Meeting Minutes, November 2022
Call to Order and Approval of July 21, 2022, Meeting Summary
AHRQ Director’s Highlights
Update on AHRQ Efforts to Support Secretary Becerra and HHS in Recommitting to Advancing Patient Safety
Update on the Patient-Centered Outcomes Research Trust Fund Subcommittee (PCORTF SNAC)
Chair's Wrap-Up and Final Comments
NAC Members Present
Edmondo J. Robinson, M.D., M.B.A., M.S., Moffitt Cancer Center (NAC Chair)
Andrew D. Auerbach, M.D., M.P.H., University of California, San Francisco
Komal Bajaj, M.D., M.S.-H.P.Ed., Albert Einstein College of Medicine
Asaf Bitton, M.D., M.P.H., Ariadne Labs, Brigham and Women’s Hospital
Melinda B. Buntin, Ph.D., Vanderbilt University School of Medicine
Caroline Carney, M.D., M.Sc., Magellan Health
Susan Edgman-Levitan, P.A., Massachusetts General Hospital
Neil I. Goldfarb, Greater Philadelphia Business Coalition on Health
Krista Hughes, B.C.P.A., Hughes Advocacy
Catherine H. Ivory, Ph.D., R.N., Vanderbilt University Medical Center
Mireille Jacobson, Ph.D., M.A., University of Southern California, Leonard Davis School of Gerontology
Kannan Ramar, M.D., F.A.A.S.M., F.C.C.P., Mayo Clinic
Jeana A. Reyes, M.S.N., R.N., Horizon Blue Cross Blue Shield of New Jersey
Patrick S. Romano, M.D., M.P.H., University of California, Davis
David F. Schmitz, M.D., F.A.A.F.P., University of North Dakota School of Medicine and Health Sciences
Henry H. Ting, M.D., M.B.A., Delta Air Lines, Inc.
Yanling Yu, Ph.D., Washington Advocates for Patient Safety
Jiajie Zhang, Ph.D., The University of Texas Health Science Center at Houston
Ex Officio Members and Alternates Present
Shari M. Ling, M.D., Centers for Medicare and Medicaid Services
AHRQ Staff Members Present
Robert Otto Valdez, Ph.D., M.H.S.A., Director
Kristen Dillon, M.D., SNAC Chair and Alder Canyon LLC
Erin Grace, M.H.A., Center for Quality Improvement and Patient Safety
Karin Rhodes, M.D., M.S., Office of the Director
Jaime Zimmerman, M.P.H., P.M.P., Designated Management Official
Amy Rabin, NAC Coordinator
Edmondo J. Robinson, M.D., M.B.A., M.S. (NAC Chair)
Dr. Edmondo Robinson called the meeting to order at 11:35 a.m., (Eastern). He stated that the meeting is being recorded and will become available on the Agency for Healthcare Research and Quality’s (AHRQ’s) website and asked all National Advisory Council (NAC) attendees to introduce themselves, noting that seven members would be rotating off the council. These members are Asaf Bitton, M.D., M.P.H., Melinda B. Buntin, Ph.D., Susan Edgman-Levitan, P.A., Omar Lateef, D.O., Hoangmai Huu Pham, M.D., M.P.H., Patrick S. Romano, M.D., M.P.H., and Yanling Yu, Ph.D.
Dr. Robinson referred to the draft minutes of the prior NAC meeting (July 21, 2022) and asked for any changes and approval. NAC members voted unanimously to approve the July minutes with a single change (Dr. Romano noted that in the minutes his citing of “the provider side” should be changed to “provider behavior”). Dr. Robinson reviewed the day’s agenda and introduced the Director of AHRQ, Robert Otto Valdez, Ph.D., M.H.S.A.
AHRQ Director’s Highlights
Robert Otto Valdez, Ph.D., M.H.S.A., Director, AHRQ
Dr. Valdez thanked the NAC members who are rotating off the council, and he reported on changes in AHRQ’s leadership. David Meyers, M.D., has been appointed Deputy Director for Policy and Strategic Investments and Initiatives; Mamatha Pancholi, M.S., has been appointed Principal Deputy for Programs and Operations; Arlene Bierman, M.D., M.S., has been appointed Chief Strategy Officer in the Director’s office, with a focus on aging citizens; and Tess Miller, Dr.P.H., has been appointed Acting Director, Center for Evidence and Practice Improvement (CEPI).
Dr. Valdez reviewed recent publications of AHRQ’s intramural health systems research, which focused on several major issues in our society. A 13-year cohort study found that rural hospitals that were facing financial distress and that were multi-hospital affiliated experienced a lower rate of closure compared with rural hospitals that were independent during a period of financial distress. Dr. Valdez indicated that there is a need for a different definition of “rural” that respects the nuances and complexities that are involved, and he also noted that there are strengths and weaknesses that are defined by the community members and issues that need to be addressed other than poverty. He said that such perspectives can point to various aspects of resilience that could be applied to urban settings as well.
Another publication reported on the reduction in antibiotic starts associated with the AHRQ safety program in more than 400 long-term care facilities, and an additional publication reported a reduction in antibiotic prescriptions for acute respiratory tract infections in ambulatory practices in the same safety program during the COVID-19 pandemic. Dr. Valdez stressed the need to ensure that such information is provided to care delivery systems/clinics and emphasized that AHRQ remains dedicated to expanding and transforming primary care practice.
Dr. Valdez stated that Making Healthcare Safer is an AHRQ publication and a website that provide playbooks/tools and information regarding decisionmaking around clinical safety practices. He noted that AHRQ is celebrating the 20th anniversary of the National Healthcare Quality and Disparities Report (now available online). He also noted that AHRQ’s CEPI Evidence Discovery and Retrieval (CEDAR) project is a new tool that brings together evidence to help people create apps and other possibilities for care delivery and improvement. AHRQ’s social determinants of health database continues to be available for researchers and systems, and a synthetic database on all-payer claims will also become available.
Dr. Valdez described AHRQ’s mission as producing scientific evidence that makes healthcare safer, higher quality, more accessible, equitable, and affordable. The agency is charged with conducting science and implementation through partnerships, and the evidence is to be derived through attention to healthcare safety and quality with several special areas of emphasis, such as maternal healthcare.
The agency recently supported a health equity summit attended by researchers from across the healthcare spectrum to address ways in which the issues can be discussed, to determine issues to be addressed in research venues, and to consider various leverage points. Summit participants were asked to consider what is needed to accelerate equity and implement change and how AHRQ can serve as a catalyst for equitable care delivery. The summit featured and developed themes that included the use of a common language, the importance of leadership, study designs and guidelines, and the importance of the ecosystem of healthcare. The meeting resulted in calls for AHRQ to advocate for healthcare safety and quality courageously, to continue to convene in the future, to serve as a trusted resource, and to foster community inclusion.
Dr. Robinson asked about next steps and how to benefit from leveraging in moving forward. Dr. Valdez responded that the agency is studying the summit findings and current efforts regarding health equity and is considering an internal agenda that includes researchers and reviewers. Neil Goldfarb suggested that developing and working with an equity agenda is not the same as providing focused attention on structural racism. Dr. Valdez agreed, citing the socioeconomic effects involved. Dr. Robinson and Ms. Edgman-Levitan added that the area of disabilities should be included in the definition of equity. Dr. Yu asked about metrics for equity and how AHRQ could be involved in developing such metrics. Dr. Valdez stated that the agency is in the beginning stages of drawing up a research agenda for metrics to identify successes in this area.
Update on AHRQ Efforts to Support Secretary Becerra and HHS in Recommitting to Advancing Patient Safety
Erin Grace, M.H.A., Center for Quality Improvement and Patient Safety, AHRQ
Erin Grace presented a session on AHRQ’s and Director Valdez’s emphasis on a systems approach to patient safety, which is key for efforts in areas such as Long COVID, health equity, and the well-being of healthcare workers. Department of Health and Human Services (HHS) Secretary Xavier Becerra had charged AHRQ with working across HHS agencies to advance a collective commitment regarding patient safety and invited representatives of large healthcare systems to a listening session on November 14, 2022. The session featured presentations by representatives of AHRQ, the Centers for Disease Control and Prevention, the Centers for Medicare & Medicaid Services (CMS), and the Food and Drug Administration. Healthcare patient safety leaders also contributed to this session, and the meeting provided an opportunity for stakeholders to offer advice for the soon-to-be-launched (early 2023) Action Alliance—that is, the National Healthcare System Action Alliance to Advance Patient Safety, which will seek to partner with healthcare systems, Federal agencies, patients, families, and other stakeholders. The Action Alliance will use a plan, or framework, that was recently created to advance patient safety. AHRQ co-chaired the steering committee that derived the plan, which focuses on culture, leadership, governance, patient/family engagement, healthcare workforce safety, and learning systems. The program will be aligned with AHRQ’s ongoing patient safety research and improvement activities, which include the use of the agency’s wide array of evidence-based tools and resources. Secretary Becerra also charged AHRQ with convening a cross-HHS workgroup to advance patient safety by coordinating and aligning safety activities and providing input for the Action Alliance.
Dr. Valdez added that those attending the listening session demonstrated strong enthusiasm for this effort; more than two-thirds of the invitees from large healthcare systems joined the event, and there was a sense that patient and workforce safety efforts represent an opportunity for recovery from the pandemic. There was also agreement that there is a need to move forward in a less complicated way, such as by using a smaller standard set of measures, and that it is important to address instability in the workforce. It was agreed that AHRQ tools are useful in this respect and that AHRQ should proceed to develop additional safety tools.
Ms. Grace noted that the listening session highlighted a need for standardized training, with an emphasis on safety in the teaching curricula for healthcare careers. Such training could be conducted annually and could address workforce turnover. Health system representatives expressed a desire for engaging in public-private efforts. Ms. Grace presented NAC members with the following questions for discussion: What are the challenges being faced? What can HHS bring to the Action Alliance? How can the Action Alliance support the advancement of patient safety?
Dr. Bitton stated that the systems for safety improvement need to develop trust and should go beyond attention to error rates to a consideration of the needs of individuals. This focus could be one that connects with the equity agenda, and it was noted that a system that acknowledges and apologizes for lapses in safety can help lead to trust.
Dr. Romano noted that AHRQ recently identified gaps in performance measurement, and he indicated that the agency’s patient safety indicators are helpful and that it is hoped that these indicators will continue to be endorsed and improved. The Patient Safety Network continues to disseminate information, especially in the areas of education and training. Dr. Romano called for the leveraging of such activities. It was also noted that the new ICD-11 will include recognition of quality and safety to help drive improvement.
Dr. Edgman-Levitan, P.A., cited the need for national quality goals (including safety goals) that could guide in the identification of measures that are no longer worthwhile. A set of simple and actionable measures is needed, in part because measurement is expensive. AHRQ can play a role in bringing together stakeholders to address these issues, and the Patients for Patient Safety US survey will be helpful in gathering and making actionable data on the culture of safety. There remains a need to broadcast the resources and information that AHRQ offers, especially in the area of training.
Caroline Carney, M.D., M.Sc., stressed the importance of payers in patient safety, suggesting that the leveraging of all-payer databases will be helpful in moving forward. She also noted that settings of care are wildly different—and that, for example, the psychiatric venue often is disregarded as pertains to safety—and this is something AHRQ could help address, in addition to addressing polypharmacy and medication errors.
Catherine H. Ivory, Ph.D., R.N., referred to attributions within the healthcare team, such as who is contributing to outcomes and how these individuals and their attention to quality and quality measurement can be identified. This could influence staffing, especially nurse staffing. It would also be important to identify what other members of the workforce can contribute to attaining higher quality care. There is also a need to reduce unnecessary variations in care and to determine how the capacity of consumers to report on quality can be expanded.
Dr. Yu, Ph.D., stressed the need to create a learning process in real time, as in improving treatments for patients. The COVID pandemic pointed at ways to respond. Patient-reported outcomes are key to developing trust, as are the provision of transparent care and transparent data collection. Drs. Robinson and Romano suggested that a National Patient Safety Board would be helpful in these areas. Ms. Edgman-Levitan added that the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Consortium is considering, along with CMS and patient safety advocates, the identification of patient and family views on safety, which will be evaluated using measures.
Kannan Ramar, M.D., raised the question of what the Action Alliance should do in light of the wide spectrum of issues to be addressed and suggested that perhaps the Alliance should consider both intermediate and long-term strategies. Dr. Ramar stressed the importance of psychological safety and teaming for a safe healthcare culture and indicated that both education and simulation are in need of advancement. Regarding how technologies might advance current efforts, it was noted that perhaps data could be more effectively used for prediction and for prescriptive modeling.
Mr. Goldfarb stressed the importance of public reporting and transparency, which will spur investments in quality and safety. He encouraged AHRQ to become more involved in ambulatory-care standard measurement, perhaps starting with medication errors.
Komal Bajaj, M.D., raised the issue of trust in the context of a culture of safety and as the foundation for measurement and improvement. She noted that there are ways to improve psychological safety, such as through post-clinical event debriefing. Henry H. Ting, M.D., M.B.A., added the idea of incorporating external perspectives regarding safety. He cited the airline industry’s safety procedures, including training, assessment of competence, and maintenance of competence, and he suggested that the healthcare industry should consider using these strategies.
Regarding safety, Jiajie Zhang, Ph.D., cited the need for information and the lack, at times, of understanding, and that better diagnostic tools and technology will help. Krista Hughes stressed the importance of involvement of the patients’ families in healthcare, research, and more. She said that trust and transparency are needed, in addition to better communication, new measures that include patient experiences (voices) regarding safety, and better data to identify harms. She also suggested that telemedicine is needed, even as its use seems to be declining since earlier during the pandemic.
Andrew D. Auerbach, M.D., M.P.H., remarked on the need to use data more effectively and to determine whether responses were optimal during the pandemic (teams, patient workflow, etc.). Dr. Robinson noted a comment from David F. Schmitz, M.D., F.A.A.F.P., stressing the need to attend to unique rural healthcare needs as they are related to quality.
Update on the Patient-Centered Outcomes Research Trust Fund Subcommittee (PCORTF SNAC)
Karin Rhodes, M.D., M.S., AHRQ, and Kristen Dillon, M.D., Alder Canyon LLC
Dr. Karin Rhodes introduced a session on the NAC subcommittee (PCORTF SNAC) that has been considering the agency’s future use of investment dollars from the Patient-Centered Outcomes Research (PCOR) Trust Fund. Created by the Affordable Care Act in 2010, the PCOR Trust Fund was reauthorized in 2020, and AHRQ is slated to receive about $1 billion from the Trust Fund over a 10-year period, with a directive to support the dissemination of research evidence. The 10-year window allows for strategic planning. Dr. Rhodes presented a schematic of a proposed strategic plan, featuring mission, priorities, and desired outcomes. She noted that the subcommittee’s deliberations have featured input from subject matter experts and that the subcommittee produced a report and recommendations based on its work during the past year and presented them to the NAC for discussion.
Dr. Kristen Dillon reviewed the SNAC’s work, noting that the Charges to the SNAC included providing input on strategic planning management and evaluating AHRQ’s PCOR Trust Fund investments, with a focus on disseminating and implementing research evidence and fostering innovations in the training of health service researchers. She stated that the subcommittee members agreed that issues of equity should be applied across the priority areas of the strategic plan. The members also stressed the importance of addressing multiple chronic conditions.
The SNAC had convened four online meetings, each with a specific theme, that led to the development of a draft subcommittee report. The members will meet for a fifth time in January 2023 to follow up on the cogent points offered during this current NAC meeting. The primary messages of the draft report were that the subcommittee members were unified in their enthusiasm for the opportunities that the Trust Fund offers and expressed optimism for improving the quality of care and the experience of receiving healthcare. The subcommittee’s draft report on strategic planning describes the boundaries of the Trust Fund’s capacity, and it was noted that a great deal of healthcare work could fit into this framework. It was suggested that perhaps a next step could be to narrow the framework into an agenda that features decisionmaking tools and portfolio design. A further recommendation in the report is for AHRQ to make patient experience and engagement an overarching principle across the research portfolio.
The report included many more pointed recommendations for the use of Trust Fund dollars:
- Seek to close the gap between what we know about effective healthcare and what is being implemented in healthcare systems.
- Bundle implementation and training components.
- Create accountability structures for the equitable distribution of funds among institutions.
- Prioritize work for settings that provide care for underserved populations.
- Innovate training programs.
- Build partnerships that result in change.
The subcommittee encouraged innovation in designing the dissemination and implementation portfolio, the careful selection of evaluation strategies, and the use of strategies and partnerships that reduce barriers. Finally, the SNAC members proposed the authorization of continuing work by the SNAC itself under updated Charges.
Dr. Dillon provided questions to guide a group discussion, and she asked NAC members to suggest topics for the SNAC to address during its January meeting.
Mr. Goldfarb raised the topic of the business community and how value is needed for employers; it was suggested that this topic should be included in the recommendations. What might be AHRQ’s role in getting employees engaged? Training could be advanced with academic/business partnerships.
Dr. Zhang suggested that the evaluation strategy should focus on both implementation and population health outcomes. Dr. Bitton added that implementation science and population health can be inter-related and involve large partnerships, which AHRQ could foster. A goal might be to take the long-term bets on strategic priorities, because even with failure learning will occur. AHRQ could use the funding to go beyond the usual players and avenues and embrace new partnership and coalitions. It was noted that it would also be important to go beyond pilot studies and academic career paths and discover the playbook that a practice in a multi-stakeholder system might need in order to transform itself.
Dr. Yu expressed the opinion that healthcare outcomes are extremely important because they provide information regarding whether an approach will help patients and their families; she also suggested that improved implementation will be helpful and that there should be an additional focus on patient organizations/stakeholders. Dr. Bajaj referred to training programs for healthcare workers and said that she appreciated the SNAC’s attention to such programs. She encouraged a focus on programs that reach many kinds of people who are involved in providing healthcare. It was also suggested that the Federal groups should seek to identify helpful synergies in these areas.
Dr. Carney encouraged a focus on payer partnerships and suggested that perhaps payers could take the lead in research; she also suggested that non-traditional settings, such as Walgreens, should be explored to determine how what happens in these settings influences primary care. Dr. Ivory also focused on partnerships and stated that what we know about good patient outcomes will follow. She suggested that research is needed on what happens with wide implementation. Furthermore, we should determine how to mediate the barriers and focus on what we know while recognizing the variations in care. Also, it would be important to look at primary care teams across geographic settings and fiscal outcomes.
Dr. Bitton suggested looking at the compositions of committees and study sections for research. They might include representatives with various capacities and state and local health officials in addition to representatives from academia. Dr. Schmitz added that Practice-Based Research Networks (PBRNs) could possibly receive grants that could be integrated in underserved communities. Dr. Carney suggested that AHRQ should offer a research fellowship that requires partnerships with payers or other private entities. Dr. Romano proposed that the NAC reauthorize the SNAC and perhaps bring in a greater diversity of voices and perspectives. He noted that Congress asked specifically for PCOR research that will advance economic outcomes.
Dr. Robinson asked NAC members to consider whether to reauthorize, with changes, the SNAC. He also asked members to propose topics for the current SNAC to address during its January meeting.
Dr. Robinson asked NAC members to vote whether to accept or reject the SNAC’s recommendations as presented in the report. The members voted unanimously to accept the recommendations.
Shannon Davila, M.S.N., R.N., of the ECRI Institute, reviewed her organization’s national program, the Patient Safety Organization Safe Tables, which serves to raise awareness of healthcare safety issues and brings together workforce representatives, healthcare providers, patient representatives, researchers, and government officials to improve the delivery of patient care. The program kicked off in January 2021 and has been conducting analyses and distributing clinical solutions and protocols to improve outcomes and the safety culture. Recent activities have included supporting national Safe Tables and disseminating best practices and feedback. A recent discussion involved patient safety risks associated with virtual care delivery. Other discussions dealt with understanding and preventing diagnostic errors in the areas of falls and antibiotic stewardship. Four national Safe Tables are being planned for next year’s first and second quarters. Topics will include maternal health, root-cause analyses, and equity in patient care. The ECRI Institute considers the Safe Tables program to be a critical element of the healthcare learning system and part of the national action plan for patient safety.
Chair's Wrap-Up and Final Comments
Dr. Robinson reviewed some notable suggestions from the meeting. These included taking big bets, expanding the range of stakeholders, and incorporating them into the work, re-engaging around patient safety, and merging equity into all activities. He encouraged NAC members to submit possible topics for upcoming NAC meetings. The retiring members offered their farewells.
Dr. Bitton thanked the agency and encouraged further efforts in stakeholder engagement.
Ms. Edgman-Levitan stated that AHRQ has a great deal of influence in healthcare improvement and offered to work on a marketing team for the agency to help advance the areas of patient experience and engagement. She also applauded AHRQ staff.
Dr. Romano stated that this experience has been both an honor and privilege and added that this is an exciting time for the agency, with the re-authorization of the PCOR Trust Fund and the focus on equity while improving safety.
Dr. Yu agreed that the experience has been an honor and privilege and expressed gratitude, noting that she has learned much by serving on the NAC. She expressed interest in continuing to be part of the AHRQ-led initiative to carry forward this work in patient safety.
Dr. Valdez thanked all members for their input and noted that he appreciated the members’ observations and recommendations.
Jaime Zimmerman, M.P.H., P.M.P., encouraged members to submit their ideas for improving the meetings and the dissemination of AHRQ’s work.
Dr. Robinson thanked the members, the presenters, Director Valdez, and AHRQ staff, and noted that the next NAC meeting will take place on March 6, 2023. He adjourned the meeting at 2:46 p.m., Eastern Time.
Edmondo J. Robinson, M.D., M.B.A., M.S., Chair
National Advisory Council
Agency for Healthcare Research and Quality