CDC National STD Conference David M. Stevens, M.D. AHRQ Center for Clinical Quality Improvement & Patient Safety

Core Conclusions There are serious problems in quality There are serious problems in quality – Between the health care we have and the care we could have lies not just a gap but a chasm. The problems come from poor systems…not bad people The problems come from poor systems…not bad people – In its current form, habits, and environment, American health care is incapable of providing the public with the quality health care it expects and deserves. We can fix it… but it will require changes We can fix it… but it will require changes

Quality is a system property

“The First Law of Improvement” Every system is perfectly designed to achieve exactly Every system is perfectly designed to achieve exactly the results it gets. the results it gets.

Health Professions: 21 st Century 20 th century21 st Century AutonomousTeam work Solo practiceSystems of care Continuous learningContinuous Improvement Blame/shameProblem Solving KnowledgeChange Individual patientsDiverse populations Adapted from K. Shine, IOM

HHS Reports: Quality and Disparities in Health Care First national comprehensive efforts to measure the quality of health care in America and differences in access to health care services for priority populations First national comprehensive efforts to measure the quality of health care in America and differences in access to health care services for priority populations – Presents data for clinical conditions, including cancer, diabetes, end-stage renal disease, heart disease, HIV and AIDS, mental health, and respiratory disease – Includes data on maternal and child health, nursing home and home health care, and patient safety Reports available at:

HRSA/BPHC Supported Federally Qualified Health Centers Community controlled Community controlled Comprehensive Primary Care Comprehensive Primary Care 768 organizations 768 organizations 3,552 sites: rural & urban 3,552 sites: rural & urban

Health Center 10.3 Million Users Diverse Diverse – White: 36% – African American: 25% – Hispanic: 35% – Asian/other: 4% Poor Poor – 39% uninsured – 88% low income with 67% below poverty level HRSA/BPHC supported Federally Qualified Health Centers

Key Strategic Elements In Health Disparities Collaborative Leadership Leadership Transform care through models of care, improvement & learning Transform care through models of care, improvement & learning Infrastructure/Support System Infrastructure/Support System Strategic Partnerships Strategic Partnerships HRSA/BPHC Strategy for Health Centers

Informed, Activated Patient Productive Interactions Prepared, Proactive Practice Team Improved Outcomes Delivery System Design Decision Support Clinical Information Systems Self- Management Support Health System Resources and Policies Community Health Care Organization Care Model

What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement? Model for Improvement PlanAct DoStudy Associates in Process Improvement

How Rapid is Rapid? Year Year Months Months Weeks Weeks Days Days One day or less One day or less

BPHC Health Disparities Collaboratives Select Topic Planning Group Identify Change Concepts Participants Pre-work LS 1 P S AD P S AD LS 3 LS 2 Supports VisitsListserv 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

Phase 1 Phase 2 1.Sustain and Spread 2.Continued reporting and progress toward national goals 3.Integration of models into the organizational structure 4.Increasing registry size 5.Continued support and interaction BPHC Health Disparities Collaboratives

Accomplishments November, ,000+ patients in registry 170,000+ patients in registry Improved clinical outcomes: Improved clinical outcomes: – Reduction in average HbA1c, ultimately affecting patient mortality and morbidity (>62,000 with average HAb1c = 8.03) – Improved blood pressure control in hypertensive patients (>37% of hypertensive patients with BP 37% of hypertensive patients with BP <140/90) – Appropriate use of drugs for asthma (>84% of patients with persistent asthma on anti-inflammatory meds) – High rates of follow-up and improved symptoms/functionality for depression patients (Over 5000 patients with diagnosis of depression with 54% having a PHQ in last 6 months) – Cancer Screening (50% adults, age 51 or greater, with time appropriate colorectal cancer screening) – Diabetes Prevention (over 30% yield in pre-diabetes screening) Building an infrastructure and capacity for the long term Building an infrastructure and capacity for the long term

Chlamydia Screening: Contributions from Care Model Effect of a clinical practice improvement intervention on Chlamydial screening among adolescent girls Effect of a clinical practice improvement intervention on Chlamydial screening among adolescent girls Shafer MA, Tebb KP, Pantell RG, Wibbelsman CJ, Neuhaus JM, Tipton AC, Kunin SB, Ko TH, Schweppe DM, Bergman DA JAMA, 2002 Dec 11: 288(22):

Care Model : Implications for Y2P Care Model Elements Examples Pt Self-Mgt** Partner notification Decision Support Flow chart, staff training Practice Design Universal urine collection when register Clinical Info System Prevalence among patients, follow up system Community ** Schools, after school venues Health care organization notes from chiefs celebrating success

Stages of Facing Reality Stage 1. “The data are wrong” Stage 1. “The data are wrong” Stage 2. “The data are right, but it’s not a problem” Stage 2. “The data are right, but it’s not a problem” Stage 3. “The data are right; it is a problem; but it is not my problem.” Stage 3. “The data are right; it is a problem; but it is not my problem.” Stage 4. “I accept the burden of improvement” Stage 4. “I accept the burden of improvement”

Clinica Campesina: Barriers We Overcame The belief that our patients cannot change and that little changes don’t matter The belief that our patients cannot change and that little changes don’t matter The idea that we need consensus to change anything The idea that we need consensus to change anything The concept that improving care means more work The concept that improving care means more work That we cannot improve without more FTE That we cannot improve without more FTE The belief in a provider oriented rather than patient oriented care system The belief in a provider oriented rather than patient oriented care system