The Elements of Health Care Quality The Elements of Health Care Quality and Current Improvement Effortsand Current Improvement Efforts

Carolyn M. Clancy, MDCarolyn M. Clancy, MDDirectorDirector

Agency for Healthcare Research and QualityAgency for Healthcare Research and Quality

Bipartisan Congressional Health Policy ConferenceBipartisan Congressional Health Policy ConferenceJanuary 13, 2007January 13, 2007

Health Care Quality Health Care Quality

Varies – Varies – A LOTA LOT; ; NOTNOT clearly related to $$ spent clearly related to $$ spent Matters – can be measured and improvedMatters – can be measured and improved Measurement science is evolving:Measurement science is evolving:

– Structure, process and outcomesStructure, process and outcomes

– Broad recognition that patient experience is essential Broad recognition that patient experience is essential component*component*

Strong focus on public reporting is goodStrong focus on public reporting is good– Motivates providers to improveMotivates providers to improve

– Not yet ‘consumer friendly’Not yet ‘consumer friendly’

Current LandscapeCurrent Landscape

Numerous reports confirm substantial gap between best possible and actual care.

Increasing demands from purchasers that providers demonstrate quality delivered.

Public reporting of performance leads to improvements.

Recognition of urgent need to align disparate monitoring initiatives.

Initiatives that link payment with performance have proliferated in the private sector.

Challenges and EnablersChallenges and Enablers

Quality assessment has been tightly linked with site of care or individual clinicians; few integrated or episode-based metrics.

Robust measures not yet developed for all physician specialties.

Quality alliances – collaboration between providers, purchasers, consumers and accreditors – have produced uniform public reporting for hospitals (HQA) and physicians (AQA).

HQA and AQA addressing gaps in existing measure sets, and need for measures that span care delivery.

Efficient data capture remains an aspiration – current electronic health records do not support.

252562628787

Insurance companies identify andInsurance companies identify andreward doctors and hospitals whoreward doctors and hospitals whoachieve excellence in the qualityachieve excellence in the qualityand efficiency of careand efficiency of care

2222

1818

Somewhat Somewhat importantimportant

69699191You have information about theYou have information about thecosts of care to you BEFORE youcosts of care to you BEFORE youactually get the careactually get the care

77779595You have information about theYou have information about thequality of care provided by different quality of care provided by different doctors or hospitalsdoctors or hospitals

Very Very importantimportant

TotalTotalvery or very or

somewhat somewhat importantimportant

How important is itHow important is itto you that: (percent)to you that: (percent)

Public Views on Quality,Public Views on Quality,Cost and P4PCost and P4P

Source: Commonwealth Fund Survey of Public Views of the U.S. Health Care System, 2006.

National Reports on Quality and DisparitiesNational Reports on Quality and Disparities

Paired ReportsPaired Reports

NHQRNHQR

– Snapshot of quality of Snapshot of quality of health care in Americahealth care in America

– QualityQuality

– Variation across statesVariation across states

NHDRNHDR– Snapshot of disparities in Snapshot of disparities in

health care in Americahealth care in America– Quality + AccessQuality + Access– Variation across Variation across

populationspopulations

Context for Current Quality Context for Current Quality Improvement EffortsImprovement Efforts

Good News: Quality is improving; disparities are Good News: Quality is improving; disparities are narrowing…narrowing…

Bad News: Progress is too slowBad News: Progress is too slow What moves the ball:What moves the ball:

– Public Reporting Public Reporting – PaymentPayment– Common MeasuresCommon Measures– (Health IT)(Health IT)– (Consumer engagement)(Consumer engagement)

Disparities inDisparities in Medicare Health Plans Medicare Health Plans

Performance on four primary outcome Performance on four primary outcome measures is lower for blacks than whitesmeasures is lower for blacks than whites

Hemoglobin Hemoglobin A ControlA Control(Diabetes)(Diabetes)

80.280.2

60.260.2

LDL-C LDL-C Control Control

(Diabetes)(Diabetes)

Blood Pressure Blood Pressure ControlControl

(Hypertension)(Hypertension)

72.272.2

57.257.262.962.9 71.671.6

53.453.4

72.272.2

LDL-C Control LDL-C Control (Coronary Event)(Coronary Event)

White Rate

Black Rate

JAMA October 25, 2006

Per

form

ance

, %

Quality of Hospital Care for Heart Attack and Quality of Hospital Care for Heart Attack and Heart Failure: Poor Counties, Rich CountiesHeart Failure: Poor Counties, Rich Counties

47%

13%

26%

17%

15%

21%

7%

24%

5%

25%

0%

20%

40%

60%

80%

100%

Hospitals in PoorCounties

Hospitals in RichCounties

***** (Highest Quality Care)

****

***

**

* (Lowest Quality Care)

Source: Gannett News Service, Rating Hospital Heart Care, 2006.

Getting to high quality Getting to high quality health carehealth care

The most powerful contribution The most powerful contribution information technology can make information technology can make to improving health care quality…to improving health care quality…

Make the right thing to doMake the right thing to do the easy thing to dothe easy thing to do

Growing HIT Evidence BaseGrowing HIT Evidence Base

Health IT helps improve Health IT helps improve quality of care in large health quality of care in large health care organizations that create care organizations that create their own systems and devote their own systems and devote substantial resources to EHR, substantial resources to EHR, CPOE,e-prescribing, and CPOE,e-prescribing, and other applicationsother applications

HIT has potential to enable HIT has potential to enable dramatic transformation of dramatic transformation of health care safety, health care safety, effectiveness and efficiencyeffectiveness and efficiency

Costs and Costs and Benefits of Benefits of

Health Health Information Information TechnologyTechnology

AHRQ Southern CaliforniaAHRQ Southern California Evidence-Based Practice Center-Evidence-Based Practice Center-RAND Corporation, April, 2006RAND Corporation, April, 2006

AHRQ Research: Improving AHRQ Research: Improving Quality through HITQuality through HIT

Over 125 projects and Over 125 projects and demonstrations to better demonstrations to better understand how health IT understand how health IT can improve the safety, can improve the safety, quality and efficiency of quality and efficiency of health carehealth care

Projects in 43 statesProjects in 43 states Special attention to best Special attention to best

practices that can improve practices that can improve quality of care in rural, quality of care in rural, small community, safety small community, safety net and community health net and community health center care settingscenter care settings

AHRQ HIT AHRQ HIT Investment: Investment: $166 Million$166 Million

Booklet Helps Consumers Understand Booklet Helps Consumers Understand and Get Quality Health Careand Get Quality Health Care

Helps consumers identify high-quality health Helps consumers identify high-quality health care and take a more active role in their own care and take a more active role in their own health carehealth care

Explains clinical measures:Explains clinical measures:– Track and improve the quality of care provided by Track and improve the quality of care provided by

doctors, hospitals, and othersdoctors, hospitals, and others Explains consumer ratings:Explains consumer ratings:

– Indicate how satisfied people are with their health Indicate how satisfied people are with their health carecare

Lists Web sites and phone numbers for more Lists Web sites and phone numbers for more resourcesresources

Part of a series to help Part of a series to help patients take a more active patients take a more active role in their health carerole in their health care

“All Health Care is

Local.”

6 AQA Pilot Sites6 AQA Pilot Sites

Massachusetts Massachusetts Health Quality Health Quality PartnersPartners

California California CooperativeCooperativeHealthcare Healthcare ReportingReportingInitiativeInitiative Phoenix Regional Phoenix Regional

Healthcare Value Healthcare Value Measurement InitiativeMeasurement Initiative

Indiana Health Indiana Health Information ExchangeInformation Exchange

Wisconsin Wisconsin Collaborative Collaborative for Healthcare for Healthcare QualityQuality

Minnesota Community Minnesota Community MeasurementMeasurement

Getting to Best Possible CareGetting to Best Possible Care

Moving the ball right nowMoving the ball right now::

– Public Reporting – AND transparency Public Reporting – AND transparency – Payment Reforms*Payment Reforms*– Common Measures for public and private sectorsCommon Measures for public and private sectors– Enhanced support for local collaborativesEnhanced support for local collaboratives

Specific Policy OpportunitiesSpecific Policy Opportunities::

– P4P: absolute performance -- &/or improvement?P4P: absolute performance -- &/or improvement?– Rewarding the ‘leading edge’ Rewarding the ‘leading edge’ andand bringing others along bringing others along– Support for unbiased consumer information – and for effective Support for unbiased consumer information – and for effective

use of HITuse of HIT– Insist on clear synthesis of results from public and private Insist on clear synthesis of results from public and private

demonstrationsdemonstrations

Q & AQ & A