The Head of an HHS Agency Shares Her Optimism Concerning Improved Quality and Safety in U.S. Health Care
Carolyn Clancy, MD, is director of the Agency for Healthcare Research and Quality (AHRQ), a section of the U.S. Department of Health and Human Services (HHS). Her experience as a physician and researcher, as well as her years of work in the federal government, provide a high-level perspective on patient safety and health care quality both today and into the future.
HP: What initially drew you to health care?
Clancy: What drew me to health care was the opportunity to combine my interest in science with my interest in working with people, and to make a difference in people's lives. My strong belief is that recommendations I make to patients should be what they would recommend for themselves if they knew as much about medicine as I do.
HP: What are some of the new initiatives of AHRQ?
Clancy: AHRQ's mission is to improve the quality, safety, efficiency, and effectiveness of health care for all Americans. We do this through programs that promote the use of health information technology to improve the quality and safety of health care, build the foundation of evidence for the delivery of safe and effective health care services, and develop the measures and instruments for measuring and reporting health care quality.
One of our initiatives is called the Personalized Health Care Initiative. It helps us face the challenge of providing the right care to the right patient at the right time — and get it right the first time. AHRQ's fiscal year 2008 budget request to Congress includes $15 million for this initiative. Our goal is to accelerate the integration of cutting-edge innovations in personalized medicine, including genomics, into clinical practice through an electronic "network of networks." To create this network of networks, we will form a sustainable partnership of public, private payers, and delivery systems to generate evidence as a natural byproduct of health care delivery.
This effort will further develop three key areas. The first is building data capacity and infrastructure. The second is integrating administrative and clinical data to ensure that costs are tied to outcomes. And the third is accelerating the development of quality measures. The long-term result of this effort will be greater cost-effectiveness, other advances in clinical practice, and improved quality and safety for patients.
HP: What's the role of the federal government in improving quality and patient safety in health care?
Clancy: The federal government plays multiple roles in improving quality and patient safety in health care. One of the most important roles of the federal government is supporting research and implementation. AHRQ has been the leading funder of research on patient safety — and specifically research that promotes and evaluates the use of health information technology as a tool to improve quality and safety.
Another role for the federal government is as a convener. We can bring together organizations that normally would not collaborate because of proprietary issues or market competition. For example, under HHS Secretary Michael Leavitt's Values-Driven Health Care Initiative, we are bringing together local organizations and businesses in strategic collaboratives to promote transparency in health care quality and the price of health care services, as well as in the use of health information technology.
The federal government also is the leading purchaser of health care services in this country, and it can serve as a model for private purchasers and state and local governments. We can accomplish this by using state-of-the-science evidence to make decisions about which health care services we will cover and provide; by being transparent about the quality and the cost of the services we provide; and by ensuring that we provide the highest-quality, safest health care services possible.
The federal government also can help the private sector track the quality of health care services and access to those services. For example, AHRQ's annual National Healthcare Quality Report tracks the health care system through quality measures, concerning, for example, the proportion of heart attack patients who received recommended care when they reached the hospital, or the percentage of children that received recommended vaccinations. The companion annual National Healthcare Disparities Report, meanwhile, summarizes which racial, ethnic, or income groups are most likely to benefit from improvements in health care. Together, every year, these reports give the nation the most comprehensive picture of the quality of, and access to, health care. This information provides a roadmap to improvement.
HP: What are the greatest barriers to improving quality and patient safety?
Clancy: One of the greatest barriers to improving quality and patient safety is changing the culture of health care in this country. We are very lucky in this nation to have the world's finest nurses, physicians, and other health care workers. However, as we all know, the health care system in which they practice is not the best it can be. There is much room for improvement in just about every area of health care."
If the key to improvement were only the use of technology or the development of hardware and software, we would have achieved the goal of a safe, high-quality health care system a long time ago. Building a culture of quality requires a broad transformation, a complete change in culture, a commitment to achieving and sustaining an effort that likely will change the way that many facilities do business.
Several AHRQ-funded studies have found that an effective systems-level approach to a climate of patient safety fosters a blame-free, continual-learning environment in which vulnerabilities are reported and evidence is used to amend existing practices that focus on patient care. When this approach is not taken, the result can be adverse working conditions that affect patient safety and employee performance.
The "culture of blame" is one of the top seven barriers to implementing a patient safety system. The other barriers are competition for scarce resources in a system in which patient safety is not considered to be a top priority; lack of resources, including inadequate staffing and work overloads; availability and cost of patient safety; resistance to change; lack of commitment at the executive level; and a culture of "cover up" when it comes to medical error.
As my predecessor, the late John Eisenberg, used to say, improving the quality and safety of health care is a "team sport," and to overcome these barriers, everyone in the health care system, especially including patients, needs to be equal players.
HP: In recent years, where have you seen the most promising improvements in the areas of patient safety and quality?
Clancy: Physicians, nurses, and other health care professionals have always been committed to providing the highest-quality, safest health care possible, but they practice in a system that often creates situations in which quality can fail and errors can occur. The most promising improvement is that professionals in the health care system are making a concerted and focused effort to change a fragmented and flawed system so we can improve quality and safety.
We are seeing results. I am very encouraged that AHRQ's National Healthcare Quality Report continues to document modest improvements — about 3.1 percent — across the quality measures that make up the report. This pace is very slow, and we still have a great deal of room for improvement, but the trend is going in the correct direction.
The greatest quality gains occurred in U.S. hospitals, where quality improved 7.8 percent. Ambulatory care — which encompasses health services provided at doctors' offices, clinics, or other settings without an overnight stay — improved by 3.2 percent. Nursing home and home health care improved by one percent. Hospital care for heart attack patients improved 15 percent. Hospital care for pneumonia patients improved 11.7 percent. Steps taken to avoid complications after surgery improved 7.3 percent.
We can attribute these improvements to focused initiatives sponsored by HHS' Centers for Medicare and Medicaid Services (CMS). Quality improvement organizations under contract with CMS, for example, work with hospitals, consumers, doctors, and other caregivers to foster appropriate and timely care. The Hospital Quality Alliance, a public-private collaboration that includes hospital organizations and CMS, provides quality measurement information to consumers and others as an incentive for hospitals to improve care.
Another improvement is that consumers are far more aware of the problems in the health care system and are taking steps to be involved in their health care. In 2006, the Kaiser Family Foundation and AHRQ released an updated survey capturing the public's views and knowledge of medical errors and their experiences in taking steps aimed at improving the quality of their care. This survey, which was conducted last August, is an update of surveys conducted by Kaiser, in conjunction with AHRQ, in 2002 and 2004.
The bad news revealed in the survey results is that there are more Americans, 51 percent, who report being dissatisfied with the quality of health care than the 41 percent who say they are satisfied. More specifically, the survey found that more Americans, 55 percent, reported that they understand the term "medical error." This is up from 43 percent in 2004 and 31 percent in 2002. After being given a common definition of medical errors, some 43 percent say preventable medical errors occur "very often" or "somewhat often" when people seek care from a health professional.
The good news is that Americans are taking steps themselves to improve the quality of care they receive. Eighty-three percent ask their doctor questions about their health or any treatment that he or she has prescribed. Seventy percent report that they check the medication given by their pharmacist against the doctor's prescription. Fifty-four percent bring a list of all their medications to a doctor's appointment. This is up from 48 percent in 2004. Forty-five percent report bringing a friend or relative to a doctor's appointment to help ask questions. And one in three Americans says that he or she, or a family member, has created a set of medical records to ensure that health care providers have all of the patient's medical information.
HP: What would you advise health care consumers about their responsibilities when it comes to patient safety?
Clancy: The most important responsibility that consumers have is to be involved in their own health care. We know that patients who are involved in their health care and communicate effectively with their clinicians are more likely to have a positive impact on preventing medical mistakes and helping to improve the safety and quality of their health care. When patients are more involved in their health care, they can make better decisions, receive a higher level of care, help reduce medical mistakes, and feel better about the health care they receive. (See Box) for more information about a program designed to help patients avoid medical errors.)
HP: From your unique perspective, where do you see U.S. health care in 10 years?
Clancy: I believe that, in 10 years, we will have a health care system that has undergone a culture change that allows it to overcome the barriers that I mentioned previously. This new system will embrace an empowered and informed patient who is an equal partner in his or her health care. The system will provide for a blame-free environment in which medical errors are opportunities for learning and not recrimination.
In 10 years, we will have a health care system that harnesses the power of health information technology in a way that makes the right thing to do also the easy thing to do. We also will have a health care system that rewards the best performance and innovation in delivering high quality, safe health care.
AHRQ also recently collaborated with the Advertising Council of America to launch a new multimedia campaign, called "Questions are the Answer," aimed at encouraging all patients to get more involved in their health care by asking questions. The goal of the effort is to encourage patients to be prepared and to think about the questions they should ask during medical appointments. It is important that patients ask those questions and make sure they understand the answers.
Further information — including an interactive "Question Builder" that allows people to generate a personalized list of questions they can bring to each medical appointment — can be found at http://www.ahrq.gov/questionsaretheanswer.
5 Steps to Safer Health Care
To help patients avoid medical errors, AHRQ, in partnership with the American Hospital Association and the American Medical Association, developed a program called "5 Steps to Safer Health Care." The five steps are:
1. Ask questions if you have doubts or concerns.
Ask questions and make sure you understand the answers. Choose a doctor you feel comfortable talking to. Take a relative or friend with you to help you ask questions and understand the answers.
2. Keep and bring a list of ALL the medicines you take.
Give your doctor and pharmacist a list of all the medicines that you take, including nonprescription medicines. Tell them about any drug allergies you have. Ask about side effects and what to avoid while taking the medicine. Read the label when you get your medicine, including all warnings. Make sure your medicine is what the doctor ordered and know how to use it. Ask the pharmacist about your medicine if it looks different than you expected.
3. Get the results of any test or procedure.
Ask when and how you will get the results of tests or procedures. Don't assume the results are fine if you do not get them when expected, be it in person, by phone, or by mail. Call your doctor and ask for your results. Ask what the results mean for your care.
4. Talk to your doctor about which hospital is best for your health needs.
Ask your doctor about which hospital has the best care and results for your condition if you have more than one hospital to choose from. Be sure you understand the instructions you get about follow-up care when you leave the hospital.
5. Make sure you understand what will happen if you need surgery.
Make sure you, your doctor, and your surgeon all agree on exactly what will be done during the operation. Ask your doctor, "Who will manage my care when I am in the hospital?" Ask your surgeon, "Exactly what will you be doing? About how long will it take? What will happen after the surgery? How can I expect to feel during recovery?" Tell the surgeon, anesthesiologist, and nurses about any allergies, bad reaction to anesthesia, and any medications you are taking.
Carolyn Clancy, MD
Carolyn M. Clancy, MD, was appointed director of the Agency for Healthcare Research and Quality (AHRQ) in 2003. Prior to her appointment, she was director of the agency's Center for Outcomes and Effectiveness Research. AHRQ is the lead federal agency charged with improving the quality, safety, efficiency, and effectiveness of health care. As one of 12 agencies within the Department of Health and Human Services, AHRQ supports health services research aimed at improving the quality of health care and promoting evidence-based decision making.
Clancy, a general internist and health services researcher, is a graduate of Boston College and the University of Massachusetts Medical School. Following clinical training in internal medicine, she was a Henry J. Kaiser Family Foundation fellow at the University of Pennsylvania. Before joining AHRQ in 1990, she was an assistant professor in the Department of Internal Medicine at the Medical College of Virginia in Richmond.
Clancy is a clinical associate professor at George Washington University School of Medicine and serves as senior associate editor of Health Services Research. She has published widely in peer-reviewed journals and has edited or contributed to seven books. She is a member of the Institute of Medicine and was elected a master of the American College of Physicians in 2004.
Her major research interests include various dimensions of health care quality, including women's health, primary care, access to care services, and the impact of financial incentives on physicians' decisions.
This interview was conducted on April 25, 2007.