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, AMNews
staff.
Feb. 24, 2003. Additional information
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.
AHRQ supports 13 evidence-based practice centers in North
America.
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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.
The National Guideline Clearinghouse has more than 1,000
practice
guidelines on its Web site.
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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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�ADDITIONAL�INFORMATION:�
Carolyn M. Clancy, MD
Position: Director, Agency for Healthcare Research and
Quality
Born: July 19, 1953, in Philadelphia
Family: Married, no children
Specialty: Internal medicine
Medical degree: University of Massachusetts Medical School,
Worcester, 1979
Residency: Worcester Memorial Hospital, Worcester, Mass.,
1979-1982; Henry Kaiser Family Foundation Fellow at the University
of
Pennsylvania, Philadelphia, 1982-1984
Previous jobs: Assistant professor, department of internal
medicine, Medical College of Virginia in Richmond, 1984-1990
Personal note: Last movie seen, "My Big Fat Greek
Wedding." The
movie was "just like my growing up in a big family -- everyone
has an
opinion!"
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Copyright 2003 American Medical Association.
All
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