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A just-the-facts approach to quality

At the helm of the Agency for Healthcare Research and Quality, Carolyn Clancy, MD, works to encourage doctors and others to make sure strategies for quality care and patient safety are followed.

By Joel B. Finkelstein, amednews staff. Feb. 24, 2003.

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The Nation is their Patient
Doctors serve America at all levels of government. This occasional series explores how their medical background influences what they do.

Carolyn M. Clancy, MD, newly appointed director of the Agency for Healthcare Research and Quality, aims not only to build an evidence base for improving health care quality but also to help physicians incorporate that information into their practices.

Dr. Clancy, who had served as the agency's acting director since the middle of last year, keeps her hand in practice by supervising residents once a week at George Washington University. She spoke with AMNews recently about the agency's activities.

Question: Why does the agency no longer develop practice guidelines?

Answer: When the agency was first created in late 1989, we supported the development of clinical practice guidelines and developed about 20 in all. In 1996, we changed our process. We changed it for a number of reasons, partly because there was some controversy about practice guidelines when you got to that part of clinical decision-making for which there was no good evidence.

Q: How is the agency involved in this process, and what is its new focus?

A: What we did is shift gears and now support 13 evidence-based practice centers across North America that conduct systematic reviews. These reviews look at hundreds and sometimes thousands of articles on a particular topic. They rate the quality of those articles and then put that in a comprehensive report that lays out the evidence. It is very much a just-the-facts approach.

The topics are selected based on input and nominations from professional organizations, government agencies, health plans, consumer groups and others. It is our expectation that when we are finished with a report, these groups will take the report and use it as the basis for practice guidelines and quality improvement programs. We provide the science, and our partners use that to improve care.

We also recognized that many professional organizations had developed their own guidelines. So we developed a partnership with the AMA and the American Assn. of Health Plans to support an Internet-based repository of clinical practice guidelines called the National Guideline Clearinghouse, which was created in 1997. It gets 60,000 visits per week, about 42% of those from physicians. There are between 1,100 and 1,200 practice guidelines on the site now. Not any guideline can go up there. It has to be evidence-based, and there are very clear criteria that are agreed on by us, the AMA and AAHP.

Q: How is the agency looking at the issues surrounding medical errors?

A: Initially, we had made some modest investments in this area. Then in 2001, we were given $50 million by Congress to identify safety problems and improve them. Some projects look at different strategies for reporting errors; some look at issues, such as how health care professionals are organized into systems, what is the impact of fatigue, or how to use information technology to reduce errors.

Q: What is the agency doing to move research findings into practice?

A: Many people once believed that if you conducted the right study that the findings would be so compelling that they would lead to immediate change. This is what I sometimes refer to as the Newtonian approach to dissemination: It all rolls downhill from gravity. In the mid-1990s it became very clear ... that knowledge is necessary but not sufficient to affect change. Knowledge needs to be linked with a supportive practice environment and incentives for change.

What I think plays out on a very large scale is what sometimes plays out for me as a physician. I see a patient; we both agree it is time for a mammogram; the patient leaves; and I realize I forgot to give her the referral. We don't have a system in place to act as a default mechanism. So a big focus of our studies is to try to identify which strategies make the right thing the easy thing to do.

Q: What can doctors do to improve the quality of their services?

A: Doctors have long worked very hard to keep up-to-date on scientific evidence, to make sure that the care that they provide to their patients is based on science. Where, I think, doctors have not done so well, and neither has anyone else, is to ensure that knowledge is part of the system in which they see patients.

A big, big message on patient safety from the Institute of Medicine report on medical errors and from other studies is that it's not just decisions but the systems in which patients get care. For example, we know that getting antibiotics in a timely fashion is very important in terms of outcome for people with pneumonia. So all parts of the system have to work together to make sure a patient gets an antibiotic, the appropriate antibiotic, within eight hours. So doctors and others are going to have to learn how to work together in systems of care.

Q: What importance does technology play in addressing some of the systemic quality problems that have been identified over the past 10 or 20 years?

A: We believe that information technology is a vital part of the solution. That's not to say that human beings can be replaced by computers, but that information technology is going to be vital in terms of taking us to the next level of improving quality and safety of health care. The residents I teach almost all have handheld computers. Whereas I used to walk around with a clipboard, they have got a PalmPilot. We are conducting a study in community practices, looking at whether electronic prescribing can reduce medication errors.

We will also have to focus on making it work well, establishing systems so that it doesn't add to the doctor's work but actually makes it easier. That's going to be the real trick.

Q: Analyzing quality of care across physicians or medical centers usually identifies significant variability in practices and outcomes. How can these gaps be closed?

A: That's the critical question. One strategy being used right now is based on growing interest in public reporting about the quality and safety of health care.

This past year, for example, the Centers for Medicare & Medicaid Services began reporting publicly on the quality of nursing home care. Very recently, the American Hospital Assn., the American Assn. of Medical Colleges and the Federation of American Hospitals got together to launch a voluntary reporting initiative for select clinical conditions. They are going to be reporting on a patient-experience-of-care survey. The agency supports the science underlying those measures and to make sure they are valid, and to make sure they are updated and based on current evidence.

But reporting is only step one. It's sort of like getting your kid's report card; then what? The challenge is how do we take this information and use it to improve the quality of care. This September, the agency is going to produce the first national report of quality of care. I think that is going to prompt a lot of discussion and conversation, and I'm hoping and looking forward to working with the AMA and other physician organizations to try to get to the next level of how we can reduce inappropriate variation.

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