Meeting Minutes, November 2017

Contents

Summary
Call to Order and Approval of July 26, 2017, Summary Report
Director's Update
The Healthcare Cost and Utilization Project (HCUP)
Update on Learning Health System
Update on AHRQ's Patient Safety Learning Laboratories
Further Discussion with the Panel of Speakers
Public Comment
Acknowledgment of Dr. McGlynn
Chair's Wrap-Up and Adjournment

Summary

NAC Members Present

Elizabeth A. McGlynn, Ph.D., Kaiser Permanente (Chair)
Alice S. Bast, Beyond Celiac
Christina J. Calamaro, Ph.D., CRNP, Children’s Healthcare of Atlanta (via telephone)
Jennifer E. DeVoe, M.D., D.Phil., M.Phil., M.C.R., Oregon Health & Science University
Robert S. Dittus, M.D., M.P.H., Vanderbilt University Medical Center (via telephone)
José Julio Escarce, M.D., Ph.D., University of California, Los Angeles
Donald A. Goldmann, M.D., Institute for Healthcare Improvement, Harvard Medical School (via telephone)
Mary D. Naylor, Ph.D., R.N., FAAN, University of Pennsylvania School of Nursing (via telephone)
Lucy A. Savitz, Ph.D., M.B.A., Intermountain Healthcare (via telephone)
J. Sanford Schwartz, M.D., University of Pennsylvania

Alternates Present

David Atkins, M.D., M.P.H., Veterans Health Administration
Shari M. Ling, M.D., Centers for Medicare & Medicaid Services (for Kate Goodrich, M.D.)
Chesley Richards, M.D., M.P.H., FACP, Centers for Disease Control and Prevention

AHRQ Staff Members Present

Gopal Khanna, M.B.A., Director
Sharon B. Arnold, Ph.D., Deupty Director
Jaime Zimmerman, M.P.H., PMP, Designated Management Official
Karen Brooks, CMP, NAC Coordinator

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Call to Order and Approval of July 26, 2017, Summary Report

Elizabeth McGlynn, Ph.D., Chair of the National Advisory Council (NAC), Agency for Healthcare Research and Quality (AHRQ), called the group to order at 8:30 a.m. and welcomed the NAC members, other participants, and visitors, including viewers of the meeting’s webcast. She referred to the draft minutes of the previous NAC meeting (July 26, 2017) and asked for changes and approval. The NAC members voted unanimously to approve the July meeting minutes with no changes. Dr. McGlynn noted that the day’s agenda would include a period for public comment, and she asked the NAC members to introduce themselves.

Dr. McGlynn announced that five NAC members would be rotating off the Council following this meeting—Jennifer E. DeVoe, M.D., D.Phil., M.Phil., M.C.R.; Kevin L. Grumbach, M.D.; Mary D. Naylor, Ph.D., R.N., FAAN; J. Sanford Schwartz, M.D.; and Dr. McGlynn herself. She announced the appointment of Kate Goodrich, M.D., as the new Alternate Ex Officio representative for the Centers for Medicare & Medicaid Services.

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Director's Update

Gopal Khanna, M.B.A., Director, AHRQ, and Sharon B. Arnold, Ph.D., Deputy Director, AHRQ

AHRQ Vision

AHRQ Director Gopal Khanna welcomed the NAC members and thanked them for their ongoing engagement and input. He initiated a brief session focused on a vision for the Agency and unique opportunities as the Agency’s work moves forward. The U.S. health care system has grown in recent decades from a $2 trillion enterprise to a $3 trillion enterprise. This economic investment is expected to rise to at least $5 trillion by the year 2025. Mr. Khanna stated that the overall system will become more rather than less complex over time.

AHRQ and its researchers have established a role in the system but now need to evolve to address radical changes ahead. As an example, Aetna Insurance Company is becoming a "platform" rather than an insurance company. It is becoming part of a larger, more complex entity featuring CVS stores/pharmacies. AHRQ must continue its current role in aiding the move of research to practice; yet it must evolve to serve shifting elements in the health care ecosystem. It must consider what future research should look like. Mr. Khanna suggested the following four strategies for the Agency in moving forward:

1. AHRQ must parlay its data capabilities and its core competencies, for example, by expanding the Healthcare Cost and Utilization Project (HCUP) in a horizontal fashion to address new trends, policies, and State needs.
2. AHRQ must support research in the Learning Health System (LHS), addressing the LHS cycle of data acquisition, knowledge acquisition, practice, and additional aspects, especially implementation.
3. AHRQ must embrace the paradigm of a person-360, or p-360, view of health care, which places the patient in the center of activities. This paradigm features human services as well as health care services. AHRQ is positioned to offer the widest view of the ecosystem—a transdisciplinary view.
4. AHRQ must advance its support for delivery-system research. It must support research, tools, and dissemination strategies. It must identify gaps and cause others to operationalize findings to support changing delivery systems.

Mr. Khanna stressed the importance of AHRQ continuing its programs and accentuating its best capabilities. The NAC members responded with a broad discussion.

Discussion

Robert S. Dittus, M.D., M.P.H., encouraged the Agency to be thoughtful about its resources and to include a focus on the “how” of care, that is, implementation science. We need to learn what to measure. The Agency could partner with delivery systems, including CMS.

Lucy A. Savitz, Ph.D., M.B.A., encouraged the Agency to establish alignment across the U.S. Department of Health and Human Services (HHS). This could include measures and standards. AHRQ also could collect more data on social determinants and supports. Dr. Naylor cited recent innovations in primary care and wondered whether AHRQ could support research to integrate social determinants into care, reframing the primary care system.

Donald A. Goldmann, M.D., raised the issue of scale up. AHRQ could serve to study ways to scale up what has been implemented and learned. We need strong evidence and better models that have been tested broadly and address true population health. We need to encourage the sharing of information and models among Federal agencies, private industry, insurers, and academics. Perhaps AHRQ could serve as a clearinghouse for such activity. It could fund research on spreading best practices (as in reducing healthcare-associated infections) and could indicate how research data can be used to remedy disparities. Dr. DeVoe added that AHRQ could serve to coordinate some Federal agency efforts regarding primary care.

José Julio Escarce, M.D., Ph.D., stressed the social determinants of health as fundamental drivers. The opioid epidemic is one example of a result of such important factors. Dr. Dittus noted that issues of social determinants are dealt with by other Federal agencies.

Dr. Savitz raised the issue of burdens placed on primary care today. AHRQ could serve to bring more attention to informal caregivers, such as family members. Christina J. Calamaro, Ph.D., raised the issue of equipping primary care providers with new information. What should be done about areas lacking good health care access?

Various NAC members cited the need for AHRQ to promote a brand. Dr. Dittus suggested that AHRQ identify a problem and build a brand around it. Dr. DeVoe suggested that AHRQ could be seen as an integrator for key issues. Dr. Savitz called for creating an official brief textual statement that explains the virtues and activities of AHRQ in a cogent manner.

Shari M. Ling, M.D., proposed that AHRQ seek to study behaviors within health care systems. What new ideas and evidence are not taken up and why? Mr. Khanna noted that AHRQ’s Medical Expenditure Panel Survey (MEPS) program is considering the needs of its customers and will refine its data to address them.

David Atkins, M.D., M.P.H., suggested that AHRQ ask what it does that no other agencies will do. AHRQ should ask what works from the patient perspective. He agreed with the idea of AHRQ serving as a clearinghouse helping to bring new ideas/changes up to scale.

AHRQ Updates

Sharon B. Arnold, Ph.D., AHRQ’s Deputy Director, presented the day’s agenda and then provided news and updates for the Agency.

AHRQ is being funded under a continuing resolution until December 8, with a fiscal year (FY) 2017 budget of $324 million. The House has proposed a $300 million budget for FY 2018, and the Senate has proposed a $324 million budget for FY 2018. The House proposal focuses on working to develop evidence to improve quality, safety, accessibility, and affordability of care. It seeks health services research but reduces funding for investigator-initiated research. The Senate proposal supports focus on research to improve diagnosis in care, on evidence-based practice, on health information technology, and on patient safety. Neither proposal calls for merging AHRQ with the National Institutes of Health (NIH). (This issue will be studied further.)

On September 15, 2017, AHRQ hosted a research summit in Rockville focused on the LHS. Sixty-four external stakeholders attended as well as 24 AHRQ staff members. The meeting collected input from the stakeholders on how AHRQ can act as a catalyst to advance learning health care organizations. It featured interactive small-group activities that identified strategies and interventions that would support those organizations.

In 2017 so far, AHRQ has created 34 blog posts on its site devoted to highlighting the Agency’s vision and impact. The posts have received 56,000 page views. Blog topics included the following:

• AHRQ 2.0: Strategies for Creating Value in the Digital Age.
• With AHRQ’s New Compendium, Researchers and Policymakers Gain Fresh Insights into the Nation’s Health Systems.
• Funding the Next Generation of Learning-Health-System Researchers.
• Shining a Spotlight on the Opioid Crisis Through the Power of Data.
• Next Steps to Improving Diagnostic Safety.

How AHRQ Makes a Difference

Dr. Arnold presented the following Agency updates:

Research and Evidence

• The U.S. Preventive Services Task Force produced final new recommendations for vision screening in children aged 6 months to 5 years. Topics addressed in new draft recommendations included screening for cervical cancer, prevention of falls and prevention of fractures, preventive medication for vitamin D, calcium, or combined supplementation for the primary prevention of fractures in adults, and behavioral counseling to prevent skin cancer.
• The Evidence-based Practice Centers (EPCs) produced a new systematic review on Anxiety in Children and two new methods reviews—Understanding Health Systems’ Use of and Need for Evidence To Inform Decision-Making and Discerning the Perception and Impact of Patients Involved in Evidence-based Practice Center Key Informant Interviews.
• A new AHRQ EPC-funded report, Pharmacotherapy for Childhood Anxiety Disorders, was published in the Journal of the American Medical Association in August. It concludes that behavior-based therapy and some medication-based treatments are effective in treating childhood anxiety. However, some medication-based treatments are likely to cause short-term adverse effects. Long-term effects require further study.
• On September 15, AHRQ released the initial version of the "Compendium of U.S. Health Systems, 2016," the first publicly available database that identifies and provides snapshots of the Nation’s health systems. According to the Compendium, by the end of 2016, there were 626 private health systems in the United States. About 70 percent of U.S. non-Federal general acute care hospitals are in health systems. Nearly 45 percent of U.S. physicians are in these systems. Nearly 75 percent of all U.S. hospitals that serve a high proportion of low-income patients are in these systems. The Compendium database lists systems and owned components, along with specific attributes. It will be updated periodically.
• AHRQ released a funding opportunity announcement in partnership with the Patient- Centered Outcomes Research Institute to support 10 training programs for career development relating to LHSs. Applications are due on January 24, 2018.

Tools and Training

• AHRQ published a new collection of nearly 250 tools and resources to help implement medication-assisted treatment in primary care. The tools include a focus on the needs of patients with or at risk for opioid use disorder. They address prevention, training, education, treatment, and overdose.
• AHRQ re-released tools for hurricane relief, including a surge toolkit, a facility checklist, a hospital-evacuation decision guide, and a report on disaster alternate care facilities.
• AHRQ released training materials for preventing falls in hospitals. These five training modules align with chapters in the AHRQ "Preventing Falls in Hospitals" toolkit. Preliminary data on the use of the training materials showed significant decreases in falls with injury during a 1-year period post-implementation.
• AHRQ also released training materials for preventing pressure ulcers in hospitals. Preliminary data on use of the materials showed significant decreases in pressure ulcers during a 1-year period post-implementation.
• AHRQ has modernized its TeamSTEPPS training program by adding an app that puts the structured communication tools and checklists from the TeamSTEPPS Pocket Guide at clinicians’ fingertips on a smartphone or tablet.

Data and Methods

• The 2016 National Healthcare Quality and Disparities Report revealed varying overall quality of care by State for years 2014-2015. Overall, the percentage of blacks experiencing worse quality measures (compared to reference) was greater than the percentage of whites receiving worse quality measures.
• AHRQ released its 2016 State Snapshots online tool, which uses more than 250 measures to quantify site-specific health care quality. It is derived from the 2016 National Healthcare Quality and Disparities Report.
• The MEPS program released information on the percentages of private-sector employees in establishments that offer insurance, showing a slight uptick for medium-sized firms. The program also released information on average annual growth rates in total premiums, indicating continual increases but slower rates of increase.
• The HCUP program released data on homeless emergency department visits in eight States in 2014, showing differences between teaching hospitals and non-teaching hospitals and between admission and treat-and-release. The program produced similar comparison data relating to people with common mental and substance-use disorders.
• The HCUP program produced a statistical brief describing a significant increase in breast reconstruction surgeries during 2009-2014. The sharpest rise was among women age 65 or older.

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The Healthcare Cost and Utilization Project (HCUP)

Jenny A. Schnaier, M.A., Program Analyst, AHRQ Center for Delivery, Organization, and Markets, and Pamela Owens, Ph.D., Senior Research Scientist, AHRQ Center for Delivery, Organization, and Markets

Ms. Schnaier and Dr. Owens reported on AHRQ’s HCUP program, a national information resource to support health care research and inform policy and practice. HCUP features a comprehensive set of publicly available all-payer health care data, including multiyear inpatient and outpatient data based on hospital billing records. HCUP features inpatient, emergency department, and ambulatory surgery data from 48 States. Each State owns and volunteers its data. HCUP collects the data to produce national products. It standardizes the collected data to create a number of uniform State and national databases.

The standardized HCUP data facilitate multi-State research and cross-State comparisons. HCUP is the only current source of national inpatient statistics and all-payer data. Benefits of the project include its large amount of data, uniform coding, ease of access, use of all payers, and tools created to facilitate research. Limitations include the lack of clinical detail, lack of pharmacy and laboratory data, lack of information on some hospital types (e.g., Federal), and inability to follow the entire episode of care.

Dr. Owens stated that HCUP has been answering questions for a growing number of stakeholders and is able to answer large questions, as in the following:

• The five most expensive health conditions account for 20 percent of hospital costs.
• Patients in low-income communities have higher hospitalization rates, longer lengths of stay, and lower average hospital costs.
• One-half of patients with community-acquired MRSA had a diagnosis of cellulitis or skin ulcers; among patients with hospital-acquired MRSA, the largest proportion had pneumonia.

The rate of preventable hospital stays decreased by 19 percent between 2005 and 2012. The HCUP project provides such information to Federal agencies, national groups, State decision makers, care providers, and researchers. Its data helped to inform creation of the new ICD-10 coding system, transitioning from ICD-9. HCUP also developed an ICD-10 resource tool. As a result of the creation of ICD-10 coding, rates for conditions such as postoperative sepsis, postoperative hemorrhage, and postoperative pulmonary embolism were revealed to be lower. Increased specificity of the new codes might account for the revised rates.

HCUP has played a role in responding to the opioid crisis. It revealed that, between 2005 and 2014, the national rate of opioid-related inpatient stays increased 64 percent. The rate of emergency department visits increased 99.4 percent. These results were for both sexes and all age groups, although varying by State. HCUP offers graphical presentations of such data.

HCUP has played a role in responding to the recent hurricanes in the United States. The HHS requested HCUP information regarding needed medical resources, the impact on hospital care, and the populations affected. The HCUP project was able to use estimates from previous hurricanes to predict impacts, such as hospital admissions, of imminent storms.

Dr. Owens and Ms. Schnaier explained that HCUP can expand its collection of quarterly inpatient data by adding States and increasing emergency department data. It can consider new data partnerships with States. It can perform predictive analytics to improve decision-making and support policymaking. It can expand outreach to State policymakers to enable them to use their State data for tracking and policy decisions.

Discussion

Ms. Schnaier noted that the project keeps track of the uses of HCUP data throughout the year and places that information on the Web site. It also sends reports to the project’s partners. Dr. Escarce suggested that the project expand by linking its data with the national death index.

Chesley Richards, M.D., M.P.H., FACP, suggested that the project link data across emergency departments and the individual patient level. Dr. Owens responded that some of that occurs. Dr. Atkins suggested linking with Veterans Health Administration hospital data. Dr. Dittus encouraged the project to consider adding metrics for system performance. Ms. Schnaier responded that there are plans to look at measures of systems.  Dr. Schwartz encouraged the project to advance to data on care outside hospitals, including tertiary care and ambulatory surgery. Perhaps HCUP could move toward databases that are not limited geographically and that observe episodic care.

Dr. Savitz encouraged the project to develop and distribute materials relating to, for example, expected needs in response to hurricanes in certain areas. Dr. Escarce suggested creating a generalizable model for hurricane medical response, addressing variables such as the strength of the storm. (This is being considered.) He also suggested obtaining data from Puerto Rico. Dr. Naylor encouraged the project to promote its results among Federal agencies. Jennifer DeVoe encouraged HCUP to suggest ways to use the data collected.

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Update on Learning Health System

Jaime Zimmerman, M.P.H., PMP, Program Analyst, AHRQ, Brigid Russell, M.H.A., Senior Advisor, Office of the Director, AHRQ, David Meyers, M.D., FAAFP, Chief Medical Officer, AHRQ.

The AHRQ Research Summit on Learning Health Care Systems

Ms. Zimmerman referred to AHRQ’s summit on the Learning Health Care System, which was held September 28, 2017, in Rockville. The interactive meeting was attended by leaders of health care delivery organizations, established LHS organizations, professional medical societies, Federal stakeholders, and AHRQ staff. Goals of the meeting were as follows:

• To identify the aspects of learning health care delivery organizations and practices that are necessary to achieve better organizational performance objectives related to quality, safety, cost, and the workforce.
• To recognize the role of the meeting attendees in helping to create a learning health care ecosystem.
• To explore how AHRQ can act as a catalyst for the advancement of learning health care organizations and practices.

The summit featured conversations with health care leaders, the development of a shared purpose for LHS, and brief presentations of AHRQ programs that can help to support development of the LHS. The participants developed the following shared purpose:

In collaboration with health care delivery organizations, AHRQ will develop the science and provide tools and training to support creation and development of learning health systems that can generate, use, and share evidence and best practices to systematically improve patient care and health outcomes.

Ms. Russell described the following five proposals to influence AHRQ action, which were developed by the summit participants through interactive sessions:

• Develop a business case for investing in LHS and disseminate to delivery system Chief Executive Officers.
• Develop a guide to becoming an LHS, with practical guidance and tools for health care delivery organizations.
• Accelerate the spread of evidence-based best practices across LHS.
• Produce a common data platform that accelerates sharing of data, tools, and resources.
• Advance patient-reported outcomes and patient experience measures to support the ability of LHS to pursue meaningful patient-centered improvement.

Three NAC members who had attended the summit provided brief reflections:

• Dr. Naylor recalled the summit’s discussions about LHS success so far, a need for infrastructure to support the LHS, a need for humility when attempting to implement evidence (we don’t have all the answers), and the idea of person-360.
• Dr. Savitz recalled the summit’s discussion of a need to recognize that an LHS can mean different things to different people and systems. Systems need to learn from each other. The ACTION (Accelerating Change and Transformation in Organizations and Networks) could be instrumental; AHRQ could serve to identify enablers for sharing among systems.
• Dr. Goldmann recalled the summit’s discussion of defining LHS. We have to recognize the national level, the collaboratives, the community systems, and the ways data will be combined. In the process of research-learning-adapting in a changing health care environment, the LHS will depend on a kind of agility of the data.

Discussion

NAC members made additional comments. Dr. Escarce noted that issues regarding payment and incentives will have to be addressed within the LHS. Dr. Dittus suggested that case studies could serve to advance ideas about saving money and producing evidence. We need a vision of what success will look like. Dr. Savitz agreed on a need to build infrastructure, avoiding leaps from new project to new project. An LHS will be dynamic, with participants coming and going. Dr. Ling recognized the fact of variation among LHS systems and the need for leadership. Dr. Atkins stressed the importance of culture that is informed by evidence and context.

AHRQ Exemplars

Dr. Meyers, AHRQ’s Chief Medical Officer, introduced six AHRQ representatives who then described briefly six AHRQ programs that could help to support development of the LHS. These exemplars had presented at the LHS summit in September.

• Edwin Lomotan, M.D., FAAP, described AHRQ’s CDS Connect, a program focused on developing a prototype infrastructure platform for creating and sharing a clinical decision support (CDS) system.
• Herbert S. Wong, Ph.D., M.A., described AHRQ’s Comparative Health System Performance Initiative, which is identifying and comparing characteristics of good health system performance in 600 U.S. health systems today.
• Therese Miller, Dr.P.H., described AHRQ’s EvidenceNOW project, which is studying transformation and use of evidence to improve quality of care in primary care practices, with a focus on cardiovascular health.
• James Cleeman, M.D., described AHRQ’s Comprehensive Unit-based Safety Program, which is advancing safety and reducing harms, especially in the area of healthcare-associated infections.
• Harry Kwon, Ph.D., M.P.H., described AHRQ’s Learning Health System Competencies project, which is developing core competencies to be addressed in training programs for the next generation of researchers.
• Erin Grace, M.H.A., described AHRQ’s Measurement-Powered Quality Improvement project, which is advancing measurement and the integration of data. Examples of the program’s work include the development of quality indicators and the development of tools in the Consumer Assessment of Healthcare Providers and Systems program.

Discussion and Suggestions

Dr. DeVoe asked whether information from the CDS Connect program is shared. Dr. Lomotan responded that there is a repository that can be accessed.

Dr. Savitz encouraged the Comparative Health System Performance project to consider public-private collaborations. Dr. Dittus suggested that the program consider the evolution of systems.

Dr. Atkins suggested that the EvidenceNOW program address sustainability of improvements in the practices.

Dr. Dittus asked how AHRQ runs the CUSP program. Dr. Cleeman responded that AHRQ puts out requests for people to run the programs then steers the efforts. Dr. Dittus added that AHRQ should consider using the program to identify characteristics of care within hospitals.

Dr. Dittus suggested that the LHS Competencies project consider the issue of interdisciplinary education. Dr. McGlynn added the idea of creating an evidence base around competencies.

Dr. Goldmann encouraged the Measurement-Powered Quality Improvement project to seek to learn what organizations are doing with the tools that AHRQ develops.

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Update on AHRQ's Patient Safety Learning Laboratories

Jeffrey Brady, M.D., M.P.H., Center for Quality Improvement and Patient Safety, AHRQ, Kerm Henriksen, Ph.D., Center for Quality Improvement and Patient Safety, AHRQ, and Alan Ravitz, Ph.D., Johns Hopkins University Applied Physics Laboratory

Dr. Brady, Director of AHRQ’s Center for Quality Improvement and Patient Safety, introduced a session on the AHRQ Patient Safety Learning Labs, which take a systems engineering approach to allow researchers and practitioners to evaluate clinical processes and enhance work and information flow to improve patient safety. The program comprises 13 grant projects featuring multidisciplinary teams. Overarching objectives of the program are to create new ways of thinking and learning and to produce fresh, promising approaches that can be tested, revised, and further developed.

The program’s multidisciplinary teams include clinicians, architects, designers, engineers, human factor specialists, and end-users. Each of the 13 projects has chosen patient safety areas for which new designs are needed to achieve synergistic impact. The projects apply systems engineering methodology featuring problem analysis, design, development, implementation, and evaluation. The program has encouraged work in under-resourced communities and work addressing areas with high cost of care.

Dr. Henriksen presented some details of the projects, which feature team-building, brainstorming, and rapid prototyping of new designs. Early failure is welcome, as it can lead sooner to success. The projects seek to engage in processes of design, small-group trials, revision/improvement, large-group trials, integration of components, and testing in simulated settings followed by clinical settings. Initial problem analysis is crucial. Dr. Henriksen described three of the projects: Ambulatory Care for At-Risk Populations at the University of California, San Francisco; Optimizing Mother and Neonate Safety at Stanford University; and Eliminating Harm and Reducing Waste in the Intensive Care Unit (ICU) at Johns Hopkins University.

Dr. Ravitz focused on the Johns Hopkins ICU project, which is developing high-level design requirements for an ideal ICU, using systems engineering methods. The project is using a systems engineering model that the Johns Hopkins University Applied Physics Laboratory developed for the U.S. Navy’s submarine force. A focus on the end-user is one key to the method. The project is actually three projects, (1) developing a concept of operations for a harm-free ICU, (2) demonstrating potential for clinical improvement through device interoperability, and (3) measuring system stress to reduce harm and improve performance in the ICU.

Dr. Brady listed challenges for the projects. For example, building a multidisciplinary team can be difficult, institutional bureaucracy can be an impediment, integration of projects can be difficult, and initial progress can be slow. The program has found that the principal investigators have welcomed the shared learning that occurs across projects.

Discussion and Suggestions

Dr. Goldmann asked for clarity in what the program means by "a cluster of closely related harms," and he encouraged the program to avoid the use of buzzwords in describing the design process. Dr. Henriksen responded that the program is considering such issues and recognizes a learning opportunity for the grantees. Dr. Goldmann suggested that a successful marriage between health system services research and systems engineering requires boldness and the understanding of a big picture. Dr. Brady added that the program has requested that grantees communicate in timely fashion regarding observed impacts of their work.

Dr. Richards inquired whether the program is funding labs or funding work on particular problems. Dr. Brady responded that, although the grant mechanism (P30) is for funding a lab, each project is a mix including the goal for a particular problem. Dr. Richards proposed that successful labs become centers of excellence in time and consider working with industry and expanding beyond patient safety. Dr. Brady stated that the current projects tend to focus more on the setting than on the patient.

Dr. Ling wondered when a solution is considered to be realized—when it is integrated into care? Dr. Brady noted that one output of the projects can be ways in which elements interact. Another can be changes in clinical behaviors including responses to alarms. Dr. Henriksen agreed that sustainability must be considered. Will the institution decide to continue the new operations?

Dr. Schwartz encouraged the program to bring together the research groups to advance learning and to seek evolutionary improvement in models. Both financial and safety sustainability will be important. Perhaps academic medical centers could provide matching funding since these are laboratories. AHRQ could raise the expected standards in cases of additional funding.

Dr. DeVoe proposed thinking more broadly about safety, as inpatient behaviors outside the clinic. Dr. Naylor stressed the importance of safety during health care transitions, and she encouraged the program to seek originality.

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Public Comment

Peggy Binzer, Executive Director of the Alliance for Quality Improvement and Patient Safety (AQIPS), spoke briefly about the Alliance’s work. AQIPS is a nonprofit professional association that represents patient safety organizations and their providers. The Alliance attempts to incubate innovation, implement programs featuring systems analysis, perform gap analysis for emergency departments, and convene physicians, especially surgeons, to discuss quality. It supports outcome analyses and studies of electronic medical record devices. It seeks to solve problems for health care providers and advance value. Ms. Binzer expressed her desire to attend future NAC meetings and the Alliance’s desire to work with the NAC in the area of LHS.

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Acknowledgment of Dr. McGlynn

The AHRQ staff presented Dr. McGlynn with a plaque honoring her years of service as Chair of the NAC. Dr. McGlynn expressed her gratitude, praised the ongoing work of the Agency, thanked the other NAC members who were rotating off the council, and thanked all NAC members and AHRQ staff. Mr. Khanna reported that Dr. Goldmann has agreed to become the new NAC Chair.

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Chair's Wrap-Up and Adjournment

Dr. McGlynn asked the NAC members for final thoughts. Dr. Dittus proposed that the NAC identify, in a future meeting, a single big challenge that AHRQ could articulate for constituencies outside the professional fields. A model for such an effort is the NIH’s attention to the idea of precision medicine. Perhaps AHRQ could promote a precision health system program with the patient as target. Dr. Schwartz encouraged the idea, suggesting a need to add a health services research component. He proposed a future NAC discussion of the movement to new payment systems. How will that affect safety and quality?

Dr. McGlynn asked the Council members to forward any additional ideas for the agendas of future meetings. She noted that the next NAC meeting will take place on March 16, 2017, at AHRQ headquarters. Mr. Khanna thanked the NAC members, presenters, and AHRQ team. Dr. McGlynn adjourned the meeting.

Respectfully submitted,

Elizabeth A. McGlynn, Ph.D., Chair
National Advisory Council
Agency for Healthcare Research and Quality

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