Keynote Plenary Address

Carolyn M. Clancy, M.D., Director, Agency for Healthcare Research and Quality

2008 AHRQ Annual Meeting, Bethesda North Marriott Convention Center, Bethesda, MD,
September 8, 2008

Select for Dr. Clancy's speech (Flash video®, 1 hour, 16 minutes, 477 MB)

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Good morning and welcome!

Welcome to the second Annual AHRQ Conference, which we fondly call "AHRQ-A-Palooza"! Thank you very much for joining us.

We had a sellout at the first Annual Conference last September, and I remarked, jokingly, that the reason everyone came was because it was free.

We increased the audience size by several hundred for this meeting, and we still had to close registration down early. So, while the AHRQ Annual Conference is still free, I think the numbers show that we may be onto something with respect to providing an effective forum for the initiators of change.

By initiators, I mean:

• People who are not only talking about needed transformation in the U.S. health care system, but who are also engaging in transformational activities.
• People who are aggressive in their fight to ensure that Americans will soon have access to the best possible care—all of the time, every time.
• People who refuse to give up.

AHRQ initiatives are at the leading edge of efforts to improve the Nation's health care. We support research on what's most effective in health care delivery. We partner with public and private sector organizations to ensure AHRQ's research is translated into changes in practice, and we're helping patients play a more active role in the decisions made about their care.

I cannot tell you how excited I am to have you here again to exchange ideas, discuss the issues at hand, and talk about how we can take the U.S. health care system to a much better place.

The theme of the second AHRQ Annual Conference is, "Promoting Quality, Partnering for Change." One of the main reasons we decided on this is because we have seen the quality and value that can be generated through partnerships and collaboration, and we want to emphasize those benefits while we're working together this week.

We talked last year about the system being broken and unsustainable in its current state. Well, unfortunately, very little has happened since then. In fact, the rate of improvement in quality—which has consistently been pretty slow anyway—has gone down.

According to our own statistics from the National Healthcare Quality Report, health care quality improved by 3.1 percent in 2006. Last year, health care quality improved by 2.3 percent.

To me—and I'm going to use a football reference here in the spirit of the new season—this means we're way behind at halftime, and if we don't make some adjustments fast, the second half isn't going to be much better.

Today, we have a window of opportunity made possible by all of the attention that is being paid to changing the health care system. We need to be more engaged, aggressive, and completely committed to transforming the health care system because what we are doing clearly is still not good enough.

If we don't fully seize the opportunity we have right now to drive needed change to help us keep up with increasing service demands and improve the quality of our service, the consequences are dire—we're going to lose the game.

The symptoms of our current struggle to keep up abound throughout the system:

• The most recent National Healthcare Disparities Report that we issue annually shows that disparities in health care quality and access are either staying the same or actually getting worse.
• More than 60 percent of disparities in quality of care have stayed the same or worsened for Blacks, Asians, and poor populations. And nearly 60 percent of disparities have stayed the same or worsened for Hispanics.
• Just a couple of weeks ago, a George Mason University and Urban Institute study found that Americans who don't have health insurance will spend about $30 billion out of pocket on medical care this year. What's more, the government and other sources will end up covering another $56 billion in costs.
• A study announced in late July found that potentially preventable medical errors that occur during or after surgery may cost employers nearly $1.5 billion a year. The report, I am proud to say, was authored by AHRQ researchers Bill Encinosa and Fred Hellinger.
• Bill and Fred found that the cost of care for surgery patients who experienced acute respiratory failure or postoperative infections increased the cost of their care by 100 percent! They also concluded that studies which focus only on medical errors that occur during the initial hospital stay may underestimate the financial impact of patient safety events by up to 30 percent.

We used to talk to patients about what they could do to protect themselves from medical errors, or the possibility of a quality problem, simply because we felt it was the right thing to do. Today, having this conversation is an absolute must, because we're not keeping up. Most of the time, we have difficulty sorting out the absolute chaos that exists in health care from the places where we know gaps exist.

Actually, perhaps another conversation we should be having involves going as far as to warn our patients that these types of incidents are likely in our health care system.

A U.S. senator recently asked me why hospitals aren't doing better. That's both a very basic and profound question, right? I thought so too, until I tried to give him an answer. I said at the time, very generally, that there are three main reasons for this:

• They don't know how.
• Nobody is making them.
• The incentives are just not steep enough to make a difference.

Now that I have had time to think about it, I believe my answer was accurate, but there is much, much more to it. We're still in an environment where CEOs lie awake at night worrying about the bottom line, rather than the quality bottom line. For them, there is no established link between the two. Of course, there are examples of institutions where this is changing, but for the most part, the kind of information needed to address the quality bottom line is difficult to get to.

Another issue—one that is not getting enough attention right now—is capacity. We don't have any.

We're so much better at what I call the three Ds—development, dissemination, and demanding—than we are at figuring out how to make this transformation work. We have health IT, comparative effectiveness, efficiency measures, report cards, Web sites and magazines that rate quality, and yet, at the most basic levels, we often don't even have the capacity to learn from our worst experiences.

I am not at all suggesting that we're doing nothing. Nothing could be further from the truth. Your presence at this meeting shows the commitment to improving health care quality.

We're not sitting on our hands, watching this golden opportunity pass us by. We have made great strides on a number of fronts. The system is a lot better than it was 10 years ago, and there are new and better developments coming online virtually every day.

What I am suggesting is that we're reaching the point in American health care where it's far less a question of knowing what to do, and more about not having the infrastructure, incentives, or capacity to do it.

It's almost like we're at a crossroads. We all know or have ideas about what the U.S. health care system should look like, and we know the current system is unworkable, yet we're stuck somewhere in between the two, trying to figure out what direction will take us to where we need to be.

I think one of the reasons for this is because we have been deluded by the myth that at some point in this journey there would be a breakthrough that would reveal—drum roll here please—"The Answer."

And in the process, we've reached a point of saturation where we're now just layering more and more stuff on top of an already chaotic delivery system—essentially taking short-term tactics and confusing them with long-term solutions.

I am here to tell you, there is no magic bullet, no "Answer." It is impossible to envision that the transformation we need can occur without most, if not all, of the information and capabilities that have been developed in this transformation. But they all represent a potential means to an end. And one of the things we really need to focus on is to determine how and when all of the new information and capabilities will be most beneficial to improving the quality of care that we deliver.

So, it may be time for us to step back, look at all that we have done so far and recalibrate our efforts to make sure they are aligned with what we're trying to do. In the process, it might be helpful for us to look for areas where improvements will yield the greatest gains, in terms of better health and health care.

High on my list is completing the transition from provider-focused strategies to patient-focused strategies. If you go to have a procedure done to fix a problem and emerge with another problem, it doesn't matter to you at all where it happened. What matters most is that it happened at all.

On the health care side of this equation, we don't necessarily look at it from this point of view. Our initial interests lie closer to deciding whether the institution should be paid for taking care of the complications or whether the complications were preventable.

We are moving into a different world. People are expecting more from us, and we need to deliver value and services in ways that we have not paid much attention to before. Put simply, we need to be more flexible and attuned to the needs of our patients, to the point where every one of them feels that they are at the center of everything we do for them.

One of the activities that will take us a long way toward making the transition to a health care environment that is patient-focused is the National Priorities Partners initiative. The initiative was convened recently by the National Quality Forum to build consensus around national goals for performance measurement and improvement.

Another one of my priorities involves organizing care around patients rather than diseases. If we were organized around patients, we would be focused very squarely on patients with multiple chronic illnesses. This is an area and a group of people for whom we spend the most money and provide the worst care. It is a pretty deadly combination.

If we were looking more at the journey of patients with multiple chronic conditions as they intersect many points of health care, we would probably have much more effective road maps for guiding everyone through the system. That's one of the big issues that we continually overlook.

I don't know about all of you, but one of the questions I get from people a lot—and these are often knowledgeable, influential policymakers—has to do with navigating their way through the system.

They'll tell me a story about a family member who has recently been hospitalized for cancer or some other serious illness, and as they describe what happens next and try to coordinate their care they pretty much ask, "Did we miss the part where someone gave us a map and sort of an overall framework for what to do next? Maybe we weren't paying attention."

And I say no. Actually, once you leave you are on your own and that's something we can change. Because the deeper patients travel through the system, the more complex it gets and the more they get lost. We need some kind of GPS for consumers in health care, to get them as far into the system as they need to go, and to help them with the self-management of their care in the process.

Another priority for me lies in the area of health IT, and this is probably as much an observation as it is an actionable suggestion. Again, there is no magic bullet, or "Answer." The health care system is far too expansive and developed for us to start over and incorporate health IT in the redesign.

However, there is one approach that would make a world of difference. And that is to make sure that our capacity to move data is strongly connected with the capacity to actually do something with it.

As we're thinking about using health IT and electronic health records, and even personal health records, to help us develop and report on quality far more easily than we do today, that same capacity could be linked with information to remind clinicians and patients about the right thing to do to begin with.

There is an amazing disconnect between our ability to generate data and having the capacity to produce actionable information that can be used right now. This is a phenomenon from the early days of the information technology boom.

Software engineers used to be able to build just about anything and people would come and buy the products because they were new and exciting. Soon people realized that these early tools were actually toys with promise, and they started demanding that tools be developed specific to their needs.

We in health care have come to the technology party later than most industries. We're at the stage where we have generated tons and tons of relevant data, and now we need to start figuring out how it's going to be used.

Of course, one of the good things about being late adopters is that we can take advantage of all the successes—and failures—that took place before our arrival, and the developers can build us tools that are a lot better and more efficient.

The key here is making sure that we figure out exactly what we need and let them know. And we need to think more creatively and innovatively about getting information that will help us achieve our goals faster.

We're at the crossroads.

What I think we're starting to grasp, and a real big driving force behind this meeting, is that identifying the points of synergy between the different areas, where health IT meets comparative effectiveness for example, is incredibly important. Working together gets us there a lot faster. Because, at the end of the day, the success of our endeavors rests with the care that our patients receive, and the outcomes of that care. Collaboration makes it easier for us to find the synergies, develop the right measures, and create the necessary tools.

There is also one very important intangible associated with collaboration in creating a health care system that can provide quality treatment for the right patient, at the right time, the first time, every time. Collaboration that focuses on the greater good of the patient can lead to an environment that causes people to become more involved in their own care.

As we all know, if our patients are not engaged in what we are trying to do for them, we've got problems.

This brings to mind Jessie Gruman. I'm not sure how many of you know her. Jessie is the founding executive director of the Center for the Advancement of Health, an organization in Washington, DC, which works to ensure that evidence on social, behavioral, and economic factors is applied to the prevention, management, and treatment of disease. She also used to serve on our National Advisory Council.

When Jessie was 20 years old, she was diagnosed with Hodgkin's Disease. She got the best of care, all the right doctors and the latest treatments. But at the time, she was thinking, "Here we are spending billions on research and probably hundreds of thousands of dollars on my care, but its success is all dependent on my showing up."

She went into describing pretty frankly how she often wasn't compliant with the advice she was receiving. For example, she was told not to go out because she was immuno-compromised and pretty much said, "I ignored that. I went dancing."

Well, you know what? If you're treating a 20-year-old person, you have to be thinking about these sorts of issues. They want to go out dancing. They're not going to regard reasonable life for the next year or however many months as staying home.

There was a story in Newsweek a few weeks ago about the problems inherent in keeping teens with chronic illnesses safe. The title was, "Meds Schmeds, Gimme Fries." It talked about how many kids are playing Russian roulette with diets and medicine.

The article went on to describe a study at Cincinnati Children's Hospital that found that 74 percent of adolescents dramatically overestimate their ability to manage their asthma. Other kids are leaving their epinephrine at home when they're wearing tight clothes or playing sports. Two 19-year-olds in New York died this year after they stopped taking their HIV medications.

People with chronic illnesses are an increasingly large subgroup and, to be honest, there are times when medicine is not that helpful, in part because we sometimes don't know the answer. Sometimes, it comes down to communication between the patient and doctor, where the patient can say, "I know that every time I'm short of breath for a few minutes it doesn't mean I need to call 911, but when should I be worried?" This whole idea of, "I had to show up for this to work," really got my attention.

As health care researchers and professionals, we have a chance to carry the day. We are superbly positioned and empowered to be at the forefront of efforts to get people more engaged in their own care, help patients with multiple chronic conditions, make it easier for everyone to navigate the system, find those areas where improvements will yield the greatest gains, and build the tools and strategies to address them.

It is our charge, our opportunity, and our responsibility to make an impact, and I have a list of challenges for you to think about as the conference unfolds. But first, I want to tell you a little bit about what's in store for the next 3 days. As you saw on the agenda, it is packed with a wide variety of topics for you to choose from.

AHRQ now has two new portfolios:

• One is the Value portfolio, which supports the development of health care activities that help reduce unnecessary waste while improving quality.
• The other is called Innovations and Emerging Issues. With this portfolio, we are looking to identify and support ideas and projects that have the potential for highly innovative solutions to health care challenges.

There are several sessions on Value and Innovations and Emerging Issues for you to learn more about what we're planning in these areas.

We also have a number of Lunch and Learn sessions for you to choose from each day. The first ones, which are right after this session, are about:

• Contracts and Grants.
• The GRADE Methodology.
• Value/Innovations and Emerging Issues.
• Health IT.
• Getting to Know the U.S. Preventive Services Task Force.

Tomorrow and Wednesday, the topics include Effective Health Care, the Media, and we also have a Data Users Workshop.

In addition, we have interactive displays of AHRQ products and tools, along with extramural and intramural research posters in the Market Place Café, as we did last year. This year we have about two dozen displays of new quality improvement tools and applications that you can try out while you're here. So, please be sure to visit the Market Place Café.

But, as I mentioned at the beginning, the theme of the second AHRQ Annual Conference is, "Promoting Quality, Partnering for Change." Partnering and collaboration is the soul of everything I have been talking about. It is at the core of the AHRQ mission and should be the common denominator in everything that we all do.

This past spring, Secretary Leavitt commissioned the first Chartered Value Exchanges. These are health care organizations in States and across regions that have joined together to find local solutions that can be used on a national scale to help improve the quality of health care in the United States. We've learned a lot about the power of collaboration through the Chartered Value Exchanges. In each of these communities, what we're seeing is purchasers, employers, consumers, clinicians, and health care organizations sitting down together to figure out how we get to solutions. They're finding an equilibrium, a way to balance the urgency that consumers and purchasers feel about learning more about quality, and fixing it faster, and the concerns that providers have about getting it right, being as accurate and precise as possible.

That tension offers a great opportunity and a great forum for people to work together and move past finger pointing, to actually working on solutions, and that's what makes these exchanges very exciting. This goes to the first item on my list of challenges for you:

First, decide what one or two issues you'll think about differently as a result of attending the AHRQ meeting.

It may be that your passion is all about health IT, so you're going to seek out people who are focused on evidence-based medicine to see how you can work together. If you're focused on chronic illness care, it could be that you're going to seek out the people who help the patients who report on compliance.

Second, ask yourself what you can do when you get home to take steps toward making sure that your work can be used in creating a system that helps us get smarter over time.

Dennis Quaid was on 60 Minutes a few months ago talking about how his infant twins received massive overdoses of heparin because he's Dennis Quaid. But, also because the same thing that happened to his twins happened in Indianapolis the year before, and it's happened again since he was on 60 Minutes, and it will happen again, and again. That is the worst thing about safety as we know it today.

And finally, ask what you're doing to respond to patients' express needs, and then ask yourself, "How do I know?" If you can't report on and measure all of the great work you're doing, its potential will not be fully realized. It's like a tree falling in the woods when no one is around to see or hear it happen.

To me, everything that I have outlined this morning spells opportunity, especially with all of the attention the system has been getting and will continue to receive in the coming months and years. We have to move forward; we have to turn the page; we have to be more aggressive; and we have to move a lot faster.

More work? Possibly, but the important issue here is that this is an opportunity for all of us to work collectively to develop a system that makes the right thing the easy thing to do. And in order to do this, we must take advantage of all available lessons learned—in and outside of the health care system—as we move forward, so that we can have a quality system to work with, as we address the growing demands of the 21st Century.

Again, thank you very much for attending the second Annual "AHRQ-A-Polooza."

Have a terrific week!

Current as of September 2008

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Internet Citation:

Keynote Plenary Address. Remarks by Carolyn Clancy at the 2008 AHRQ Annual Conference, September 8, 2008. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/sp090808.htm

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