CDC National STD ConferenceCDC National STD Conference

David M. Stevens, M.D.David M. Stevens, M.D.AHRQAHRQ

Center for Clinical Quality Center for Clinical Quality Improvement & Patient SafetyImprovement & Patient Safety

Core ConclusionsCore Conclusions

There are serious problems in qualityThere are serious problems in quality– Between the health care we have and the care Between the health care we have and the care

we could have lies not just a gap but a chasm.we could have lies not just a gap but a chasm. The problems come from poor systems…not bad The problems come from poor systems…not bad

peoplepeople– In its current form, habits, and environment, In its current form, habits, and environment,

American health care is incapable of providing American health care is incapable of providing the public with the quality health care it expects the public with the quality health care it expects and deserves.and deserves.

We can fix it… but it will require changesWe can fix it… but it will require changes

Quality is a system propertyQuality is a system property

““The First Law of Improvement”The First Law of Improvement”

Every system is perfectly Every system is perfectly designed to achieve exactly designed to achieve exactly

the results it gets.the results it gets.

Health Professions: 21Health Professions: 21stst Century Century

2020thth century century 2121stst Century Century

AutonomousAutonomous Team workTeam workSolo practiceSolo practice Systems of careSystems of careContinuous learningContinuous learning Continuous Continuous

Improvement Improvement Blame/shameBlame/shame Problem SolvingProblem SolvingKnowledgeKnowledge ChangeChangeIndividual patientsIndividual patients Diverse Diverse

populationspopulations

Adapted from K. Shine, IOM

HHS Reports: Quality and HHS Reports: Quality and Disparities in Health Care Disparities in Health Care

First national comprehensive efforts to measure the First national comprehensive efforts to measure the quality of health care in America and differences in quality of health care in America and differences in access to health care services for priority populationsaccess to health care services for priority populations– Presents data for clinical conditions, including cancer, Presents data for clinical conditions, including cancer,

diabetes, end-stage renal disease, heart disease, HIV and diabetes, end-stage renal disease, heart disease, HIV and AIDS, mental health, and respiratory diseaseAIDS, mental health, and respiratory disease

– Includes data on maternal and child health, nursing home Includes data on maternal and child health, nursing home and home health care, and patient safetyand home health care, and patient safety

Reports available at: http://www.qualitytools.ahrq.govReports available at: http://www.qualitytools.ahrq.gov

HRSA/BPHC Supported HRSA/BPHC Supported Federally Qualified Health Federally Qualified Health

CentersCentersCommunity controlledCommunity controlledComprehensive Primary CareComprehensive Primary Care768 organizations768 organizations3,552 sites: rural & urban3,552 sites: rural & urban

Health Center 10.3 Million Health Center 10.3 Million UsersUsers

DiverseDiverse– White: 36%White: 36%– African American: 25%African American: 25%– Hispanic: 35%Hispanic: 35%– Asian/other: 4%Asian/other: 4%

PoorPoor– 39% uninsured39% uninsured– 88% low income with 67% below poverty level88% low income with 67% below poverty level

HRSA/BPHC supported Federally Qualified Health Centers

Key Strategic Elements In Health Key Strategic Elements In Health Disparities CollaborativeDisparities Collaborative

LeadershipLeadership Transform care through models of Transform care through models of

care, improvement & learningcare, improvement & learning Infrastructure/Support SystemInfrastructure/Support System Strategic PartnershipsStrategic Partnerships

HRSA/BPHC Strategy for Health Centers

Informed,ActivatedPatient

ProductiveInteractions

Prepared,ProactivePractice Team

Improved Outcomes

DeliverySystemDesign

DecisionSupport

ClinicalInformation

Systems

Self-Management

Support

Health System

Resources and Policies

Community Health Care Organization

Care Model

What are we trying toaccomplish?

How will we know that achange is an improvement?

What change can we make thatwill result in improvement?

Model for Improvement

PlanAct

DoStudy

Associates in Process Improvement

How Rapid is Rapid?How Rapid is Rapid?

YearYear MonthsMonths Weeks Weeks DaysDays One day or lessOne day or less

BPHC Health Disparities BPHC Health Disparities CollaborativesCollaboratives

Select Topic

Planning Group

Identify Change

Concepts

Participants

Pre-work

LS 1

P

S

A DP

S

A D

LS 3LS 2

Supports

E-mail Visits Listserv

Phone Assessments Senior Leader Reports

Time for setting aims, allocating resources, preparing baseline data leading to the first 2 day meeting.

Action period 1: Adapt and test the ideas for improved

system of care

Action period 2: further develop the

system of care at the pilot site and spread the

system to other sites

Congress & beyond

A

Select Topic

Planning Group

Identify Change

Concepts

Participants

Pre-work

LS 1

P

S

A D

P

S

A D

LS 3

LS 2

Supports E-mail Visits Phone Assessments Senior Leader Reports

Time for setting aims, allocating resources, preparing baseline data leading to the first 2 day meeting.

Action period 1: Adapt and test the ideas for improved

system of care

Action period 2: further develop the

system of care at the pilot site and spread the

system to other sites

Congress & beyond

Phase 1 Phase 21. Sustain and Spread2. Continued reporting and progress

toward national goals3. Integration of models into the

organizational structure4. Increasing registry size5. Continued support and interaction

BPHC Health Disparities Collaboratives

AccomplishmentsAccomplishmentsNovember, 2002November, 2002

170,000+ patients in registry170,000+ patients in registry Improved clinical outcomes:Improved clinical outcomes:

– Reduction in average HbA1c, ultimately affecting patient mortality Reduction in average HbA1c, ultimately affecting patient mortality and morbidity (>62,000 with average HAb1c = 8.03)and morbidity (>62,000 with average HAb1c = 8.03)

– Improved blood pressure control in hypertensive patients (>37% of Improved blood pressure control in hypertensive patients (>37% of hypertensive patients with BP <140/90)hypertensive patients with BP <140/90)

– Appropriate use of drugs for asthma (>84% of patients with Appropriate use of drugs for asthma (>84% of patients with persistent asthma on anti-inflammatory meds)persistent asthma on anti-inflammatory meds)

– High rates of follow-up and improved symptoms/functionality for High rates of follow-up and improved symptoms/functionality for depression patients (Over 5000 patients with diagnosis of depression patients (Over 5000 patients with diagnosis of depression with 54% having a PHQ in last 6 months)depression with 54% having a PHQ in last 6 months)

– Cancer Screening (50% adults, age 51 or greater, with time Cancer Screening (50% adults, age 51 or greater, with time appropriate colorectal cancer screening)appropriate colorectal cancer screening)

– Diabetes Prevention (over 30% yield in pre-diabetes screening)Diabetes Prevention (over 30% yield in pre-diabetes screening) Building an infrastructure and capacity for the longBuilding an infrastructure and capacity for the long term term

Chlamydia Screening: Chlamydia Screening: Contributions from Care ModelContributions from Care Model

Effect of a clinical practice improvement Effect of a clinical practice improvement intervention on Chlamydial screening among intervention on Chlamydial screening among adolescent girlsadolescent girlsShafer MA, Tebb KP, Pantell RG, Wibbelsman CJ, Shafer MA, Tebb KP, Pantell RG, Wibbelsman CJ,

Neuhaus JM, Tipton AC, Kunin SB, Ko TH, Schweppe Neuhaus JM, Tipton AC, Kunin SB, Ko TH, Schweppe DM, Bergman DADM, Bergman DA

JAMA, 2002 Dec 11: 288(22):2846-52JAMA, 2002 Dec 11: 288(22):2846-52

Care Model : Implications for Y2PCare Model : Implications for Y2P

Care Model ElementsCare Model Elements ExamplesExamplesPt Self-Mgt**Pt Self-Mgt** Partner notificationPartner notification

Decision SupportDecision Support Flow chart, staff trainingFlow chart, staff training

Practice DesignPractice Design Universal urine collection Universal urine collection when registerwhen register

Clinical Info SystemClinical Info System Prevalence among Prevalence among patients, follow up systempatients, follow up system

Community **Community ** Schools, after school Schools, after school venuesvenues

Health care organizationHealth care organization E-mail notes from chiefs E-mail notes from chiefs celebrating successcelebrating success

Stages of Facing Stages of Facing RealityReality

Stage 1. “The data are wrong”Stage 1. “The data are wrong” Stage 2. “The data are right, but it’s not Stage 2. “The data are right, but it’s not

a problem”a problem” Stage 3. “The data are right; it is a Stage 3. “The data are right; it is a

problem; but it is not my problem.”problem; but it is not my problem.” Stage 4. “I accept the burden of Stage 4. “I accept the burden of

improvement”improvement”

Clinica Campesina: Clinica Campesina: Barriers We OvercameBarriers We Overcame

The belief that our patients cannot change The belief that our patients cannot change and that little changes don’t matterand that little changes don’t matter

The idea that we need consensus to The idea that we need consensus to change anythingchange anything

The concept that improving care means The concept that improving care means more workmore work

That we cannot improve without more FTEThat we cannot improve without more FTE The belief in a provider oriented rather The belief in a provider oriented rather

than patient oriented care systemthan patient oriented care system