The 2008 TRUST Award recipient discusses improving quality in health care with actionable research, consistent policies, a national report card and more.
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| Deborah Bohr | Cynthia Hedges Greising |
Most of the quality-of-care and health status measures that are used today were advanced by Robert H. Brook, M.D., Sc.D., F.A.C.P., and his research teams. Dr. Brook established the scientific basis for determining whether medical procedures are used appropriately. He has also focused policy-makers’ attention on quality-of-care issues and their implications for the nation’s health.
In honor of his groundbreaking and far-reaching work in quality measurement and outcomes of care, the Health Research & Educational Trust (HRET) recently announced that Dr. Brook will receive the 2008 TRUST Award. Dr. Brook is vice president and director of RAND Health at the RAND Corporation in Santa Monica, Calif. He also is professor of medicine and co-director of the Robert Wood Johnson Clinical Scholars Program at the David Geffen School of Medicine, and is a professor of health services at the School of Public Health at the University of California, Los Angeles. A prolific scholar, Dr. Brook has published more than 300 peer-reviewed articles. He recently spoke with H&HN OnLine about the quality of care movement.
Q. How has quality improvement (QI) and patient safety in health care progressed in the past 10 to 20 years?
A. If I look at results on quality of care from the RAND Health Insurance Study conducted in the 1970s, compared with results from work that Elizabeth McGlynn is doing now, I am disappointed. We are still doing the right things only about half of the time.
Based on these data, we have to look at how we train doctors. We get very bright students and train them at renowned institutions, but when we are finished, there is huge variation in practice and ability. For instance, students at the bottom of their class go to residencies in hospitals with less teaching, which increases the gap in performance. Other businesses do not do it this way. We have a system that deliberately increases variation. Until we solve that problem, we will not change the quality problem.
In addition, there has been very little organized investment in quality of care. Other industries spend 6 percent to 8 percent of their budgets on improving performance. In health care, less than one-half of 1 percent is spent on that. We need to produce a national quality report card with more validity than the current one. A $50 million to $100 million investment per year is needed. But at this moment, there is no political will to allocate funds to produce such information.
Q. If you could wave a magic wand, what things would improve quality of care in our institutions?
A. When the health maintenance organization (HMO) bill was written 35 years ago, it created a movement toward managed health care. The creators of HMOs said that if we combined business experts and medical experts, the system would be better than any other in the world. That did not happen. Instead, everyone blamed one another.
Doctors believe that guidelines are cookbooks and that managers in insurance companies are interested only in cost control. Insurance companies believe that doctors are arrogant and cannot be managed. In addition, doctors have no loyalty to any single organization because they are part of many networks.
No one can figure out how to change the primary care structure so that management and clinical expertise can be brought together. How do we get physicians and insurance executives to like each other and to work together in the interest of patients?
Q. What research areas are you directing at RAND these days?
A. We are very interested in trying to understand how different policy levers affect health, quality and cost. We are trying to improve the scientific evidence on how various types of QI efforts affect health. We are trying to increase knowledge about depression and the link between exposure to violence and mental health.
We are working to change the culture of researchers so that the end result is not a peer-reviewed article but an action plan that uses science to make a difference in quality, health and cost. We also need to change the culture of philanthropy so that it is no longer acceptable to just produce science or evidence. We need a communication strategy. We must guarantee to the American public that the results of research will be used.
We also have to change the way we approach research. To reduce disparities in health, it is not sufficient just to have a community advisory board unless the community is part of the team and cares about results produced by the joint research effort. The information produced by that effort has to be actionable and used by the community.
We also have to break down barriers between different social systems, such as education and health services. For example, our work at RAND shows that one of the major barriers to learning in inner cities is that students must overcome post-traumatic stress related to all the violence they have seen. There are effective school-based therapies that can reduce bullying. How do we put education and health services together?
Q. What is the outlook for quality-of-care research? How can we accelerate positive change?
A. I was a student in the field of health services research when it was born. In the last third of a century we have been very, very successful at developing measures and analytical tools. We can operationalize the World Health Organization’s definition of health, and no one thought we would be able to do that. The real challenge at the moment is using research findings to make a difference. To do that we will have to change the health services research field, and change the relationship of funders to researchers in profound ways.
Currently, researchers are often content with producing descriptive findings. That is very different from developing an actionable plan, say for redeploying X billion dollars annually. If you are describing only what is currently happening in the world, people will rightly perceive that you are going to have very limited effect, if any.
In another vein, the health care provider community has yet to reconcile what it believes about the business case for quality and the fact that it keeps asking for more reimbursement. For example: I can visit a hospital’s senior leaders in the morning and ask, “Is there a business case for quality?” They will pull out all sorts of analyses describing the enormous amount of money that can be saved by eliminating waste and improving quality. Over lunch, I will ask them about reimbursement policy, and the same leaders will say they do not get enough reimbursement. I tell them that their morning and lunch conversations are contradictory … and they cannot wait for me to get on the next plane.
If people believe there is so much waste in the system—and I believe there is—why isn’t it a national priority to identify it and eliminate it? A responsible leader should say that we do not need any more money. If we did that, I believe there would be greater political willingness to cover health care for everyone. I also believe it would be easier to convince people to pay for new technology, which will have some health impact but cost more. At the national level, there needs to be an absolute commitment to having a detailed report on quality and waste, and its variation across physicians and facilities.
The real issue is that we cannot talk about any of this without realizing it involves change that will put some people out of a job and give others more money. Look at the Bethlehem Steel plant in Pennsylvania—it is unoccupied and still surrounded by barbed wire. Why hasn’t anyone put that land and those buildings to better use? Look how long it takes to make change. Can we change health care? Can we do it in a gentle manner?
Deborah Bohr, M.P.H., is senior director, special projects, and Cynthia Hedges Greising is staff writer at HRET in Chicago.
The 2008 TRUST Award will be presented to Dr. Brook by HRET on July 24, 2008, at the Health Forum-American Hospital Association Leadership Summit in San Diego. Created by HRET in 2003, the TRUST Award is given annually to a health care leader who exhibits visionary leadership.
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