# Presentation: 534972

## CDC National STD Conference

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

## Slide 2

## 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

## 
Quality is a system property

- Quality is a system property

## “The First Law of Improvement”

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

## Health Professions: 21st Century

- _20__th__ century_				_21__st__ 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

## 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

## HRSA/BPHC Supported Federally Qualified Health Centers

- Community controlled
- Comprehensive Primary Care
- 768 organizations
- 3,552 sites: rural & urban

## 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

***HRSA/BPHC supported Federally Qualified Health Centers***

## 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***_* *

## Care Model

**Informed,**
**Activated**
**Patient**

**Productive**
**Interactions**

**Prepared,**
**Proactive**
**Practice Team**

**Improved Outcomes**

**Delivery****System**
**Design**

**Decision**
**Support**** **

** ****Clinical****Information****Systems**

**Self-****Management ****Support**

**Health System**

**Resources and Policies**

**Community**** **

**Health Care Organization**

**Care Model**

- 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?

- Model for Improvement

**Plan**

**Act**

**Do**

**Study**

*Associates in Process Improvement*

## How Rapid is Rapid?

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

## BPHC Health Disparities Collaboratives

**Select Topic**

**Planning Group**

**Identify Change Concepts**

**Participants**

**Pre-work**

**LS 1**

**P**

**S**

**A**

**D**

**P**

**S**

**A**

**D**

**LS 3**

**LS 2**

**Supports**
-             E-mail	                  Visits			Listserv
- Phone	         Assessments          Senior Leader Reports

*Time for setting aims, allocating resources, preparing baseline data leading to the first 2 day meeting.*

*Action period 1:  Adapt and test the ideas for improved system of care*

*Action period 2:  further develop the system of care at the pilot site and spread the system to other sites*

**Congress & beyond**

**A**

**Notes:**
Fellowship:
Common purpose
Separate at some point
Learn from one another and count on strengths and knowledge of others

## 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

## AccomplishmentsNovember, 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

## 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

## Care Model : Implications for Y2P

| Care Model Elements | Examples |
| --- | --- |
| Pt Self-Mgt** | Partner notification |
| Decision Support | Flow chart, staff training |
| Practice Design | Universal urine collection when register |
| Clinical Info System | Prevalence among patients, follow up system |
| Community ** | Schools, after school venues |
| Health care organization | E-mail notes from chiefs celebrating success |

## 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”

## 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**