who are prescribed an ACE inhibitor when they leave the hospital after being treated for heart failure. This is a treatment that works. We have the evidence in hand. Yet, for the lowest State, only 52 percent of these patients get the care that we know is effective. And even the highest State, at 80 percent, is less than we should aim for.

The gaps are glaring. And I don't just mean the gap between States. Much more fundamental is the gap between what we know and what we achieve—even at our best.

For example—We know how important it is for adults over 50 to get screening for colon cancer. But in our best performing State, only two-thirds have ever received one of the preferred screening procedures. And in the lowest performing State, it's only 38 percent.

Likewise—We know that older patients should receive antibiotics promptly when they're hospitalized with pneumonia. Yet, even in our leading State, just under 77 percent of Medicare patients are getting antibiotics within 4 hours. In our trailing State, it's less than half: 46.1 percent.

There is so much work to be done. 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.

Change is possible:

For example: for the five measures of nursing home quality, our report showed that performance improved by almost 15 percent. There was actually a decrease of 37 percent in nursing home patients who have moderate to severe pain.

And the progress was even more rapid for nursing homes that received intensive help as part of the CMS Nursing Home Quality Initiative. For chronic pain, the intensive group had a decline of 46 percent.

So rapid change can be made. But so far, it's the exception, not the rule. And that is especially true in the area of health care disparities.

Twenty years after the Department of Health and Human Services issued its first broad report on disparities:

  • Blacks still receive poorer quality of care than whites for about two-thirds of quality measures.
  • Hispanics have worse access to care than non-Hispanic whites for about 90 percent of access measures.
  • Poor people receive lower quality of care for about 60 percent of quality measures and have worse access to care for about 80 percent of access measures than those with high incomes.

I wonder sometimes if we've become inured to these facts. Measurement is critical—but measures are not enough. I can testify for all my colleagues at AHRQ that we worked hard on our quality reports. But that was the easy part.

How do we translate information into action? That's the real question.

We need to summon up the energy that this difficult job demands. As health professionals and as citizens, we should be feeling "shock and awe" when we see these chaotic differences in quality of care.

All of us know personal stories about individuals who have failed to get the quality of care they needed. We hear the stories one-by-one. Sometimes the result is a near-miss; sometimes it's tragic.

Clinicians likewise experience their practices in a "one-by-one" fashion. They make personal connection with their patients, and they do their best, patient by patient. But we all need to be able to see more.

Our quality measures show us patterns that can't be seen "one-by-one." They show us what is really at stake in delivering higher quality care. For example:

  • If everyone age 50 and older received recommended colorectal cancer screening, there would be some 70,000 fewer colorectal cancers and 30,000 fewer deaths each year.
  • If everyone 65 and older received recommended pneumococcal vaccination, there would be some 18,000 fewer deaths each year. But so far, pneumococcal vaccination is increasing at only about 2.5 percent each year.

The stakes are bigger than any of us can see on our own. And if we don't improve more rapidly, our health care system will hardly be prepared to deliver the medical care of the future. This is a point made strongly by the director of the National Cancer Institute. His goal is to develop techniques that will make cancer a manageable disease. But that will require a health care system that delivers care in the right way.

AHRQ and our sister agencies at HHS and throughout the Federal and State governments are taking important steps.

But of course, the real "doers" must be the men and women at the patient level. We all know it's a vast effort, with thousands of different parts. And AHRQ's quality reports can serve as a unifying force, and a roadmap, as we each work in our own areas.

At the same time, AHRQ's data can also be made more useful—especially by making these data more targeted.

That's why today, we're making available new presentations of State data from our Quality Report. Until now, it's been complicated for States to extract their own data from our reports—to see where they stand and determine where their priorities should lie.

Today, we're offering new products to the States—breaking out their data, making their strengths and weaknesses clear, and showing where they rank on 14 key individual measures.

Each State has areas where it is strong and areas where improvements are needed. And the picture is different for every one of them.

Let me be clear—this is not about ranking State health care systems from top to bottom on quality of care. The picture is much too complex for that. There is no "best State" or "worst State." Improvement is needed in every State. The important task is to look measure by measure to understand where we stand and what the next steps should be.

We all know that the closer we come to the source of the care, the more actionable our information becomes. And that information also needs to be as clear as it can be. AHRQ is taking this new step today to help all of us see where our own States stand.

It's crucial that all of us understand: These data are a tool, not a grade. They are a compass pointing to improvement, not a finger pointing blame.

In particular, they do not mean that any State can be satisfied or complacent—because improvement is needed in every State.

It's equally important to understand that this State information is just one part of a bigger picture—a hopeful picture.

It's part of the "Quality Challenge" that lies before us.

It's the challenge that's being carried out in the Medicare program: to find the quality data, publish them, and let the data drive improvement in health care facilities.

It's the challenge that was made by the Institute of Medicine to find and correct medical error: its challenge to be open about problems and to share accountability for improvement.

What is the "Quality Challenge?" It's nothing less that a new attitude toward our mission and our profession. It's a new formula for giving our best. Most of all, it's the spirit we bring to this task.

I'd like to suggest four C's to describe it:

  • Candor.
  • Comparison.
  • Consequences.
  • Courage.

Candor—Because without truly acknowledging that improvement is needed, and meaning that enough to find the facts and share them, we wouldn't be able to move. The stakes are too high to stand still. Candor is the starting point.

Comparison—In part, because we want patients to be able to compare and choose the right care for themselves. But even more important, because our clinicians need to compare themselves and their facilities with others, in order to know where they stand. That's how improvement happens. What athlete ever broke a performance record without knowing what the record was? Comparison is information turning into action before our eyes.

Consequences—Of course, this includes the consequences of consumer and payer choice. Consumers deserve to find and choose the best care for themselves. But it also means more. When our shortcomings become known, we find the energy and the know-how to correct them. The most important consequences will be the positive ones—the changes that clinicians make themselves, when they know what is possible.

And, because there will be bumps on this road...

Courage—As we move into a new Quality Paradigm in health care, we need to give credit to our physicians and nurses and other clinicians. These features—"candor," "comparison," "consequences"—represent a culture change and a personal challenge to every one of us. 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.

Of course, there's a fifth "C" as well—Cooperation.

Those of us at the national level can help find the data and the patterns. But the hard choices and the real action must take place at the local level.

And that is happening. I see islands of innovation everywhere I travel. Hospitals, doctors, nurses, and other clinicians are developing novel solutions. By focusing on their own priority areas in their own communities and clinics, they're finding creative, real-world solutions that work.

We need more of that kind of initiative and creativity. And we need to build bridges. We need to find where successful innovations have been made and share these new approaches widely.

At AHRQ, we want to take responsibility for building those bridges... and connecting those who are improving health care with those who still need the roadmap to improvement. That's why today, I'm committing a million dollars this year to a new initiative—AHRQ QualityConnect—to help uncover what works and share "lessons learned" with those at the frontline of improvement. When progress is being made, we need to be there to help uncover the new approach, the new tool, the new idea. And we'll share these—through meetings, the Web, our research networks—and whatever else you think you need to improve our health care system. I want to have this initiative in place this summer.

At the same time, of course, AHRQ is available to help States drill down in the data and understand better where State priorities may lie. And we're anxious to hear from States what other kinds of technical assistance would help them.

These are a few of the "Quality Bridges" that we need. They're built on individual energy and creativity—and on cooperation.

Where do we go from here? I have a few ideas—and we'll hear many more today.

  • We need to maintain constant focus, both nationally and, especially, in our own communities and clinical settings.
  • We need to acknowledge the power of the metrics. We've built a new vocabulary of quality measurement. We should use measures in every setting and keep improving them.
  • We also need the power of health information technology. The President and Secretary Leavitt have drawn the Nation's attention to the way health IT can make complete patient information available. It can also improve quality of care by making treatment information available. And it will be crucial for measuring our performance. Health information technology is a key element of quality improvement.
  • We need the leadership in our health care settings to be directly involved in quality improvement and visibly committed—not because improvement comes only from the top, but because our leaders, through their commitment, can empower everyone in the organization to come forward with ideas and enthusiasm.
  • We need to understand the central importance of health care disparities in improving our quality of care. Disparities remain stubbornly in place, and our Nation is grappling with this on many fronts. But I'd like to suggest that a special goal for clinicians is communication. Quality of care is not likely to improve if the care itself is not understood. Communication is crucial.
  • We need to keep improving our knowledge of what works best in health care. Effectiveness research is one of the foundations for improving quality. That foundation needs to keep growing.
  • We need to understand and support the new culture of the "Quality Challenge." And we need to be sure this new culture is reaching into our health professions education.
  • We need a shared understanding of the complexity of quality improvement. We are looking toward a transformation of health care. We need to share what we learn. And we need consistent scorecards, like AHRQ's quality reports.
  • Finally, we need to appreciate the full meaning of patient centeredness. One of the four categories in AHRQ's Quality Report indeed is "patient centeredness." But that does not simply mean focusing on what we see as the patient's needs. It also means reaching out beyond our own knowledge. It means listening to what patients themselves see as quality of care. These may not always be the clinical issues that we know to be important. We may be surprised. But it's important to listen—it's part of that word, "care."

I said earlier that I'm hopeful. We've developed new tools, and we're beginning to use them. There's much to learn and challenges to be met. But I believe there's no turning back.

Our patients and citizens are understanding better every day what is at stake Our health care payers are recognizing that quality is the shortest road to cost effectiveness. These are important factors that will help us "stay the course" on quality improvement.

But in my view, the most important factor is professional pride. Everyone in our health care system goes to his or her work to heal, to help, to make a difference for the better. In the end, their own personal vision, their professionalism, and their courage are how quality improvement will happen.

For my agency, this has been a long journey. AHRQ and its predecessor agencies supported much of the foundation we're building on. For years, we've been developing the medical evidence base, and we're looking for new opportunities to help translate our research into practice.

Today, all of us need to work together...

  • toward the day when every dollar we invest in health care buys a dollar's worth of value...
  • and the day when Americans don't just "have the best health care in the world"—rather, that they actually get the best quality health care, consistently, in their own hospitals and physicians' offices.

This is the "Quality Challenge." We can make it happen.

Current as of April 2005


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