The Next Generation of Health Care: Addressing Certainity

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The Next Generation of Health CareAddressing
Certainity Uncertainty
Ronda G. Hughes, PhD, MHS, RN Senior Health
Scientist Administrator Agency for Healthcare
Research Quality University of Oklahoma,
College of Nursing Wednesday, September 16, 2009
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Today

• Health Policy
• Health Services Research
• Driving Forces of Change Research
• Nursings Opportunities

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21st Century Health Care
Improving quality by promoting a culture of
safety through Value-Driven Health Care
Information-rich, patient-focused enterprises
Information evidence transform interactions
from reactive to proactive (benefits harms)
Evidence is continually refined as a by-product
of care delivery
21st Century Health Care
Actionable information available to clinicians
AND patients just in time
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Quality Chasm Series
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How Can We Enhance Our
Efforts?
The Evolution of Translational Research
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AHRQs Focus Strategic Goals

• Quality Deliver the right care at the right time
  to the right patient
• Safety Reduce the risk of harm by promoting
  delivery of the best possible health care
• Efficiency Enhance access to effective health
  care services reduce unnecessary costs
• Effectiveness Improve health care outcomes by
  encouraging the use of evidence to make more
  informed health care decisions

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Research Priorities for Value Where We Need
Knowledge

• Measures of value, cost, efficiency within and
  across sites of care
• Methods, modeling, and data sources for measuring
  and tracking value and efficiency, projecting
  impact of policy, payment, organizational change
• Impact of consumer incentives on consumer
  behavior, costs and ROI for multiple stakeholders
• Impact of Federal and State regulatory and legal
  changes on organization, financing,
  accessibility, delivery, quality and cost of
  health care
• Impact of Medicare, Medicaid, SCHIP benefit
  provisions management on enrollment,
  utilization, costs, and quality
• Impact of public reporting strategies

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Health Services Research

• HSR is a multidisciplinary field of inquiry,
  both basic applied, that examines the use,
  costs, quality, accessibility, delivery,
  organization, financing, outcomes of health
  care services to increase knowledge
  understanding of the structure, processes,
  effects of health services for individuals
  populations.

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Structural Characteristics
Enabling Factors Leadership, Technologies,
Communication, Financial Resources
Patient - Patient-centered care - Evidence-based
care
Employee/ Staff - Workflow workload -
Collaboration - Occupational Safety
Organizational - Efficiency - Effectiveness -
Quality improvement
Microclimates
Employee/Staff Actions (e.g., handwashing,
providing evidence-based care, etc.)
Patient Actions (e.g., adherence, collaboration)
Processes
Outcomes
Patient
Employee/ Staff
Organizational
Source Stone P Hughes RG. In Hughes RG
(ed). Patient Safety Quality an Evidence-based
Handbook for Nurses. AHRQ 2008.
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HSR Competencies

• Acquire knowledge of the context of health
  health care systems, institutions, actors, and
  environment
• Apply or develop theoretical conceptual models
  relevant to health services research
• Pose relevant important research questions,
  evaluate them, formulate solutions to health
  problems, practice and policy
• Use or develop a conceptual model to specify
  study constructs for a health services research
  question develop variables that reliably
  validly measure these constructs
• Describe the strengths weaknesses of study
  designs to appropriately address specific health
  services research questions
• Sample and collect primary health health care
  data /or assemble manage existing data from
  public and private sources
• Execute document procedures that ensure the
  reproducibility of the science, the responsible
  use of resources, the ethical treatment of
  research subjects
• Demonstrate proficiency in the appropriate
  application of analytical techniques to evaluate
  HSR questions
• Work collaboratively in teams within disciplines,
  across disciplines, /or with stakeholders
• Effectively communicate the process, findings,
  implications of health services research through
  multiple modalities with stakeholders Knowledge
  translation to policy and practice
• Knowledge translation to policy and practice

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Sources of Evidence

• Research Studies
• Randomized clinical trials
• Cross-sectional studies
• Case series studies
• Case control studies
• Systematic Reviews
• Critical analysis of the quality research studies
• Qualitative or quantitative synthesis
• Clinical Guidelines Recommendations
• Expert opinion
• Clinical decision-making

SOURCE Haynes, Devereauxs, Guyatt. ACP J Club
2002 136A11-14.
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Evidence-based Clinical Decisions
Patient Preferences Actions
Clinical state, Setting Circumstances
Clinical Expertise
Research Evidence
Health Care Resources
SOURCE Haynes, Devereauxs, Guyatt. ACP J Club
2002 136A11-14.
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Evidence-Based Guideline Clearinghouses

• The National Guidelines Clearinghouse is a
  comprehensive database of evidence-based clinical
  practice guidelines related documents
• The National Quality Measures Clearinghouse is a
  database Web site for information on specific
  evidence-based health care quality measures
  measure sets
• The goal of both is to promote the dissemination,
  implementation use in order to inform health
  care decisions

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AHRQ Comparative Effectiveness Research
http//effectivehealthcare.ahrq.gov
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You Can Only Improve What You Can Measure
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Education Skills

• 5 Competencies
• Provide patient-centered care
• Work in interdisciplinary teams
• Employ evidence-based practice
• Apply quality improvement
• Utilize informatics

• 6 Competencies
• Patient-centered care
• Teamwork Collaboration
• Evidence-based Practice
• Quality improvement
• Safety
• Informatics

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Evidence-Based Nursing
Patient Safety Quality An Evidence-Based
Handbook for Nurses

• More than 90 experts, 51 peer-reviewed chapters
• Intended for all nurses, especially those in
  universities hospitals
• Provides practice implications for nurses sets
  forth a research agenda
• Links with curriculum on patient safety quality
  improvement developed by UNC

www.ahrq.gov/qual/nurseshdbk
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Working Conditions the Work Environment

• Leadership
• Organizational Climate
• Built Environment
• Patient Acuity
• Care Models
• Restructuring Mergers
• Turbulence
• Staffing
• Temporary/Agency/Contingent Workers
• Workload
• Workflow
• Work Stress Burnout

Patient Safety Quality An Evidence-Based
Handbook for Nurses
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Nurse Staffing, Quality of Care, Patient
Outcomes
Staffing of nursing personnel relative to
service volume
Quantity (dose) of Nursing attention
Staffing Staff qualifications (education, experie
nce, etc.)
Quality of nursing care - Safety of acts -
Prevention vs. rescue
Administrative practices
Model of care delivery
Safety outcomes
Care needs of population
Organizational environment
Clinical outcomes
SOURCE Clarke S, Donaldson N. Nurse staffing.
In Hughes RG (ed.). Patient Safety Quality an
Evidence-based Handbook for Nurses. AHRQ 2008.
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To date, surprising little attention has been
directed toward developing nursing care
performance measures indicators that are
influenced by nursing care (Ken Kizer, 2004).
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Nurse Sensitive Indicators

• Are defined as those structure, process, and
  outcomes most affected by nursing care.
• Are used to promote the highest level of patient
  safety and healthcare outcomes in acute care
  hospitals.
• Are recommended for public reporting.

Source NQF, 2004 Herrin et al, 2006 Savitz et
al, 2005)
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NQF 3 Categories of Measures

• Patient-centered outcome measures (8)
• Nurse-centered intervention measures (3)
• System-centered measures (individual, team,
  organization) (4)
• Criteria for selection
• Important
• Scientifically acceptable
• Useable
• Feasible

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Nursing Care-Sensitive Performance Measures

• Nursing-Centered Intervention Measures (3)
• Smoking cessation counseling for AMI, heart
  failure, pneumonia
• System-Centered Measures (4)
• Skill mix, nursing care hours/patient day,
  practice environment scale, voluntary turnover
• Patient-Centered Outcome Measures (8)
• Failure to rescue, pressure ulcer prevalence,
  falls and restrain prevalence, falls with injury,
  urinary tract infection for ICU patients

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Eliminate serious, preventable, costly
medical errors
CMS Never Events

• October 1, 2008
• Serious Preventable Event (SPE) object left in
  surgery
• SPE air embolism
• SPE blood incompatibility
• Catheter-associated urinary tract infections
• Pressure ulcers
• Vascular catheter-associated infection
• Surgical site infection (mediastinitis after
  coronary artery bypass graft surgery)
• Hospital-acquired injuries (fractures,
  dislocations, intracranial injury, crushing
  injury, burns, other causes)

• October 1, 2009
• Surgical site infections following certain
  elective procedures
• Legionnaires disease
• Extreme blood sugar derangement
• Iatrogenic pneumothorax
• Delirium
• Ventilator-associated pneumonia
• Deep vein thrombosis/Pulmonary Embolism
• Staphylococcus aureus septicemia
• Clostridium difficile associated disease

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Length of Stay is longer for patients with
hospital acquired complications
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It is time that we.

• Make visible our contributions to patient care.
• Articulate to the public the value of nursing to
  healthcare systems and patient outcomes.
• Document empirically through research, nursing
  contributions to patient outcomes.

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The 3Ts Road Map to Transforming U.S. Health
Care
Improved health care quality and value
and population health
Basic biomedical science
Clinical efficacy knowledge
Clinical effectiveness knowledge
Key T1 activity to test what care
works Clinical efficacy research
Key T2 activities to test who benefits from
promising care Outcomes research Comparative
effectiveness Research Health services
research
Key T3 activities to test how to deliver
high-quality care reliably and in all
settings Measurement and accountability of
health care quality and cost Implementation of
Interventions and health care system
redesign Scaling and spread of effective
interventions Research in above domains
Source JAMA, May 21, 2008 D. Dougherty and
P.H. Conway, pp. 2319-2321. The 3Ts Roadmap to
Transform U.S. Health Care The How of
High-Quality Care.
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Change is Hard!
Knowing is not enough we must apply. Willing is
not enough we must do. Goethe

• Identify problems
• Develop strategy
• Pilot phase in
• Increased resource need
• Cause effect

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Electronic Data Information

• Evidence-based practice clinical
  decision-making.
• Lack of evidence
• Synthesis needed actionable steps/practices
• Measurable translatable to practice
• Improve the quality of health care delivery.
• Tools not available or convenient
• Link data for patients, across sites of care.
• Inconsistency in application
• Various languages used
• Improve communication among clinicians.
• Interdisciplinary care
• Handoffs

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Opportunities

• Use best available evidence for decision making
• Generate evidence for practice policy
• Improve patient, nurse system outcomes

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Research Gaps

• Workforce measures
• Pain assessment and management measures
• Nurse-centered intervention process measures
• Measures for other gaps
• Sufficiency of measures against evaluation
  criteria

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Funding Opportunities

• Dissertation Grants
• Conference Grants
• AHRQ has funds available for convening
  professionals to effect change
• AHRQ Tools/Resources
• http//effectivehealthcare.ahrq.gov
• www.innovations.ahrq.gov
• http//psnet.ahrq.gov

http//www.ahrq.gov
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Ronda G. Hughes, PhD, MHS, RN Senior Health
Scientist Administrator Senior Advisor for
End-of-Life Care Center for Primary Care,
Prevention, Clinical Partnerships Agency for
Healthcare Research Quality 540 Gaither Road,
Suite 6000 Rockville, MD 20850 Phone (301)
427-1578 Fax [phone] E-Mail
Ronda.Hughes_at_ahrq.hhs.gov