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Testimony

Statement by
Carolyn M. Clancy  M.D.
Director
Agency for Health care Research and Quality
U.S. Department of Health and Human Services

on
First, Do No Harm: Improving Health Quality and Patient Safety 

before
Committee on Health, Education, Labor and Pensions
United States Senate


Thursday May 5, 2011

Good morning, Senator Harkin and members of the committee.  I am very pleased to be here today to talk to you about our Administration’s efforts to improve the quality and safety of health care.

The title of this hearing – “First, Do No Harm: Improving Health Quality and Patient Safety” – is very fitting.  It is one of the earliest lessons that a medical student learns, and it is a promise that a medical student makes when he or she receives a white coat on becoming a doctor.

But not doing harm is just the bare minimum for health care; we all strive for so much more.  

Health care professionals go to work every day wanting to provide the highest quality, safest, most appropriate care for their patients.  The bottom line is that patients should not go to a hospital or other health care setting with a fear that they will get sicker not better.

Unfortunately, with the complexity of health care, deficiencies in the systems in which they practice, needed improvements in teamwork and communication, and impaired information flow, high quality, safe health care may be perceived as a challenge.

We have made progress in engaging doctors, nurses, patients and others involved with our health care system in working together to make the challenge less daunting and high quality, safe health care a reality.    However, we have a lot more work to do.

Before I outline two exciting new initiatives recently announced by the Department of Health and Human Services (HHS) to address these challenges, I would like to describe briefly a snapshot of the quality of our health care system to help frame our discussion today.

Scope of the Problem

The 2010 National Healthcare Quality Report, released earlier this spring by my agency, the Agency for Healthcare Research and Quality (AHRQ), found that improvements in health care quality continue to progress at a very slow rate—about 2.3 percent a year.   

Data from other sources also highlight the problems:

  • In a report last November, the HHS Inspector General found that one out of every seven hospitalized Medicare beneficiaries is seriously harmed in the course of their care and less serious harm is equally common. Almost half of the events are preventable.  According to this report (http://oig.hhs.gov/oei/reports/oei-06-09-00090.pdf) this doesn’t just produce anguish and tragedies for families and patients, it wastes over $4.4 billion Medicare dollars every year.
  • According to CDC, at any one point in time one in 20 patients in U.S. hospitals will have a healthcare-associated infection www.cdc.gov/about/advisory/pdf/ACD_Minutes_04_12_10_Final.pdf.

These results are simply unacceptable because we know we can do better.   And we must do better.

The National Strategy for Quality Improvement in Health Care

We need to accelerate our overall efforts to improve quality and focus specific attention on areas that need the greatest improvement.  

In March, the U.S. Department of Health and Human Services  released a roadmap that will guide us to making lasting, measurable improvements in the quality and safety of health care services for all Americans.

The National Strategy for Quality Improvement in Health Care, commonly referred to the “National Quality Strategy,” was called for under the Affordable Care Act and is a significant step in creating national aims and priorities to guide efforts to improve the quality of health care in the United States.

The fundamental objective of the National Quality Strategy is to promote quality health care that is focused on the needs of patients, families, and communities.  At the same time, the strategy is designed to move the system to work better for doctors and other health care providers – reducing their administrative burdens and helping them collaborate to improve care.

Before I provide you with a broad outline of the National Quality Strategy, it is important to note that it was developed based on evidence-based results of the latest research.  Moreover, it was a collaborative, transparent process that included input from a wide range of stakeholders across the health care system, including federal and state agencies, local communities, provider organizations, doctors and other health care professionals, patients, businesses, employers, and payers. In addition, I would like to note that we are working closely with the developers of the National Prevention Strategy.

This process of engagement will continue in 2011 and beyond.  The National Quality Strategy is designed to be an evolving guide for the nation as we continue to move forward with efforts to measure and improve health and health care quality.  HHS will continue to work with health care providers and its other partners to create specific quantitative goals and measures for each of these priorities.  While the strategy articulates common goals, it is not intended to specify how those goals are achieved.  Rather, the strategy explicitly recognizes the importance of encouraging and learning from local innovations in improving care.

At its core, the National Quality Strategy will pursue three broad aims. These aims will be used to guide and assess local, State, and national efforts to improve the quality of health care. The aims are:

  • Better Care: Improve the overall quality by making health care more patient-centered, reliable, accessible, and safe.
  • Healthy People/Healthy Communities: Improve the health of the U.S. population by supporting proven interventions to address behavioral, social and, environmental determinants of health in addition to delivering higher-quality care.
  • Affordable Care: Reduce the cost of quality health care for individuals, families, employers, and government.
    To advance these aims, we plan to focus initially on six priorities.  These priorities are based on the latest research, input from a broad range of stakeholders, and examples from around the country.  They have great potential for rapidly improving health outcomes and increasing the effectiveness of care for all populations.

The six priorities are:

  • Making care safer by reducing harm caused in the delivery of care.
  • Ensuring that each person and family are engaged as partners in their care.
  • Promoting effective communication and coordination of care.
  • Promoting the most effective prevention and treatment practices for the leading causes of mortality, starting with cardiovascular disease.
  • Working with communities to promote wide use of best practices to enable healthy living.
  • Making quality care more affordable for individuals, families, employers, and governments by developing and spreading new health care delivery models.

These priorities can only be achieved with the active engagement of health care professionals, patients, health care organizations, and many others in local communities across the country. Since different communities have different assets and needs, they will likely take different paths to achieving the six priorities. This Strategy will help to assure that these local efforts remain consistent with shared national aims and priorities.

Over time, our goal is to ensure that all patients receive the right care, at the right time, in the right setting, every time. The United States leads the world in discovering new approaches to prevent, diagnose, manage, and cure illness. Our institutions educate and train exceptional doctors, nurses, and other health care professionals.  Yet Americans don’t consistently receive a high level of care.  Achieving optimal results every time requires an unyielding focus on eliminating patient harms from health care, reducing waste, and applying creativity and innovation to how care is delivered.  The National Quality Strategy provides the framework to achieve this.

Another important component of the National Quality Strategy is that it aligns and coordinates the wide range of interests and efforts to move quality forward.  Everyone involved in health care has an important role in promoting high quality care.  It starts with health care providers, but employers, health plans, government, advocates, and many others also have an interest in improving the quality of care.  Employers and other private purchasers, for example, have been leaders in demanding better quality by pushing provider organizations to achieve new levels of excellence.

The National Quality Strategy outlines a common path forward for all these groups and aims to make high quality, affordable care more available to patients everywhere.

The Strategy will be updated annually and will provide an ongoing opportunity to identify and learn from those providers and communities that are leading the way in delivering high quality, affordable care.  It is our hope that this national strategy creates a new level of collaboration among all those involved with health care delivery who are seeking to improve health and health care for all Americans.

The Affordable Care Act calls on the National Quality Strategy to include HHS agency-specific plans, goals, benchmarks, and standardized quality metrics where available.  By design, the Strategy does not include these elements in the first year, in an effort to allow them to be developed with additional collaboration and engagement of the participating agencies, along with private sector consultation.

We believe nation-wide support and subsequent impact is optimized when those needed to implement strategic plans participate fully in their development.  We have begun implementation planning across HHS and have established a mechanism to obtain additional private sector input on specific goals, benchmarks, and quality metrics in 2011.

As implementation proceeds, we will monitor our progress in achieving the Strategy’s three aims, along with other short- and long-term goals, and will refine the Strategy accordingly. Our goal is to keep this Strategy open and inclusive.  One way in which we hope to achieve this goal is to provide updates annually.

The National Quality Strategy is available at www.HealthCare.gov/center/reports. Additional background information can be found at www.ahrq.gov/workingforquality/.

It is hoped that other public and private groups seeking to promote better health and health care delivery will also use the National Quality Strategy to hold themselves accountable.  The Agency for Healthcare Research and Quality is tasked with supporting and coordinating the implementation planning and further development and updating of the Strategy.

The Partnership for Patients:  Better Care, Lower Costs

As I noted during my introduction, we need to make sure that patients feel safe going to the hospital and other health care settings.   

Ensuring the safety of patients is integral to the National Quality Strategy and a significant priority for this Administration.

Hospitals are showing that it is possible to deliver better care.  We can, over time, eliminate many types of patient injury.  The way to do that is to improve the care systems to allow doctors, nurses, and others to do what they desperately want to do: deliver safe care.

And what’s clear is that no one can do this alone.  America’s doctors and nurses are already doing their best to take care of their patients.  Simply telling them to solve this problem on their own would be both unfair and unproductive.  

To that end, the Department is bringing together leaders of major hospitals, employers, health plans, physicians, nurses, patient advocates and others in a shared effort to make hospital care safer, more reliable, and less costly for all Americans.

Last month, we launched The Partnership for Patients – a landmark initiative with two basic but fundamental goals: Prevent patients from being harmed while in the hospital, and reduce the number of preventable rehospitalizations that occur after patients are discharged from the hospital.  

The specific objectives under these goals are challenging, but we believe that they are achievable, and we have set a goal that by the end of 2013, we can reduce cases of preventable harm by 40 percent compared to 2010, and reduce re-hospitalizations within 30 days of discharge by 20 percent compared to 2010 by targeting preventable readmissions.

The rewards are worth the challenges we may face.  

Our estimates are that the process of reducing preventable hospital-acquired conditions by 40 percent will prevent 1.8 million injuries and avert 60,000 deaths of hospital inpatients over the next three years.  

A 20 percent reduction in hospital readmissions would result in eliminating 1.6 million unnecessary rehospitalizations. Reaching both these targets would save up to $35 billion across our health care system over three years, including up to $10 billion for Medicare.  Over ten years, the reduction in Medicare costs could be around $50 billion.  

This initiative has been developed over the last several months under the leadership of HHS and  its agencies, including my own (AHRQ), the Centers for Medicare  & Medicaid Services (CMS), the Centers for Disease Control and Prevention, the Office of the Assistant Secretary for Health, the Food and Drug Administration, the Health Resources and Services Administration, the Administration on Aging, and the Indian Health Service, as well as with our colleagues at the Department of Veterans Affairs Veteran’s Health Administration, and the Department of Defense’s Military Health System.

CMS will commit up to $1 billion in new funding from the Affordable Care Act towards achieving the goals of the Partnership for Patients.  Since the program was announced, the CMS Administrator, Dr. Donald Berwick, has been leading the program through CMS’s Center for Medicare and Medicaid Innovation and has interacted with thousands of health care providers, hospital leaders, and others at in-person meetings and on national conference calls.

Under the initiative, we are providing hospitals and physicians with an unprecedented range of resources about what other health care providers have already done, and are doing, to improve patient safety.  Already more than 1,250 hospitals across the country have pledged their support as well as clinicians and other care providers, health plans, unions, employers, and consumers and patient organizations.  In the months to come, we expect that number will continue to grow.

The Partnership for Patients is pursuing a variety of activities to make significant improvements possible nationwide.  Three of these activities are:

  • One, we are developing, testing  and making available specific and useful tools that are based on the best research to date on what works to prevent adverse events and rehospitalizations.  These include a tool to help prevent pressure ulcers in hospitals (http://www.ahrq.gov/research/ltc/pressureulcertoolkit/) and another tool to avert dangerous blood clots that can occur after surgery. (http://www.ahrq.gov/qual/vtguide/)  
  • Two, we are continuing to support efforts to spread successful innovations that have worked well in one or a few hospitals to larger and more diverse settings.  This will build off of HHS’s previous experience in these areas:
    • One of the best examples is a project in Michigan to reduce central line-associated bloodstream infections in hospital intensive care units.  This resulted in at least a 45 percent reduction in these dangerous infections   in less than 18 months.  These reductions have been sustained for more than five years. Currently, there is an ongoing, nationwide effort to implement the quality improvement program that yielded these results, and we are excited to report that 22 States are seeing similar reductions in these life-threatening infections.  
    • Another very successful initiative involves the prevention of unnecessary readmissions through the Re-Engineered Discharge Project, known as Project RED. Patients who have a clear understanding of their after-hospital care instructions, including how to take their medicines and when to make follow-up appointments with their doctors, are 30 percent less likely to be readmitted or visit the emergency department than patients who lack this information.
  • Three, we are identifying private sector initiatives that have led to useful tools or generated exemplary results.  Some examples of promising private sector initiatives are the recent toolkit developed by the March of Dimes to help prevent harm to mothers or infants during the birth process and work published by Ascension Health on how that hospital system has greatly reduced obstetrical adverse events.

Public-private partnerships are critical to the success of the Partnership for Patients.  The Federal government is partnering with other public- and private-sector groups to encourage patients and families to participate in their care to improve transitions between hospitals and home and securing the active involvement of other organizations representing patients, families, and consumers, in efforts to prevent unnecessary rehospitalizations.  

We know that the new Center for Medicare and Medicaid Innovation, AHRQ, and the other participating Federal agencies have a collaborative role to play with stakeholders to achieve these ends, and that a top-down solution is not the road to success.   

Success will come as health care providers and hospital leaders adopt or develop, and then actually implement, methods that have been shown to be effective.  As we recommend and implement new methods to improve patient safety and care transitions, the new Center for Medicare and Medicaid Innovation will test how to introduce national models known locally to improve care and reduce costs.  

In the coming years, it is our intent that a greater portion of Medicare’s hospital payments will be tied to quality results and to reward those that deliver the best care.  

We know that the type of change we are talking about today will not come easily.  But we also know it can be done if we work together.  By assembling this Partnership for Patients and by committing to its ambitious goals, we are sending a clear message that we can no longer accept hospital care in which safety and efficiency is not the norm.  We need a cultural change in our health care system to make safe, high quality care our top priority.

Conclusion

Mr. Chairman, thank you again for inviting me to discuss National efforts to improve the quality and safety of our Nation’s health care system.  

Through the National Quality Strategy and the Partnership for Patients, we are committed to working closely with our Departmental colleagues, States, and the private sector to ensure that all patients get high quality, safe, appropriate and affordable health care.

I appreciate this opportunity and look forward to answering any questions.

Last revised: June 18, 2013