Remarks to the National Quality Forum

---

by HRSA Administrator Mary K. Wakefield

October 15, 2009
National Harbor, Md.

---

For those of you who know us, HRSA has long been known as “the access agency,” and expanding access to health care certainly has been at the core of our work on behalf of socioeconomically, geographically, and medically underserved populations. But an emphasis on access is clearly not enough; across the agency’s programs our focus needs to be even sharper -- that access must be to high-quality care.

The truth is that many of our thousands of grantees have, for years, been deeply involved in efforts to not just provide access to health services but also to improve the health care they deliver as the science evolves and our efforts evolve, too.

But first, for those of you who may not know the full range of work we do at HRSA, let me tell you more about how we invest our $7 billion annual budget:

• Our health centers provide primary care to more than 17 million low-income, often-uninsured people at 7,000 delivery points throughout the country;
• Our Ryan White HIV/AIDS program grantees provide care to more than half a million people living with HIV/AIDS.
• Health workforce programs help train the next generation of the health care workforce, and then we use our National Health Service Corps to place them where they're needed most. The NHSC repays up to $50,000 in student loans for advance practice nurses, doctors, dentists and others who serve a minimum of two years in areas with too few health professionals.
• Our rural health policy office provides financial and technical support to keep struggling rural hospitals open and works with them and other rural providers with a sharp focus on sustaining and strengthening the quality of care they provide.
• We also run the 340B Drug Pricing Program, which gives safety-net providers access to discounted pharmaceuticals. And we have a range of other programs – from Poison Control Centers to the National Vaccine Injury Compensation Program to the National Practitioner Data Bank.

With that general sense of some of HRSA’s portfolio, let me turn your attention to some of the efforts underway at HRSA designed to improve quality of care.

Much of our work, especially in the health center system we fund and oversee, has been done through what we call “health disparities collaboratives.” In recent years, 90 percent of health centers have participated in the effort. These collaboratives bring together teams of health center staff – doctors, dentists, nurses, and social workers – to improve their systems of care by learning about and then implementing better ways to work together, better ways to care for their patients.

Data collection and analysis of patient outcomes are at the core of the collaboratives' work. Health centers track patient outcomes and that information informs their thinking about the value of the changes they implement. Each year all of our health center grantees input information into the Uniform Data System (UDS) on patient demographics, services provided, staffing, clinical indicators, utilization rates, costs and revenues.

Staff review the UDS information to ensure compliance with legislative and regulatory requirements. They also use it to identify interventions capable of improving care for patients suffering from chronic diseases like asthma, cancer, cardiovascular disease and diabetes. Bureau staff then work with State Primary Care Associations and individual grantees to share what we’ve learned about best practices in clinical care and the strategies to implement them.

Last year, the health center program established a core set of clinical performance measures for several key health conditions and age groups served by health centers. These measures are aligned with those of national quality measurement organizations, such as the Ambulatory Care Quality Alliance and here at the National Quality Forum.

For the first time, health centers in 2008 reported on nationally:

• childhood immunization rates;
• entry into prenatal care;
• PAP testing;
• low birthweight;
• control of hypertension; and
• diabetes.

In addition to tracking these core health indicators, health centers also report data by race and ethnicity on low birth weight, diabetes and hypertension in order to inform the efforts that health centers undertake to eliminate disparities in health outcomes.

Here are some preliminary findings from the 2008 data and I think you’re the first group to hear it:

• Over the past year, the percent of low birthweight babies decreased from 7.8 percent to 7.6 percent, which is lower than the most recent national average of 8.3 percent. In addition, the rate of entry into prenatal care in the first trimester increased slightly from 64 percent to 65 percent.
• In the aggregate, 70 percent of children are immunized, and over 30 percent of health centers exceed the Healthy People 2010 goal of 80 percent.
• On another front, 62 percent of hypertensive patients have their blood pressure under control; more than 30 percent of health centers exceed the Healthy People 2010 goal of 68 percent.
• And 73 percent of diabetic patients have HbA1c less than 9.

We’ll have more complete findings from the 2008 data available to the public soon.

There are clear opportunities for improvement and you’ll want to keep in mind that the majority of patients receiving care at health centers have a high degree of complexity, including homelessness, low income, comorbidities, health-compromising behavior such as substance abuse – and many are uninsured.

You may know that health centers received $2 billion in funds under the Recovery Act that President Obama signed in February. Those funds have been allotted to create new health centers, expand and renovate existing ones, and, also, for equipment upgrades. Many centers are using a large portion of those funds to install or improve their health information technology.

Two weeks ago, HHS Secretary Kathleen Sebelius announced $28 million in grants to health centers networks to implement electronic health records and other HIT innovations. Of that total, five grants totaling over $2.5 million were targeted to help health centers devise plans to use existing EHRs to improve patient health outcomes. In making the awards, Secretary Sebelius noted the link between HIT and quality when she called the increased use of HIT “a key focus of our reform efforts because it will help to improve the safety and quality of health care.”

Other HRSA bureaus are also engaged in efforts to promote care quality. Some of the most interesting work in the quality arena comes from our oldest bureau, the Maternal and Child Health Bureau, which has been a public health champion for almost 75 years.

MCH oversees the Title V block grant program to states, which has instructed generations of Americans on issues like basic monitoring of a child's health, proper nutrition during pregnancy, prevention of childhood injuries, and strategies to avoid sudden infant death.

All of the 59 states and territories that get MCH block grants report annually on their progress toward meeting health targets on 18 National Performance Measures. We publish these data on our Web site. The measures include dimensions such as:

• percent of third grade children who have received protective sealants on at least one permanent molar tooth; and
• the percent of mothers who breastfeed their infants at 6 months of age.

When state officials apply for block grant funds each year, as they are required to do, MCHB program staff meets on site with them and talks to them about their performance on these measures, and, if needed, about ways to improve performance.

Since 2001, MCHB has funded a smaller quality effort, not as widely known, but with an impact that touches the delivery of care to children everywhere. It’s called “PECARN,” an acronym for the Pediatric Emergency Care Applied Research Network. It’s the first federally funded pediatric emergency medicine research network in the United States. With an investment of just over $5 million annually, PECARN conducts research on the prevention and management of acute illnesses and injuries in children and youth of all ages through a network of 21 participating hospitals.

Let me tell you about two major improvements that have emerged from the PECARN research supported through HRSA.

The first involves the treatment of bronchiolitis, a common infection of the respiratory tract in infants and a leading cause of their visits to hospital emergency rooms. PECARN researchers at the network’s hospitals tested patients over a three-year period and discovered that the most commonly used medication to fight the illness – corticosteroids – was ineffective in reducing the rate of hospital admission, or in improving their respiratory status after four hours of observation, or in improving their final outcomes.

The PECARN findings were published in July of 2007 in the New England Journal of Medicine and, since they address inappropriate use of care, are, we hope, being followed in emergency rooms across the country – although I recognize there is much that needs to happen to ensure that adoption happens.

Another PECARN study, this one of childhood head trauma, identified children at very low risk of clinically important traumatic brain injuries for whom a CT scan would be unnecessary. Its findings, which were published just last month in the September 2009 edition of The Lancet, will hopefully reduce the number of unnecessary CT scans for children and limit their exposure to radiation, sedation, and emergency transportation.

Quality activity is taking a new turn in our HIV/AIDS Bureau, or HAB. HAB is HRSA’s major bureau by annual appropriation, with funds of more than $2.2 billion in FY 2009, a few million more than the budget for the health center program.

In 2006, congressional reauthorization of the Ryan White HIV/AIDS Program made client-level data reporting a requirement for the first time; that requirement became a mandate for Ryan White grantees in January of this year. Some grantees have been collecting client data for years, but others needed to upgrade their computer systems to tackle the new requirement.

To move the process along faster, HAB staff launched a capacity building initiative to help grantees adapt to the new demands. Since September of last year, the initiative has helped 17 grantees buy or enhance HIT systems capable of meeting the new requirements and just awarded grants to help dozens more.

2009 is a transition year for grantees, as the entire system moves from an old data reporting system, which collected data in the aggregate, into this new one, called the Ryan White Services Report. The challenges of the transition in terms of hardware, software, and training alone are substantial, but data security, an essential part of any health data collection effort, is a special concern for people living with HIV.

And while our grantees are in the beginning and middle stages of this move to the new reporting system, already we’re starting to see how the client-level data can be used to make real program improvements.

Our staff have told me that grantees who have upgraded their IT capacity and completed the conversion to the new reporting system “can look at service utilization patterns in minutes to see how resources are allocated to meet the needs of clients. They can improve service linkages by checking on how referrals are being made and how well clients are adhering to their treatment plan.”

We’re happy with the progress that is being made in this transition, and in the future we’ll be able to provide a fuller report on grantee performance and patient outcomes.

Following the lead of efforts with the health centers that I mentioned earlier, we’ve extended the collaborative model into other HRSA programs. We’ve used it to bring together hospitals and organ procurement organizations to boost donation rates at hospitals, and now we’re using it to integrate clinical pharmacy services into health care delivery in an effort to improve care quality and reduce medical errors.

Two weeks ago I was in Dallas to speak to what we call the Donation and Transplantation Community of Practice. It’s a multi-year HRSA initiative that brings together hospital executives, donation and transplantation professionals, and organ procurement organizations to identify and share best practices to integrate organ donation into hospitals’ end-of-life care.

Executives from more than 400 hospitals were there, all committed to achieving and sustaining one or more of three national goals for donation:

• a donation rate of 75 percent or more of eligible donors at their facilities,
• increasing the number of organs donated per individual donor to 3.75 or higher, and
• expanding clinical processes for recovering organs.

Thirty of the hospitals earned Gold Medals for reaching or exceeding all three of the national goals. The commitment of the people and organizations in the Community of Practice has helped make possible the transplant of 3,088 more organs from deceased donors in 2008 than in 2003.

Even so, this is an important area to further improve in, because despite their best efforts, the list of people waiting for transplants to save or enhance their lives keeps rising.

Over the past year and a half, HRSA organized another collaborative, this one to improve patient safety by integrating clinical pharmacy services into the treatment of high-risk, high-cost patients with complicated medical problems.

Last month marked the end of the Collaborative’s first year, and 25 teams have already shown progress in improving patient outcomes, integrating clinical pharmacy services into service delivery models, and reducing adverse drug events.

Right now the Collaborative has 110 teams spanning 40 states; the teams represent 350 organizations, and we plan to add more as the second year gets underway.

As in the other Collaboratives, this one is marked by inquiry and learning, testing of best practices, and monitoring and adjustment of plans by provider organizations.

Team members report averting 3,000 potential adverse drug events, and many teams have cited instances in which a life-threatening adverse drug event was identified and resolved.

I’d like to conclude today by recalling the words of one of my esteemed HRSA predecessors, Dr. Claude Earl Fox, who was famous for telling his staff that “Data drives dollars.” No one knows that better than a federal health administrator in his or her regular appearances before Congressional committees, whose members always, and rightly, want to know what taxpayers are getting for their money.

What Dr. Fox meant, of course, was that we need to collect data to verify top-flight performance by all of the thousands of grantees HRSA funds each year. If we can’t do that, budgets and the programs they support will be forever imperiled. Frankly, that is how it should be.

With the growth in the capacity and sophistication of health information systems, we see clearly that – with the right data – we can go beyond verifying performance to improving it across our federal programs.

I’ve told all my managers that they need to:

• Collect the right data to determine performance;
• Track outcomes; and
• Encourage testing of the effectiveness of their grantees’ work.

We need better data to more sharply define our grantees’ impact and the health of the populations we serve.

And when we have the data and know how grantees are doing, we need to be ready to:

• Intervene to improve performance among those that could do much better;
• Support the efforts of those in middle to help them improve;
• And help further raise the efforts of the best performers.

And while I’ve given you snapshots of a set of our programs’ efforts, I also know there is much more we should do agency-wide to lift the quality of care for the populations we serve.

This is the path we’re charting at HRSA. I think it’s one that will improve the quality of care our grantees provide and one that will verify the value of the work we do on behalf of the American people.

Thank you.