Keynote Plenary Address

Carolyn M. Clancy, M.D., Director, Agency for Healthcare Research and Quality

2012 AHRQ Annual Meeting, Bethesda North Marriott Convention Center, Bethesda, MD, September 9, 2012

Good afternoon! Welcome to the AHRQ 2012 Annual Conference!

It's great to see all of you—the newcomers and those of you who have attended the conference previously. To all of you, welcome!

For me and my colleagues at AHRQ, this is the highlight of our year. We have an opportunity to talk with you about what we've been doing since the last conference to help get us to the patient-centered model of care we're all working to achieve. Even more important, we get to hear from you.

This session on Sunday is a departure for us. For the previous five meetings, we've had the official kick-off plenary Monday morning. So we decided to use the change to create a more intimate session. Thus, the tables are arranged in half moons and, of course, the fireplace!

The title of the session is kind of intriguing as well: Carolyn Clancy Unplugged. I can assure you that I didn't have anything to do with it. I like it, but it was not my doing.

The intent is for us to have a very informal conversation about current and future roles for the research community.

We'd like to talk with you about the urgency for delivering on the promise of having research that helps us get to high-quality, affordable care. The resources we've been blessed with over the last few years are running low, and there are no guarantees we'll continue to enjoy this level of support.

Before we start, I have some housekeeping duties to take care of. First, you may have noticed that there is no program book for the conference. AHRQ-A-Palooza is going green. That and other key documents are posted on the conference Web site, which is http://meetings.capconcorp.com/AHRQ. Exit Disclaimer

I also want to urge you to visit the mAHRQet Place Café, our exhibit and poster area. It will be open today and tomorrow only. It will not be open on Tuesday, so be sure and stop by today and tomorrow.

For all of the “Twitterati” among us, we'll be tweeting information on the various sessions. To follow the conversation, use the #AHRQAC hashtag.

I'm going to spend a little time talking about delivering on the promise of research, and then we're going to jump into a discussion.

To help facilitate this, AHRQ Office and Center directors and experts are seated up front to help answer any more specific points that might come up.

They will also be available in the mAHRQet Place Café after the session. They are—and please stand momentarily when I call your name:

  • Francis Chesley – Office of Extramural Research, Education, and Priority Populations (OEREP)
  • Steven Cohen – Center for Financing, Access, and Cost Trends (CFACT)
  • Irene Fraser – Center for Delivery, Organization, and Markets (CDOM)
  • Howard Holland – Office of Communications and Knowledge Transfer
  • David Meyers – Center for Primary Care, Prevention, and Clinical Partnerships (CP3)
  • Bill Munier – Center for Quality Improvement and Patient Safety (CQUIPS)
  • Jean Slutsky – Center for Outcomes and Evidence (COE)
  • Jon White – Health IT

In 2010 and 2011 we used the little hand-held remotes called iClickers that allowed the audience to answer multiple choice questions.

They were so popular the first year we used them that we brought them back last year. Unfortunately, the experience wasn't quite as seamless the second time. We'll just say there were technical difficulties and leave it at that.

Actually, watching us make our way through the minefield of glitches seemed to be pretty entertaining for some.

So, even though we're not using the iClickers this year, we're going to start off with a question, in their memory.

I'm going to give you the question and four possible answers. When I get to an answer that you like, raise your hand.

Question:
When was the jigsaw puzzle invented?

  1. 1927
  2. 1867
  3. 1767
  4. 1667

The answer is: C

Englishman John Spilsbury invented the jigsaw puzzle in 1767. Spilsbury was an engraver and mapmaker. The first jigsaw puzzle was a map of the world. Spilsbury attached the map to a piece of wood and then cut out each country.

I attended several preconference meetings this morning, and it's really incredible and amazing to find out just how hard many of you are working on your pieces of the puzzle. I've been calling them puzzle pieces lately because I've heard Secretary Sebelius use the analogy several times in talking about our shared challenge of getting all of the pieces to fit together.

A new report by the Institute of Medicine offers findings, conclusions, and recommendations for building a learning health care system. Here are some of the messages:

  • We have experienced an explosion in knowledge, innovation, and capacity to manage previously fatal conditions, yet we still fall short on fundamental issues such as quality, outcomes, cost, and equity.
  • Unnecessary spending on health care totaled an estimated $750 billion in 2009 alone.
  • The Government needs to accelerate payment reforms, employers need to move beyond shifting costs to employers, and begin demanding accountability from providers, and health care professionals need to engage more in collaboration with their peers.

The committee that was convened to explore health care challenges for this report also made 10 recommendations for improving health care, ranging from improved data capacity and utility, to expanding the commitment of leaders, to building a continuously learning health care system.

The report also says that the full extent of the system's shortcomings is most evident when we look at how other industries operate: while there are human factors and other priorities unique to health care, our system could learn from observing the practices of other industries.

In a marvelous article published by The New Yorker last month, Atul Gawande wrote about how some of The Cheesecake Factory's business practices might be incorporated into what we do.

The Cheesecake Factory has figured out how to serve more than 80 million people a year, using a menu with more than 100 items. Everything from wasabi-crusted Ahi tuna to buffalo wings, miso salmon, Chianti-braised short ribs, flourless chocolate espresso cake, and on and on.

One of the few things that's not made from scratch on site—at each of their 160 restaurants—is the cheesecake, which really does come from a cheesecake factory in Calabasas, California.

The chain provides variety and quality at a cost that would otherwise be unattainable. And they do it in a timely way—they don't deliver your dad his main course while someone else at the table gets dessert. It uses its size for buying power, to centralize common functions and to be aware of and adapt to innovations much faster than smaller, independent operations.

And as Dr. Gawande notes, The Cheesecake Factory is not alone. Another obvious example? Walmart.

We too, in the health care research community, are working to deliver a wide range of consistently high- quality, affordable services to millions of people. And, while the Institute of Medicine report lays out the challenges ahead, we all already know what needs to be done.

We talk about it in conferences and meetings, and in conversations with each other all of the time. We've been talking about it for years.

But when it comes to figuring out what works—particularly what works that can be scaled and spread in a big way—the only thing that we know for sure is that there is often no real way to know for sure.

In many, many instances from the research side, this is a result of the fact that we're not thinking about how our piece fits into the larger mission—the full picture, the completed puzzle. Many of us here are researchers, and we all know how we are, right?

We're refining our piece of the puzzle, sometimes losing sight of the bigger piece, the bigger picture.

We all get caught up in our projects and tend to be oblivious to what is happening around us. This became quite apparent when we moved to the building that we currently work in and found that some researchers were concentrating at such a high level that the motion detectors which control the lights in the offices had to be recalibrated on a couple of floors.

Some of the folks were concentrating so hard that they didn't move at all. They kept getting left in the dark.

The story I always think about when I talk about this is a time when I was listening to someone presenting at AHRQ about a fantastic systematic review related to atrial fibrillation and the use of anticoagulation.

And the person got so deep into the technical details that it became difficult to remember the connection to actual human beings. So it was easy for me to see that many of the people who had come to hear this who weren't clinicians and didn't know those details were probably lost.

And if you think about it, almost everyone in the room that day knew someone who was on Coumadin or who had been on it. But the idea that this could have been someone's dad, or an uncle, or grandmother got lost in the level of the conversation. And that personal connection is what helps people understand the issue.

I'm not saying that the technical details aren't important. They're extremely important, but we can't forget the connection to humans.

So, we've got to do better than this. If we don't, all bets are off. We're at that fork in the road: we may be cutting public programs in a big way. And even with all of the activity that is taking place, we have a long, long way to go.

The good news is there are increasing opportunities to expand the use and influence of health services research.

Many of you have heard me say before that the demand for health services research is growing significantly, including in private health care systems. They don't always call it health services research, but if you listen to the questions they have, they're exactly the kinds of questions our research is intended to answer.

This means there are potential partners outside the normal channels who are seeking health services researchers.  But they use different language, right?

They're collecting data—some of them are collecting huge amounts of data—and information for a wide variety of reasons, and they often refer to our work as “analytics.”

 What needs to change?

  • The way we do our work, and with whom we do our work and report results.
  • Incorporating quality improvement, innovation, and communication.
  • Academic incentives and training programs.

What should this new model look like? That remains to be determined, although overall things to consider include—

  • Grant applications and solicitations that are designed to expand the influence of the research community in efforts to transform the health care system.
  • Stakeholders who are more engaged in making strategic decisions about the research.
  • Making evidence and insights available earlier and during different intervals of a project.
  • Being published as one step—perhaps the initial step—in the continuing process to get results into the hands of those who need it rather than the end of the research cycle.

One of the best examples of a new model that has resulted in change which is generating dramatic results is the Comprehensive Unit-based Safety Program, or CUSP.

The concept was developed by Dr. Peter Pronovost at Johns Hopkins in Baltimore, Maryland, with funding from AHRQ. The initial goal when the program began in 2005 was to help doctors and nurses in ICUs at Johns Hopkins to prevent infections. It has since become much, much more.

We have a video that explains this in more detail.

(After the video)

The national implementation that is referred to in the video involved hospital teams at more than 1,100 ICUs in 44 States. Preliminary findings indicate that hospitals participating in the project reduced the rate of central line-associated blood stream infections (CLABSIs) by 40 percent overall.

We will be releasing more details about the results of the project at a press briefing tomorrow, so stay tuned.

What's been really stunning is the turnaround at these hospitals. Many of them had been kind of monitoring safety and quality efforts but really didn't know how to do what they had been reading about or heard about.

And now, they've actually achieved very significant results, in more than a few instances, having an infection rate of zero for these types of infections for over 2 years.

Because of projects like CUSP, we're optimistic that the importance of the work we're all doing will win out at the end of the day. Clearly, there is no shortage of will and excitement across the country. We do have a shortage of understanding about the “how” and what needs to happen.

That's where your work fits in.

But it's a long process and the research community needs to be a part of this. That means the team sport for health services research takes on a whole new meaning, and I'm really excited about the opportunities ahead and very eager to hear from you.

Thank you very much.

Current as of September 2012
Internet Citation: Keynote Plenary Address: Carolyn M. Clancy, M.D., Director, Agency for Healthcare Research and Quality. September 2012. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/newsroom/speech/2012-conference-keynote.html