CDC National STD Conference

1. CDC National STD Conference David M. Stevens, M.D. AHRQ Center for Clinical Quality Improvement & Patient Safety

3. 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 systems…not 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

4. Quality is a system property

5. “The First Law of Improvement” Every system is perfectly designed to achieve exactly the results it gets.

6. Health Professions: 21st Century 20th century21st 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

7. 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.ahrq.gov

8. HRSA/BPHC Supported Federally Qualified Health Centers • Community controlled • Comprehensive Primary Care • 768 organizations • 3,552 sites: rural & urban

9. HRSA/BPHC supported Federally Qualified Health Centers Health Center 10.3 Million Users • Diverse • White: 36% • African American: 25% • Hispanic: 35% • Asian/other: 4% • Poor • 39% uninsured • 88% low income with 67% below poverty level

10. Key Strategic Elements In Health Disparities Collaborative Leadership Transform care through models of care, improvement & learning Infrastructure/Support System Strategic Partnerships HRSA/BPHC Strategy for Health Centers

11. Care Model Health System Community Health Care Organization Resources and Policies ClinicalInformationSystems Self-Management Support DeliverySystem Design Decision Support Prepared, Proactive Practice Team Informed, Activated Patient Productive Interactions Improved Outcomes

12. 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? Act Plan Study Do Associates in Process Improvement

13. How Rapid is Rapid? • Year • Months • Weeks • Days • One day or less

14. 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 A D A D S S Planning Group LS 1 LS 2 LS 3 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

15. 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

16. AccomplishmentsNovember, 2002 • 170,000+ patients in registry • Improved clinical outcomes: • Reduction in average HbA1c, ultimately affecting patient mortality and morbidity (>62,000 with average HAb1c = 8.03) • Improved blood pressure control in hypertensive patients (>37% of hypertensive patients with BP <140/90) • Appropriate use of drugs for asthma (>84% 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

17. 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

18. Care Model : Implications for Y2P

19. Stages of Facing Reality • Stage 1. “The data are wrong” • Stage 2. “The data are right, but it’s 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”

20. Clinica Campesina: Barriers We Overcame The belief that our patients cannot change and that little changes don’t 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