Editor’s Note:
Carolyn Clancy will discuss the ideas presented in this post at the Health Affairs event, “The Care We Need: NQF and 20 Years of Quality,” at 2:00 PM ET today.
Early in my career, I was afforded a unique opportunity to be at the forefront of the quality improvement movement in U.S. medicine, joining the Agency for Health Care Policy and Research in 1990 (renamed the Agency for Healthcare Research and Quality (AHRQ) in 1999). The 1999 reauthorization and new name occurred almost simultaneously with the Institute of Medicine's publication of To Err Is Human and instructed AHRQ to support research on making patient care safer.
My mentor, friend, and predecessor as AHRQ director, John Eisenberg, submitted a rapid, but comprehensive report to the president within 60 days of the publication of To Err is Human, focused on specific actions that all federal agencies could take to advance or motivate safety improvements. We also turned to the newly established National Quality Forum (NQF) to endorse a set of evidence-based best practices mitigating patient harm. For instance, while many believed computerized order entry was essential to reducing errors, the evidence review was only cautiously optimistic that it should be implemented everywhere, immediately.
As director of AHRQ from 2002–2013, I launched the inaugural annual reports to Congress on health care quality and disparities, and oversaw development of a robust portfolio in patient safety research. I spent a good amount of my time communicating the importance of evidence-based practices to support safe and equitable patient care.
In those early days we recognized that patient care would benefit from a systems approach that integrated patient safety, education, health care delivery, and clinical practice guidelines. We also knew that as a research agency we needed public and private partners to use the best evidence to inform their health care programs.
While we have made much progress in improving the safety of care that we provide patients, especially in reducing health care-acquired infections and medication errors, there is still much more to learn and implement.
Recognizing the importance of changes in the policy, professional, health care delivery, and technology landscapes, NQF established a National Quality Task Force in 2019 to reexamine our progress and to set a new agenda for the way forward. Building on lessons learned over the preceding 20 years about the imperative of collaborating with all participants in care delivery, NQF sought broad advice and input in developing the task force and reviewing the results─to inform a path forward.
The result was a roadmap for the health care community, outlining steps to achieve high-quality health care for every person in the U.S. by 2030. The report, The Care We Need, outlines a series of actionable steps that the medical community and policy leaders can take to move the needle forward on patient safety.
Speaking from my current perspective as "the DEAN," overseeing innovation, education, and research at the Veterans Health Administration (VHA), here are a few areas that I believe are most germane to quality improvement over the next 10 years in the U.S.
Generating Real-Time Meaningful Data And Actionable Measures
NQF's mission has always included endorsement of quality measures. However, unless the most important components are identified and measured, the result will be precision without purpose. It is past time for quality measures that matter to improved patient care─those that are derived from real-time data.
The past two decades have brought substantial changes in health care delivery, with more care delivered outside hospitals in outpatient settings, ambulatory surgery, and patients' homes. Advances in information and communications technologies have brought us far closer to organizing care around patients. Assuring that this care is safe and high quality means it is vitally important that we capture data as it is generated.
Health information technology has become a critical enabler of consistent excellence in patient care. The emergence of smart phones, along with remote monitoring devices, multiple virtual care platforms, and social media have expanded our concept of what's possible. The NQF Task Force's vision─that data must be available from multiple sites─is an essential step forward in achieving person-centered, rather than facility-derived, care. Linking these data to clinical actions across widely distributed settings is integral to getting the right measures.
Because VHA, part of the Department of Veterans Affairs (VA), is the nation's largest integrated health care system, we are in a unique position to act as stewards for a rich data-set composed of 9.2 million Veterans' clinical information. We have the advantage of using a single electronic health record at 1,255 sites of care across the U.S. Every Veteran who seeks care at VHA has a single health record that can be accessed by any VHA health care provider, no matter where they practice.
VA's Office of Research and Development is working to make Veteran clinical data a national resource. One recent example of this is the VA COVID-19 Cohort Master File, a case list of all Veteran and employee test results for the novel coronavirus, which is updated regularly. The COVID-19 Cohort Master File is now available for use by VA researchers. The same file has also been distributed to Oak Ridge National Laboratory, part of the Department of Energy (DOE), to support collaborative VA-DOE research.
Another example of harnessing data to improve care is the Million Veteran Program. MVP has enrolled more than 825,000 Veterans, collecting biospecimens and de-identified clinical data for research. MVP presents an exciting opportunity to conduct genome-wide association studies to uncover the biological basis for diseases like hypertension and anxiety disorders. It also gives us an opportunity to examine the quality of care we provide our Veterans.
Expanding Telehealth Services
In the early days of the COVID-19 pandemic, VA, along with government-run and private health care organizations, sought to slow the spread of infection by limiting in-person access to health care providers─reserving face-to-face visits for urgent and/or emergency situations. The VA Office of Connected Care stepped into that void by rapidly expanding telehealth services for Veterans. Prior to the pandemic, VA had already established a robust suite of telehealth services, in more than 50 clinical specialties, ranging from primary care, to tele-mental health care, to tele-wound care.
Fortunately, we had the necessary infrastructure needed to support a significant increase in telehealth services for homebound Veterans during the COVID-19 health crisis. During the period of March 1-July 13, VA increased its telehealth services for Veterans by a remarkable 1,140 percent.
Telehealth is uniquely suited to rural Veterans who sometimes live hundreds of miles from the nearest VHA medical center and specialty care. It is also well-suited to responding to natural disasters like hurricanes, which can prevent residents from accessing their health care providers in urgent situations. We now know that telehealth can be a game changer in the face of a global pandemic like COVID-19.
Addressing Health Disparities
While Medicare and other private insurers have previously been slow to reimburse telehealth services, the pandemic has made it clear that technology can be a great equalizer when it comes to Veterans and others who have difficulty accessing health care services. However, COVID-19 also reminds us that we need to renew our focus on health equity issues, including social determinants of health and disparities in health care delivery.
Research data has shown that members of the African American community and other minority groups have been disproportionately affected by COVID-19. VA data on patient demographics and COVID-19 disease incidence is in line with national trends. Preliminary VA data indicates African-American and Latino Veterans are two to three times more likely to test positive for COVID-19. However, the data shows that survivability for Veterans in VA care who are infected with COVID-19 is not affected by race.
African-American Veterans who receive care in VA are more likely to live in high-density cities in the U.S., where COVID-19 is more prevalent, according to the VA Office of Health Equity. VA researchers suggest that greater rates of COVID-19 infection among African-Americans are likely related to social risk factors that are more common in high-density cities.
The VA Office of Health Equity is leading efforts to quantify the effects of COVID-19 for Veterans who are part of minority and other at-risk groups. Together with VA QUERI's National Partnered Evaluation Initiative, they are developing research briefs on racial disparities in VA COVID-19 testing, providing local data on an array of social and demographic risk factors for poor outcomes to VA facilities across the country. An important challenge for us and health care broadly is translating information on risks to practical operational strategies to improve outcomes.
Responding To COVID-19
The experience of COVID has revealed how fortunate we are to have such dedicated health professionals whose commitment and hard work have been inspiring. It has also uncovered weaknesses in our public health system, such as the lack of a coordinated emergency preparedness plan and inadequate levels of personal protective equipment for health care workers.
VHA has experienced some of the same challenges that beset non-government health systems. However, because of our size, integration, and strong leadership, we have been able to shore up areas of weakness and take advantage of creative solutions to surmount problems raised by COVID-19.
As of mid-July, VA has admitted 6,722 patients to its health care facilities for treatment for COVID-19. As of July 20, more than 20,640 patients in the VA health care system have attained convalescence from the novel coronavirus. Yet there is more work to be done.
As part of VA's fourth mission, we have provided support and manpower to 11 states and multiple health care agencies who find themselves overwhelmed with critically ill patients. VA has deployed more than 750 employees to support non-VA facilities. Each of these dedicated professionals have volunteered to leave their families and friends for extended periods of time to help patients in need.
In response to system-wide needs for more clinicians, nurses, and ancillary staff, VA has ramped up its recruiting and outreach efforts. We established an integrated Staffing Command Cell to drive accelerated hiring and manage deployments of VA staff to areas affected by COVID-19. Since the end of March, VHA has hired over 27,860 new employees.
Taking Action
As COVID-19 continues to impact communities across the U.S., we have learned some important lessons on how to respond to a natural disaster of this scope and urgency. It has also provided a lens to better view weaknesses in our national health care system.
Here are just a few areas to consider as we strive to improve the quality of care we provide our patients:
- Assessing flexibility of systems of care
- Linking quality assessment to public health preparedness
- Focusing on health equity, including social determinants of health and disparities in health care delivery
- Including all health care workers (e.g. ambulance drivers and first responders) in the quality map
In order to respond quickly and effectively to future public health emergencies, we must improve the infrastructure that underpins our national health system. Quality improvement is a vital component of this foundation.
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