Quality of Health Care

Program Description and Context

The U.S. has many of the world's finest health care professionals, academic health centers and other research institutions.   Patients sometimes receive excessive services that undermine the quality of care and needlessly increase costs.  At other times, they do not receive the services that have proven to be effective at improving health outcomes and even reducing costs. 

A recent Institute of Medicine (IOM) report, titled Crossing the Quality Chasm: A New Health System for the 21st Century, concluded, "Quality problems are everywhere, affecting many patients.  Between the health care we have and the care we could have lies not just a gap but a chasm."   In the report, the IOM proposed 13 recommendations to build a stronger healthcare system over the next decade. 

One of AHRQ's strategic goals is to strengthen the quality of health care measurement and track improvements in the care available to Americans.  To achieve this goal AHRQ has invested in the development and testing of measures of quality, as well as studies of the best ways to collect, compare and communicate these data, and identifying and widely disseminating effective strategies to improve quality of care.  To facilitate the use of this information in the health care system, the Agency focuses on research that determines the most effective ways to improve health care quality, including promoting the use of information on quality through a variety of strategies such as information dissemination and assessing the impact of health care organization and financing.

Meeting the needs of consumers, practitioners, and policymakers will depend in part on the availability of valid and useable measures of the quality of care.  AHRQ will translate the findings from health services research, effectiveness studies, technology assessments, and clinical practice guidelines into quality of care measures and methods for everyday settings.  Basic research will develop more refined measures and improvement strategies.  Applied research and development will test the validity and reliability of the measurement instruments and facilitate their use in different population subgroups such as minority groups, chronically ill, disabled, elderly, and children and in various care settings.  Demonstration projects will assess the use of measures and tools in performance management systems and quality improvement activities.

Strategies to Improve the Quality of Health Care

The National Healthcare Quality Report. The Agency's reauthorization calls for the development of a national report on the quality of healthcare in the United States.   In developing this report, the Agency is called on by congressional legislation to expand the Medical Expenditure Panel Survey (MEPS) to collect information on quality.  In addition, the Agency is charged with assuring coordination with the private sector in the development of the report. 

The Agency's coordination of the development of a National Healthcare Quality Report is also responsive to the President's Quality Commission report, which concluded, "The lack of comprehensive information on the quality of American health care is unacceptable."  Finally, the also recent Institute of Medicine's Commission on Medical Errors called for a national report on progress on the issue.  These mandates in sum envision a report that goes beyond a compilation of available data and statistics to provide a framework for those public and private entities with an interest in improving the quality and safety of patient care.

AHRQ Quality Indicators. Health care decisionmakers need user-friendly data and tools to help them assess the effects of health care programs and policy changes, accurately measure outcomes, community access to care, utilization and cost of care. 

To meet this need, AHRQ has developed a set of quality indicators (QIs) that use hospital administrative data to highlight potential quality concerns, identify areas that need further study and investigation, and track changes over time.  These indicators represent a refinement and further development of the Quality Indicators developed in the early 1990's as part of the Healthcare Cost and Utilization Project (HCUP).

The AHRQ QIs are a set of quality indicators that have been organized into three modules:  Prevention, Inpatient, and Patient Safety QIs. 

Using these modules hospital and hospital systems can use AHRQ QIs to help answer questions such as:

• How does our hospital's cesarean section rate compare to the State or Nation?
• Do other hospitals have similar mortality rates following hip replacement?
• How does the volume of coronary artery bypass graft in my hospital compare with other hospitals?

State data organizations and community health partnerships can use AHRQ QIs to ask questions that provide initial feedback about clinical areas appropriate for further, more in-depth analysis, such as:

• What can the pediatric AHRQ QIs tell us about the adequacy of pediatric primary care in our community?
• How does the hysterectomy rate in our area compare with the State and national average?

State hospital associations can use the AHRQ QIs to do quick hospital quality and primary care access screens.  Other potential users include managed care organizations, business-health coalitions, State data organizations, and others poised to begin assessments using hospital discharge data to answer questions such as:

• Can we design community interventions in areas surrounding hospitals that have higher rates of diabetes complications?
• Which Quality Indicators can be incorporated into performance management initiatives for our member hospitals?

Finally, Federal policymakers can use the AHRQ QIs to track health care quality in the United States over time and to assess whether health care quality is improving, for example:

• How does the rate of coronary artery bypass grafts vary over time and across regions of the United States?
• What is the national average for bilateral cardiac catheterization (a procedure generally not recommended) and how has this changed over time?

Consumer Assessment of Healthcare Plans (CAHPS®). CAHPS® makes available consumers' ratings of the quality of care and services they get from their health plans.  This information is used by other consumers to make informed choices among health plans, by health care purchasers—such as employers or Medicaid programs—to select plans to offer their employees or beneficiaries, and by plans for quality monitoring and improvement.  CAHPS® already has been used by more than 20 States, 10 employer groups and a wide range of health plans and companies.  For example, CAHPS® was adopted by the Office of Personnel Management for use by the Federal Employees Health Benefits Program to survey Federal employees and report the findings to help about nine million Federal employees choose health plans during the Federal open season.  CAHPS® also merged with the HEDIS (Health Plan Employer Data and Information Set) Member Satisfaction Survey and will be used by the National Committee for Quality Assurance to evaluate and accredit managed care plans for 40 million Americans.  Finally, the Centers for Medicare and Medicaid Services (CMS) has used a specially developed version of CAHPS®  to survey over 130,000 Medicare enrollees in managed care plans.  The result of this survey, which was released in February 1999, was available to help CMS's 39 million beneficiaries who will be selecting a health plan.

These and other successful uses of CAHPS® are a testament to the importance of sustained basic and applied health services research in producing practical information for everyday health decisionmaking.

Safety of Health Care

Program Description and Context

Patient safety is a top priority in the Nation today.  It is estimated that up to 98,000 Americans die each year as a result of preventable medial errors (Kohn 1999).  The majority of these errors are a result of systemic problems rather than poor performance by individual providers.  Although the U.S. provides some of the best health care in the world there are a significant number of patients that are being harmed as a result of the process of health care.

In FY 2001, AHRQ re-named the Center for Quality Measurement and Improvement (CQMI) the Center for Quality Improvement and Patient Safety (CQuiPS).  This lends evidence to AHRQ's efforts to refocus activities to improve the quality of health care Americans receive and address preventable patient errors by reducing the risk of patients being harmed by the process of health care.

The goal of patient safety is to reduce the risk of injury and harm from preventable medical errors.  This goal can be accomplished by removing or minimizing of hazards that increase the risk of injury to patients.  Three steps must be followed to ensure that the number of medical errors are contained.  These steps are:

• Identify the causes of preventable errors and the hazard that increase the risk of injury to patients.
• Implement patient safety practices that eliminate known hazards and reduce the risk of injury to patients and create a positive safety culture.
• Maintain vigilance to ensure that a safe environment continues and a positive safety cultures are maintained.

The key words or phrases here are risk, adverse events, no-harm events, near miss, and detection.

Risk is the possibility/probability of occurrence or recurrence of an event multiplied by the severity of the event.  Hazard is anything that can cause harm.  An event is a deviation in an activity or technology that leads towards an unwanted, negative consequence. Events can be classified in three different categories.

An adverse event is an occurrence during clinical care which results in physical or psychological injury or harm to a patient or harm to the mission of the organization.  A no-harm event is an event that has occurred but resulted in no actual harm although the potential for harm may have been present.  Lack of harm may be due to the robust nature of human physiology or pure luck.  An example of such a no-harm event would be the issuing of an incompatible unit of blood for a patient but the unit was not transfused and was returned to the blood bank.

A near miss is an event in which the unwanted consequences were prevented because there was a recovery by identification and correction of the failure, either planned or unplanned.  Heinreich developed the iceberg concept of accidents and errors.  The part of the iceberg above the water represents events that cause major harm; below the water are no-harm events as well as near misses.

Strategies for Improving Patient Safety

The overall goal of reducing medical errors and improving quality and patient safety is an overall HHS goal that is shared among AHRQ and all other HHS agencies.  AHRQ's research contribution focuses on creating basic knowledge and evaluating the strength of existing evidence which provides information that can be turned into actions by those who make clinical decisions, purchasers and providers who make decisions about what services to use, pay for and how to structure those services, as well as by public policymakers.

In cooperation with other HHS agencies AHRQ will seek to improve the quality healthcare and reduce medical errors by:

1. Accelerating the implementation of existing quality measures and safety practices.
2. Developing capacity and new practices for quality and safety Improvements.
3. Detecting safety hazards and monitoring improvements in healthcare safety and quality.

The Agency believes the best way to approach improving patient safety is through an integrated set of activities to design and test best practices for reducing errors in multiple settings of care; develop the science base to inform these efforts, as well as to improve provider training in the reduction of errors; capitalize on the advances in information technology to translate proven effective strategies into widespread practice; and, build the capacity to further reduce errors in the future.  AHRQ's goal of improving the quality and safety of the healthcare that Americans receive cannot be achieved in a single year but must follow a systematic progression of activities over a number of years.

In FY 2004, activities will build on the progress made in FYs 2002 and 2003 and activities directed at stage two of the medical error "epidemic" will be added to the AHRQ portfolio with a primary focus on minimizing the risk of preventable injuries.  

Detecting Safety Hazards and Monitoring Improvement in Safety and Quality. Detection is the first step in error management.  From an organizational point of view it is important that error detection rate be high because errors that are not detected can have disastrous consequences.  Thus one of the goals of error management is to increase detection and reporting rates to decrease risk of harm to patients.  Detection Sensitivity Level (DSL) is the number of events reported to an organization.  High reporting rates indicate a high DSL while few events reported indicates a low DSL.  To achieve a high DSL an organization must eliminate impediments to reporting.  Event Severity Level (ESL) is the level risk of the events reported.  Over time the event severity level should go down as an indicator of successful error management while the detection sensitivity level (DSL) remains high.  DSL represents information while ESL represents risk.

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Risk

Information

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Developing a system that will consistently and reliably identify potential hazards to patient safety will require developing a national system of patient safety reporting and monitoring.  For example, existing data collection mechanisms, if properly coordinated and standardized, could provide a powerful national asset as an early warning system for patient safety hazards providing pooled data for analysis to develop solutions to patient safety problems and for tracking progress in patient safety. 

In addition, a successful monitoring system will require a direct investment in IT infrastructure and enhancements to improve safety monitoring.  Health care is well behind other industries in harnessing the potential of information technology.  Developing the health care IT infrastructure is key to monitoring the improvements in patient safety.  The development of options and information to support investments in IT infrastructure, including cooperative agreements to encourage IT investment and develop national models of IT infrastructure.

Finally, developing data standards and vocabulary to ensure that patient safety information can be pooled, analyzed, and used to identify hazards and safety practices will be essential.  The lack of standardized coding and language could result in a health care information system "Tower of Babel."   This initiative, in conjunction with the Department's other agencies, will strive toward the development of patient safety information standards, development of voluntary consensus on those standards and incorporation of those standards into existing departmental databases.

Accelerate the Implementation of Existing Patient Safety Practices. In July 2001, the Agency released a report, entitled Making Health Care Safer: A Critical Analysis of Patient Safety Practices, which examined the evidence supporting 79 promising safety interventions.  Many of these proven lifesaving interventions, such as the use of medications to reduce the risk of heart attacks and infections in surgical patients, are not consistently implemented. 

Key to developing and implementing this strategy will be implementing local safety improvement priorities and improving the information available to the public on patient safety.  Health care organizations and systems must be challenged to implement proven patient safety practices.  Participating organizations and systems should be encouraged to develop their own practice implementation practices from those identified in the Agency's FY 2001 report and will be provided funding to facilitate the system's investment in implementing those practices.  Finally, these organizations and systems will be required to generate information on the barriers faced in implementing the practices as well as measure the impact of the intervention on patient safety.  Cooperative agreements will include a provision to make continued funding of the program contingent upon a demonstrated ability to implement the identified priorities and measure their impact.

In addition, in order to improve the information available to the public on patient safety, the Agency will use CAHPS® to provide information about patient's experience of care; to improve the relevance of systems-based information on patient safety for the public; support value-based purchasing initiatives; and to develop mechanisms for public reporting on evidence-based safety interventions.

Developing Capacity and New Practices for Safety Improvement. The Agency's July 2001 report on patient safety interventions identified a number of promising interventions for which more effectiveness evidence is required prior to general implementation.   Many potential patient safety practices drawn primarily from non-medical fields, such as the use of simulators, bar coding, "swipe" technology, and crew resource management, require additional study to clarify their value in the health care environment.  The success of this strategy will depend on the continuing development and evaluation of new safety interventions, improving local patient safety infrastructure and capacity, and developing reliable information for purchasers and the public to support wise decisionmaking. 

Program Performance Analysis

Help for Patients and Consumers of Health Care. Americans are demanding greater value and quality in their health care.  To achieve these goals in today's rapidly changing health care environment, consumers need solid, reliable information to help them choose among health care plans, practitioners and facilities, and to participate more actively in their personal health care decisions.  AHRQ plays a unique role in helping to provide the information consumers need and want. 

In FY 2002 AHRQ has continued to build on previous successes.  For example:

• AHRQ and CMS collaborated with the CAHPS® consortium to develop a Medicare CAHPS® Disenrollee Survey of beneficiaries enrolled in managed care plans that was fielded by CMS in FY 2000.  Approximately 80 percent of this survey related to quality.  By obtaining the reason for disenrollment, it is possible to distinguish between those that are unrelated to quality (e.g., moving out of the area that the plan serves) and those that are related to quality (e.g., limited access to specialists).
• In collaboration with the California Health Care Foundation and the Pacific Group on Health, a version of CAHPS® has been developed to assess care provided at the group practice level.  This is in response to strong consumer interest in more detailed information about the ability of physicians in group practices to provide quality care.  In CAHPS® II, AHRQ will work on the development of reports to convey survey results to consumers as well as to the group practices assessed.  An additional goal is to develop strategies for working with physicians to improve areas that consumers identify as troublesome. 
• A partnership between the CAHPS® consortium and the Foundation for Accountability, with support from the David and Lucille Packard Foundation, has led to the development of a CAHPS® survey to identify children with special health care needs and collect additional information on the extent to which health plans are meeting their health care needs.  This tool is already in use by numerous State Medicaid and SCHIP (State Children's Health Insurance Program) agencies to assist them in meeting the requirements set forth in the 1997 Balanced Budget Act.  Also, the NCQA has included this survey as a requirement in the HEDIS reporting set.

CAHPS® and Small Business Innovation Research Award The State of Washington's Health Care Authority is using a decision support tool originally developed through an AHRQ grant that incorporates CAHPS® (among other data) to help State employees and retirees choose among health plans. The tool was developed as Health Plan Select, however, as customized by Washington State, is called Compare-A-Plan. Because the volume of information about health plans can be confusing, the tool is intended to help consumers learn about their health plan choices then compare and choose a plan. To accomplish this, the Web-based tool integrates price, benefits, physician choice and health plan performance measures such as CAHPS® and HEDIS. Beginning with the State's fall open enrollment period in late October 2001, Compare-A-Plan will be on the Washington State government's Web site.

 

Blue Cross of California and CAHPS® Shifting the focus from cost savings to improving quality, Blue Cross of California is changing its method of rewarding its physicians. Beginning January 1, 2002, the health plan will award bonuses to its HMO physicians and medical groups based on quality of care and patient satisfaction. The latter measure will be determined through the use of Consumer Assessment of Satisfaction (CAS) survey data, which has been derived from the AHRQ HMO CAHPS® survey.

Continuing to add to the family of CAHPS® surveys, CMS and AHRQ are also collaborating on the development of a CAHPS®  survey to obtain consumers' assessments of health and services received in nursing homes. The data, collected from nursing home residents and next of kin, will be used to help persons choose a nursing home.

AHRQ is proud of the two-pronged approach taken in its patient safety work.  The approach allows the Agency to focus on building the science while translating the results of previously funded research into practice.  AHRQ has been funding projects in patient safety for a number of years.  Building on previous work, the $50 million dollar investment AHRQ made in FY 2001 in patient safety research went to fund a variety of projects, many of which were new research initiatives.  While many of these new projects are expected to take three years to compete, the results of previous investments are now being incorporated into practice.  Research results are being used in a number of ways including:

• The Web address www.qtdrugs.org is a unique educational and research tool developed by AHRQ's CERT located at the University of Arizona Health Sciences Center.  This site currently contains a list of 72 drugs that can sometimes cause life-threatening abnormalities in heartbeats or arrhythmia.  Caregivers around the world can use this site to look up specific drugs that might pose a risk to their patients and submit clinical cases of drug-induced arrythmias to the registry.  Researchers are using the information submitted to develop profiles of people most at risk for drug-induced arrythmias and to develop a genetic test that can identify them at advance.
• Patients and their families can use new consumer tip sheet, available in English and Spanish, to play a more active role in ensuring that they get the best health care possible and to help Americans from falling victim to medical errors.
• Health care administrators and others now have information about 73 patient safety practices that are likely to improve patient safety and 11 practices which have been highly proven to work but are not performed routinely in the Nation's hospitals and nursing homes.  For example, Voluntary Hospitals of America and Premier, Inc. has used this report to guide their member hospitals in selecting projects to improve safety.
• To help patients consider the safety of their care, AHRQ worked with CMS and other organizations to support the work of the National Quality Forum, a voluntary consensus standard setting organization, to develop a list of events that were so significant and so preventable that their occurrence should trigger an investigation of the safety practices of the organization in which they occurred.  An example of such an event is surgery on the wrong site.  This list is now completed and available to the public.

New Analysis Confirms a Direct Link Between Nurse Staffing and Patient Complications and Deaths in Hospitals. Analysis of data on nurse staffing levels confirms that there is a direct link between the number of registered nurses (RNs) and the hours they spend with patients and whether patients develop a number of serious complications or die while in the hospital.  Funded by the AHRQ, investigators re-examined and refined their previous analysis released by the Health Resources and Services Administration (HRSA) in April 2001 as part of an ongoing collaboration within the Department of Health and Human Services to improve nursing care in American hospitals.

Among other things, the study found that:

• Lower staffing levels of RNs among a hospital's nurses were associated with rates of serious complications such as pneumonia, upper gastrointestinal bleeding, shock, and cardiac arrest, including deaths among patients with these three complications, as well as sepsis or deep vein thrombosis.  These complications occurred three to nine percent more often than in hospitals with higher RN staffing.
• Rates for urinary tract infections, a less serious but common infection among hospital patients, and length of time spent in the hospital were also higher in hospitals with lower RN staffing.
• Low RN staffing at hospitals makes it more likely that some patients will suffer pneumonia, shock and cardiac arrest, and gastrointestinal bleeding, and that some patient may die as a result.

Long Term Goals and FY 2004 targets

The following goals represent AHRQ's view of the future.  Success is contingent upon adequate funding.

Long-term Performance Goal	FY 2004 Targets
By 2010, at least 5 organizations will use HCUP databases, products or tools to improve health care quality for their constituencies by 10%, as defined by the AHRQ Quality Indicators. Baseline: FY 2000—Quality Indicators developed	FY 2004 Two new organizational users of HCUP will develop interventions using HCUP QIs  and one organizational user will implement an intervention based on the QIs
By 2008, CAHPS®  data will be more easily available to the user community and the number of consumers who use information from CAHPS® to make choices about their healthcare will increase by 20%. (Baseline FY 2002)	FY 2004 Produce a CAHPS® module for consumer assessments of hospital quality. Establish baseline for number of consumers using Nursing Home CAHPS®.
By 2010, evidence, translation tools and implementation strategies exist for improving the overall quality and safety of health of the American public so that:  By 2010, reduce to 105,613 admissions, the rate of hospitalizations for pediatric asthma in persons under age 18. By 2010, reduce to 520,441 the number of immunization-preventable pneumonia hospital admissions of persons aged 65 and older. By 2010, reduce to 11,570 the number of immunization-preventable influenza hospital admissions of persons aged 65 and older. By 2010, reduce to 500 per live births the number of premature babies who develop Respiratory Distress Syndrome (RDS).	FY 2004 5% decrease over baseline. 5% decrease over baseline. 5% decrease over baseline. 5% decrease over baseline.
By 2006, six national message format and clinical vocabulary standards would be identified/recommended by HHS as ready for voluntary adoption and deployment.	3 message format and clinical vocabulary standards will be recommended by HHS as ready for voluntary adoption and deployment.
By 2008 nursing homes will have evidence-based information needed to make informed purchasing strategies related to IT.	5 technologies currently shown to be effective in other clinical settings will be tested in nursing homes to evaluate the impact on safety, quality and cost of care.

FY 2004 Performance goals and targets

FY 2004 Performance Goal	FY 2004 Targets
Report on national trends in health care quality.	Report on progress in core measure set.  Identify private sector data to be used in future reports.
By 2004, 6 health facilities or regional initiatives to implement interventions and service models on patient safety improvements will be in place.	6 teams will be in place.
By 2004 at least 10 States or major health care systems will have on-site Patient Safety Improvement Corp (PSIC) staff in place.	10 States or major health care systems will have on-site experts in Patient Safety.
Identify the number and types of adverse events, no-harm events, and near miss events reported in demonstration projects.	Report on the number and types of adverse events.

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