Leveraging research into healthcare quality, costs, outcomes, and patient safety

A Profile of Dr. Carolyn M. Clancy, Director, Agency for Healthcare Research and Quality U.S. Department of Health and Human Services

Healthcare remains one of the most pressing issues of today, with a system mired in ever-increasing costs, inconsistent quality, and access pressures. Many of the healthcare reform proposals being reviewed in Congress attempt to remedy one or more of these issues. Research continues to identify ways to improve the quality and safety of healthcare, ensure access to care, increase the use of health information technology (IT), and find new ways to translate clinical research into practice. “The mission of the Agency for Healthcare Research and Quality,” explains Dr. Carolyn Clancy, director of AHRQ, “is to improve the quality, safety, efficiency, and effectiveness of healthcare for all Americans. We pursue this goal by supporting research and working very closely with those who provide care—clinicians of all disciplines—as well as with patients and policymakers, so that they can use information to improve the delivery of healthcare.”

Dr. Clancy manages a broad portfolio of scientific research that promotes enhancements to clinical and health system practices. “About 80 percent of our budget goes to grants and contracts with many academic institutions, community health centers, and hospitals focusing on improving healthcare. We now fund work in almost all 50 states,” explains Clancy. She describes her main responsibility as one of ensuring that all parts of AHRQ work together. “My day-to-day work,” notes Clancy, “is actually communicating what it is that we’re trying to do—connecting the dots between the research we’re supporting and healthcare you’re going to get.” AHRQ comprises five research centers and three offices, but she states that, “We really organize our work around portfolios: comparative effectiveness; patient safety and quality; health IT; improving value in healthcare; prevention and care management; and innovations.”

The U.S. spends more on healthcare than any other nation, yet numerous studies have found that there is really no relationship between spending and the quality of care. For Clancy, it is critical to make sure that “what we do for patients matches their needs and preferences and actually helps them to get on with their lives.” Comparative effectiveness research (CER )—systematic research that compares different interventions and strategies to prevent, diagnose, treat and monitor health conditions—offers promise. According to Dr. Clancy, the purpose of this research is to inform patients, providers, and decision makers by responding to their needs about which interventions are most effective for patients under specific circumstances. The Recovery Act allocated about 1.1 billion dollars for CER , with some $300 million allocated to AHRQ’s already-established CER portfolio. “We live in a very exciting time,” admits Clancy, “because of all of the advances in biomedical science. More and more, it’s not the case that there’s one thing to do for a particular condition—there are multiple choices. How do you make those choices?” CER is looking to fill that gap. “We think this research will help make sense of all of the rapidly expanding options and innovations in medicine. It’s all about focusing on patients’ needs, and applying the best of science to meet those individual needs,” says Clancy. 

As the nation’s lead research agency on healthcare quality, safety, efficiency, and effectiveness, AHRQ plays a critical role in the drive to adopt health IT. “I think many people don’t grasp that healthcare today is, by and large, a paper enterprise.” Her agency funds research that identifies ways to expand health IT adoption and use. It seeks to identify best practices for making health IT work and tools that can help hospitals and clinicians successfully adopt it. According to AHRQ-funded research, electronic health record adoption continues to increase slowly. The initial capital investment continues to be a significant barrier to adoption. “We believe,” asserts Clancy, “that health IT can improve the quality of care….At the same time, it can deliver customized information to the point of decision making, based on scientific evidence. That’s our goal, and we are very excited about it.” 

According to the Centers for Disease Control and Prevention, nearly 2 million patients suffer from a healthcare-associated infection in U.S. hospitals each year, resulting in 99,000 deaths and annually incurring an estimated $28-$33 million in excess healthcare costs. AHRQ funds research that aims to identify risks and hazards that result in medical errors, while seeking to find ways to prevent patient injury associated with delivery of care. “This is a growing problem,” admits Clancy, “We’ve seen people suffering serious consequences because of these infections, which are largely avoidable.” Clancy describes the Michigan Keystone ICU Project as a successful example of how to foster a culture of patient safety. It is a joint partnership between Johns Hopkins University and the Michigan Health and Hospital Association, funded by an AHRQ grant. “We supported a team from Johns Hopkins,” notes Clancy, “They focused on reducing serious bloodstream infections, using some relatively straightforward steps that can actually reduce the infection rate dramatically.” 

 ARHQ-funded research means little until its findings and lessons learned are disseminated. Dr. Clancy declares that the ultimate goal is to translate AHRQ’s research findings into clinical practice—hopefully resulting in healthier, more productive individuals and an enhanced return on our nation’s substantial investment. “We work extensively to communicate what we’re doing and to disseminate it in practical ways.”

Listen to:  The Business of Government Hour Interview with Dr. Clancy

FY 2009 Financial and Performance Reports

Jonathan D. Breul

If a tree falls in a forest, did it make a sound?

The November 15^th release of federal department and agency annual performance and accountability reports went largely un-noticed.  Not a mention in the New York Times, Wall Street Journal or Washington Post (even its Federal Page).

With so much attention to transparency and accountability – does no one care?   Or, are these reports written in such length and technical prose that no average citizen would want to read them?  According to a survey conducted by the Association of Government Accountants of 239 financial management executives across government: “The current financial reporting model costs too much and delivers little useful information to government decision-makers”

Performance and Accountability Reports

Congress and the Executive Branch created the Performance and Accountability Report (PAR) to satisfy various statutory reporting requirements.  The PAR serves at least two very important purposes.

• It is an effective and easy way for oversight organizations and others to determine the extent to which an agency is fulfilling its mission and managing its resources, plus be able to produced reliable information to support budgeting and decision-making.
• It enables agencies to present, in a comprehensive and integrated manner, the services it is providing to the public, the results it is achieving, what these accomplishments cost, and how it is managing its resources.

Pilot Program

In an effort to make the information more meaningful and transparent to the public, the Office of Management and Budget authorized a Pilot Program in FY 2007.  The Pilot Program:

• Permits an agency to replace the PAR with an Agency Financial Report and an Annual Performance Report (in recent years, the two reports had been consolidated into a single performance and accountability report).
• Permits the Annual Performance Report to be issued at the same time as the Congressional Budget Justification (in February), which allows for a more complete performance report.
• Adds a Highlight Document intended to be a brief, use-friendly and easily understood report that summarized the key performance and financial results for the novice reader.

The eleven department and agencies that participate in the PAR Pilot Program issued their Annual Financial reports on November 15, 2009.  Separate Highlights will be released by January 15, 2010, and their Annual Performance Reports will be issued in February 2010 following release of the President’s Fiscal Year 2011 Budget.  Here are the Financial reports released by the pilots so far:

• Department of Defense
• Department of Education
• Department of Energy
• Department of Health and Human Services
• Department of State (by Dec.15)
• Agency for International Development
• National Science Foundation
• Office of Personnel Management
• Small Business Administration
• Denali Commission
• National Community Service Corporation

Improving Federal Performance Reporting

Valerie Richardson’s report for the IBM Center for The Business of Government: “Increasing Transparency and Accountability in Federal Performance Reporting: Lessons from the OMB Pilot Program” examines agencies’ experience with the PAR Pilot Program.

She  concludes that it is possible for agencies to submit performance and financial information using alternative formats without diminishing the statutory purposes of performance and financial reporting documents: “Allowing agencies to use alternative methods for presenting these data presents an important opportunity to improve transparency and accountability throughout government, goals emphasized by the Obama Administration.”

Health Care Reform Implementation (Part 2)

A series of presentations at the annual conference  of the National Academy of Public Administration focused on the complicated management challenges all levels of government will be facing upon the passage of any health care reform legislation.  As one participant noted: “There’s too much of a view that programs are self-executing and you just need more inspectors general and audits. . . that happened with the Recovery Act.”  The consensus seemed to be that this assumption clearly won’t work for health care reform!

Federal challenges. As Congress debates the shape of the health care reform legislation, there are a number of administrative management issues where seasoned executives in federal agencies might want to begin thinking through.  The Department of Health and Human Services might be a logical home for such a task force, but other agencies, like Labor, Treasury, Veterans Affairs, and Defense might play important roles as well.  And someone would need to represent agencies that don’t exist yet, like the proposed Medical Choices Administration.

Even if specific policy provisions are not yet defined for the health care initiative, certain tasks can be undertaken right away, for example:

• identifying a team of top career talent that have the experience of implementing big programs,
• defining competencies and skills needed to staff potential programs,
• creating expedited hiring and procurement authorities,
• gaining authority to operate streamlined regulatory and advisory processes, and
• developing the infrastructure for collaborative cross-agency networks.
• (feel free to add to this list!)

State-local challenges. As health care coverage is expanded for low income citizens, state governments will be challenged in ramping up their existing programs.  Depending on the legislation enacted, the enrollment in state Medicaid programs could increase by about 12 million.  This will place a huge burden on state enrollment and administrative processes.  Likely concerns about potential program abuses may increase oversight costs, or at least complicate implementation efforts.

Likewise, if the proposals to create health insurance exchanges are enacted, creating new administrative structures in each state will be challenging.  The Senate bill delays implementation until 2014, but even then it would be challenging to design them, enact the regulations, educate the state providers, hire the needed staff, educate the new enrollees, and conduct the enrollment process.  Any implementation strategy would involve federal, state, local, non-profit, and for-profit stakeholders.

At the state level, fortunately, some are already thinking about implementation challenges.  For example, Alan Weil of the National Academy for State Health Policy, has developed several guides that lay out both strategic and topic-specific steps that need to be considered. One report, “Supporting State Policymakers’ Implementation of Federal Health Reform,” could serve as a useful checklist for federal implementers!

NOTE: A subsequent Gov Exec article on concerns about implementing health care reform cites a NAPA  report issued July 2009 recommending quick action on putting attention on seven specific administrative areas important to implementing any health care reform.  That report is titled “Administrative Solutions in Health Reform.”