Research Activities, September 2013
Dr. Clancy bids farewell to AHRQ
Having led AHRQ for a decade, Dr. Carolyn Clancy left the Agency August 23 to begin work as Assistant Deputy Undersecretary for Health, Patient Safety, Quality, and Value at the Veterans Administration. First and foremost a physician, Dr. Clancy worked at AHRQ for 23 years. As an internist, she continued to see patients until she became director in 2003. Before her work at AHRQ, she was director of a medical clinic and professor of medicine at several universities. She continues to chair numerous HHS and other Federal groups and sits on the editorial board of many medical journals. Dr. Clancy was named the most powerful physician-executive in health care in 2009 by Modern Healthcare and Modern Physician magazines and the first woman to top the list. She was named third on the list in 2010 and 2011.
Research Activities (RA) talked with Dr. Clancy about what has changed in health services research during the decade she was at the helm of AHRQ, areas of AHRQ's greatest impact on health care, and her personal accomplishments and future plans.
RA: Since you assumed leadership of the Agency in February 2003 you've been passionate about making health services research relevant. You wanted it to change health care delivery and to do it quickly. What's an example of how that research has changed medical practice in the past decade of your stewardship at AHRQ?
Clancy: Probably the most stunning example has been in the field of reducing healthcare-associated infections through the Comprehensive Unit-Based Safety Program (CUSP), which developed 5 steps designed to prevent certain hospital infections. We funded CUSP, led by a team at Johns Hopkins, when we first were tasked by Congress to make a difference in patient safety. What's most notable about this project was the very dynamic and vital partnership between a stellar research team of Johns Hopkins scientists, the Michigan Blue Cross Blue Shield Plans, and the Michigan Hospital Association who implemented CUSP in Michigan. What we've seen over time—and this project has now been spread across the country—is that with a practical approach that makes it easy to make science operational, you can actually have dramatic results—in this case, reductions of over 40 percent of infections in intensive care units and almost 60 percent for neonatal intensive care units.
RA: You also have a reputation for encouraging researchers, who are fiercely independent, to engage clinicians, patients, policymakers, and other stakeholders in their research to make it more relevant. You've called research a "team sport." What difference has AHRQ's engagement of stakeholders in research made in health care?
Clancy: In a number of instances, I think AHRQ's stakeholder engagement has made research far more practical. We have funded some very specific initiatives in patient safety, for example, that focus on practical improvements in patient safety. I think we are learning how to do that quickly. There is still not a roadmap for it, and to a large extent, it has to be customized. For example, for some efforts in safety it is thought to be incredibly important that the CEO literally walks around to see some of this work in progress. It gets everyone's attention. That said, some of these leaders aren't instantly comfortable doing that. They haven't actually set foot in a clinical unit for awhile and not walked around and talked to patients. So they needed some coaching to make that happen. But I am very optimistic that the earlier engagement can help us accelerate the timeline from research to practice. This Agency from the very moment it was created has had a very clear mandate to disseminate what's known to make a difference in health care. We have a unique responsibility and opportunity to shorten that timeline dramatically.
RA: Do you think it has shortened?
Clancy: I don't think anyone has done the calculation, but in some areas it has. What we see every year from the annual reports on quality and disparities is the most dramatic improvements in acute care settings. So my guess is for a number of acute care areas that timeline has indeed shortened.
RA: You are also well-known for championing the involvement of patients in their care. You've noted that patient engagement is being called by some the "blockbuster drug of the 21st century." How has AHRQ championed patient engagement and has this been an impetus for improved care?
Clancy: Over time there has been a steady increase in the involvement of multiple stakeholders in agenda-setting meetings. What I've noticed, particularly in patient safety, is that when there are consumers, patients in the room, it changes the entire conversation. So we've tried to include patients, families, caregivers, consumers, early and often, because it really brings a sense of urgency. We've tried to engage patients through a whole variety of venues, from our recently released guide on how hospitals can involve patients and families at a governance level, to supermarket announcements, public service ads, monthly advice columns and telenovelas to reach the Latino population. I've always thought we should leave no stone unturned in reaching people where they are, because if we really build a patient-centered health care system, it will be where the patients are rather than have them come in and navigate a byzantine bureaucracy.
RA: Where do you think AHRQ's research has made the biggest impact in care? Where is more work needed?
Clancy: It is hard to talk about impact, because some impacts are immediate and you can point to a big success before and after and healthcare-associated infections certainly fits that mode. In the long run, some of what we have funded that has given people tools that they can use to improve care onsite where they see patients will ultimately have the more lasting and sustainable impact. Tools include current data that can be easily accessed such as MEPS or HCUP or other sources and programs that promote teamwork in health care or assess the culture of safety in a hospital or other institution. All of these change the model of research having an impact on care from giving people fish to teaching them how to fish, which I think ultimately will have a more durable impact. In other words, clinical settings were not designed with the systematic capacity for incorporating the most up-to-date evidence in mind, so our overall strategy has to address both the ‘what' and the ‘how'.
RA: Where is more work needed?
Clancy: Two areas I think need a lot more work. One is chronic illness. A lot has to do with the fact that making dramatic improvements in chronic illness is truly a partnership between patients, caregivers, families, and what we call the clinical enterprise. That often means going way outside the usual boundaries of what we think of in clinical care. It is really easy for me to tell people what they need to do in terms of changing their lifestyle or managing their diabetes, but actually doing it is much harder. And if I am going to be successful with patients, I need to know what supports are available in the community. And frankly, that's not how most doctors and other health professionals were trained, which doesn't mean they can't learn. At the top of the list also has to be disparities in health care. We're seeing enough improvements to know that we can make change, but we are also seeing that care disparities continue to be pervasive and that we can do a much, much better job.
RA: When you first became director of AHRQ, the Agency published its first annual Healthcare Quality Report and Healthcare Disparities Report. You just published the tenth set of reports. How much have care quality and safety improved over the past 10 years, and how have care disparities changed over time?
Clancy: The good news is in quality. We have seen significant improvements across all settings and populations every year for the past 10 years. The slightly less good news is the magnitude of those improvements. We need to, and I believe, can do it much, much faster than we have. A lot of that comes down to having timely data. If I just submit data and someone tells me a year later how I am doing, it doesn't have a lot of meaning. A year ago is ancient history. If I get much more timely feedback than that, it is far more relevant. In the example I used on healthcare-associated infections, those teams got quarterly feedback.
"The health care research enterprise has to transition from describing problems to solving them." And when you start to see success, it's like rocket fuel. With the HITECH Act and the dramatic increase in the number of hospitals and physicians and others adopting electronic health records, we are going to see more and more rapid data collection and feedback that people can act on. Rapid data collection will also help us make some big improvements in reducing disparities. There remains sensitivity about how and when you collect the data and so forth. But the Affordable Care Act has provisions that specifically address those challenges, so I am very optimistic.
RA: At the recent AcademyHealth meeting you said that with passage of the Affordable Care Act, more eyes will be on the health services community to bring about change. What type of change?
Clancy: At a very high level, it means that the health care research enterprise has to transition from describing problems to solving them, in the words of an AcademyHealth leader, from "a focus on decisions to a focus on implementation." And that's a very different skill set. That's a very different team that you're working with. Ultimately it may mean that we need to train people who will be bilingual in terms of what research can bring to solving problems and what it's going to take operationally to put some of these findings into practice. But we don't actually have a clear set of competencies or clear path for people to develop that skill set.
Improving care will also require timely data and constant evaluation—and looking back to see how we are doing and where we dropped the ball. That has to be a key part of the fabric of health care. And that is not how today's health care professionals have been trained. They have been trained to focus on one patient at a time, then move on to the next patient. I think they are more than up to the task. It may mean conferences for every shift in intensive care units or weekly conferences in outpatient offices.
RA: How important a role will AHRQ's patient-centered outcomes research play in improving care in the future?
Clancy: It's going to be huge, and I'm very proud of the fact that the outcomes research work we did at the very beginning of the Agency and continue to do has created an amazing foundation of patient-centered outcomes research. We live in an incredible time, whether for treatment or diagnosis, there are two or more good options. That is such a great place to be. But knowing what's the best starting point in caring for a particular individual—trying to match what we know in science with the unique needs and preferences of that individual—that's what patient-centered outcomes research is all about. It's also about how to improve care delivery and customize it for specific settings. With the creation of the Patient-Centered Outcomes Research Institute, our role is changing, because the Affordable Care Act gives us a very explicit stream of funding to build capacity in this field, which we know how to do, and also to disseminate the results more rapidly. So that is where the rubber meets the road and we're very, very excited about that. "We live in an incredible time, whether for treatment or diagnosis, there are two or more good options."
RA: You've noted that the future direction of health services research is going to be increasingly local and that local solutions can become national solutions. What do you mean by that?
Clancy: At the end of the day, all health care is local. For example, where I am from in Massachusetts, there are four medical schools, and in Connecticut right next store there is one. Every community and region has a different mix of assets and opportunities for improvement. That's one reason it's extremely local. And fundamentally, it's local because of the way the Affordable Care Act is constructed. It is very much a State-based bill and its implementation is going to have a huge impact.
Because they are State-Federal partnerships, the State Medicaid programs tend to be very different in terms of how they work. Ultimately you can never do something that is ‘just' national. You've got to figure out the how in a much smaller unit of scale. Anyone can command all health care professionals to wash their hands all the time. In fact we've been doing that for awhile, but it doesn't work. The trick is at my hospital or in my community, how do I make this so easy and so irresistible that it becomes the new normal? I think when we work these things out on a local level, it becomes much easier to scale.
RA: What are the accomplishments as director of the Agency you are most proud of and what legacy do you leave behind?
Clancy: First, the notion of legacy always makes me a little uncomfortable, because by definition this is a team sport, so I have had the wisdom to work with the most fantastic team of people at AHRQ. Taking credit for our collective accomplishments, I think we've gotten many people much more focused on how to implement research findings in the hospital or other health care settings. We've also gotten better over time in creating research partnerships where there really is a serious partnership between those who lead and actually run care operations and those who do research. The ACTION network is a fantastic example of that. I think we've helped a lot of people work with data that they never thought was possible to do before, and that is a tribute to our folks who make it easy and fun.
Fundamentally, I think we've also helped equip patients to have more of a voice in their own care. Last, I am very proud that we have worked with many Federal and private partners in trying to figure out how to accelerate the pace of quality improvement. That includes AHRQ's role in implementing the National Quality Strategy, which is a brand new idea, as part of the Affordable Care Act. It's an annual report on progress in care quality that has become a very vital framework for HHS in partnership with the private sector, and one I am very excited about. I am also proud of funding medical liability demonstration projects that have dramatically changed the model of how health care providers address medical errors with patients and their families and have already markedly reduced malpractice lawsuits at one hospital.