CDC National STD Conference

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CDC National STD Conference

• David M. Stevens, M.D.
• AHRQ
• Center for Clinical Quality Improvement Patient
  Safety

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(No Transcript)
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Core Conclusions

• 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 systemsnot 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

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• Quality is a system property

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The First Law of Improvement

• Every system is perfectly designed
  to achieve exactly
• the results it gets.

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Health Professions 21st Century

• 20th century 21st Century
• Autonomous Team work
• Solo practice Systems of care
• Continuous learning Continuous
  Improvement
• Blame/shame Problem Solving
• Knowledge Change
• Individual patients Diverse populations

Adapted from K. Shine, IOM
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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
• 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 http//www.qualitytools.ahr
q.gov
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HRSA/BPHC Supported Federally Qualified Health
Centers

• Community controlled
• Comprehensive Primary Care
• 768 organizations
• 3,552 sites rural urban

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Health Center 10.3 Million Users
HRSA/BPHC supported Federally Qualified Health
Centers

• Diverse
• White 36
• African American 25
• Hispanic 35
• Asian/other 4
• Poor
• 39 uninsured
• 88 low income with 67 below poverty level

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Key Strategic Elements In Health Disparities
Collaborative
HRSA/BPHC Strategy for Health Centers

• Leadership
• Transform care through models of care,
  improvement learning
• Infrastructure/Support System
• Strategic Partnerships

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Care Model
Health System
Community
Health Care Organization
Resources and Policies
ClinicalInformationSystems
DeliverySystem Design
Self-Management Support
Decision Support
Prepared, Proactive Practice Team
Informed, Activated Patient
Productive Interactions
Improved Outcomes
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Model for Improvement
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?
Plan
Act
Do
Study
Associates in Process Improvement
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How Rapid is Rapid?

• Year
• Months
• Weeks
• Days
• One day or less

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BPHC Health Disparities Collaboratives
Participants
Select Topic
Time for setting aims, allocating resources,
preparing baseline data leading to the first 2
day meeting.
Pre-work
P
Identify Change Concepts
P
A
D
A
A
D
S
S
Planning Group
LS 1
LS 3
LS 2
Congress beyond
Action period 2 further develop the system of
care at the pilot site and spread the system to
other sites
Action period 1 Adapt and test the ideas for
improved system of care
Supports E-mail
Visits Listserv Phone Assessments
Senior Leader Reports
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BPHC Health Disparities Collaboratives
Phase 1
Phase 2

• Sustain and Spread
• Continued reporting and progress toward national
  goals
• Integration of models into the organizational
  structure
• Increasing registry size
• Continued support and interaction

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AccomplishmentsNovember, 2002

• 170,000 patients in registry
• Improved clinical outcomes
• Reduction in average HbA1c, ultimately affecting
  patient mortality and morbidity (gt62,000 with
  average HAb1c 8.03)
• Improved blood pressure control in hypertensive
  patients (gt37 of hypertensive patients with BP
  lt140/90)
• Appropriate use of drugs for asthma (gt84 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

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Chlamydia Screening Contributions from Care Model

• 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)2846-52

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Care Model Implications for Y2P
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Stages of Facing Reality

• Stage 1. The data are wrong
• Stage 2. The data are right, but its not a
  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

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Clinica Campesina Barriers We Overcame

• The belief that our patients cannot change and
  that little changes dont matter
• The idea that we need consensus to change
  anything
• The concept that improving care means more work
• That we cannot improve without more FTE
• The belief in a provider oriented rather than
  patient oriented care system