Geraldine Polly Bednash, PhD, RN, FAAN Adjunct Professor, U of Vermont

Geraldine Polly Bednash, PhD, RN, FAAN
Adjunct Professor, U of Vermont
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What are the critical issues facing health care
providers and researchers?
How do these drive a research agenda?
How do these shape practice?
What are the exchanges that are critical to
shaping a health care agenda that is patient
centered, focused on quality, and
accountable for its outcomes?
How do these frame expectations for health
care educators?
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Research – a public good function
Designed to advance knowledge to bring
truth to all endeavors
Critical to assuring that health care
professionals are able to intervene effectively
and safely
Practice – the translation of evidence to seek
health
Focused on seeking the best evidence to
shape care
Finding gaps and failures of evidence
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Health care as a major force in our nation’s
economy, political landscape, and
employment
Focused on bringing a level of
accountability not previously experienced
Changing the dynamics of interplay across
research and practice communities
Will mandate a new level of partnership
across research and practice communities
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Health care is undergoing a dramatic
transformation and both communities –
research and practice have a critical role to
play in the changing dynamics of health care
How these communities interact will shape
the ability of providers, systems, or patients
to meet Triple Aim goals
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The Triple Aim is an overarching theme of a
newly conceptualized patient centered care
delivery model
New care designs and new ways of practicing
must be created to accomplish three critical
objectives
• Improve the health of the population
• Enhance the patient experience including quality,
access, and reliability
• Reduce or at least control costs of care
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Transformation as revolution – seeing
dramatic reversals in earlier trends in which
accountability was not an issue
Moving away rapidly from an acute care
centric model of delivery
Focusing on the full “health” experience and
how to avoid illness care
Shaping care delivery to “do the right thing”
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Focus on accountability has begun to drive all
decisions about care delivery.
Understanding that models of care must
address the complex array of issues not
simply one element – where do you live, who
do you have as a support network, how will
you be moved out of the acute care
environment.
Improving the health of the population to
avoid illness experience. Michener work.
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Health care is an enormous economic engine
despite the fact that this huge cost is a concern to
many – employees, infrastructure, technological
innovation – all add to the economy but bring
concurrent responsibilities to be relevant
NY Times – Registered Nurses as the new “factory
worker” for middle income earnings - the health
care sector as the engine driving middle income
wage growth.
Nursing is third largest middle income occupation
in the US. 55% growth in wages for RNs in last 3
decades
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Time magazine, April 4, 2013
“Why Medical Bills are Killing Us.
Magic Marker – used to mark surgical site,
costs $6.00
Tylenol tablet –
◦ hospital charge - $1.50 per tablet
◦ Amazon - $1.49 / 100 tablets
• 30% of
spending
unnecessary—
an astounding
$600 –700
billion. (IOM)
• More than
enough to
cover the one
out of seven
Americans who
are uninsured
The $121 Binky
“Last year, health care
accounted for about onequarter of total federal
spending … health
spending will account for
almost one-half of all
federal non-interest outlays
by 2050.”
-Federal Reserve Chairman
Ben S. Bernanke,
Senate Finance Committee
June 16, 2008
Relative Risk of Death Across Quintiles of Spend
Decreased Risk
1.00
0.95
Hip Fracture
Increased Risk
1.05
Q1
Q1 = Lowest spending HSA’s
Q5 = Highest spending
Q2
Q3
Q4
Q5
Colorectal
Cancer
Q1
Q2
Q3
Q4
Q5
Myocardial
Infarction
Q1
Q2
Q3
Q4
Q5
0.95
1.10
Fisher ES, Wennberg DE, Stukel TA,
Gottlieb DJ, Lucas FL, and Pinder EL.
The implications of regional variations
in Medicare spending. Part 2:
health outcomes and satisfaction with care.
Annals of Internal Medicine, 2003. 138: 288-98.
1.00
1.05
1.10
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Defined by Lancaster (1975) as “a planned,
systematic search for information, for the
purpose of increasing the total of man’s
knowledge.”
Polit and Beck (2003)“the ultimate goal of
research is to develop, refine and expand a
body of knowledge.”
The dissemination of research is a critical
component of public service – Jensen, 2006
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Professionalism in practice – charter developed
by the American Board of Internal Medicine
Although written for physicians, has great
synergy will all health professions
Articulates professional commitments of
physicians and health care professionals,
including:
◦ Improving access to high-quality health care,
◦ Advocating for a just and cost-effective distribution of
finite resources, and
◦ Maintaining trust by managing conflicts of interest.
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The daily expression of what originally
attracted the health professional to
their field of work (or medicine) –
◦ a desire to help people,
◦ to help society as a whole
◦ To provide quality health care.
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Not too well
NIH studies indicate a 17 year lag between
the time new evidence is developed and when
it is applied in a consistent fashion across
care.
Eye examinations to check for diabetic
retinopathy – less than 50% of diabetics get
this
CLABSI – kill 31,000 a year but can be largely
prevented by following evidence based
protocols
17
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To Err is Human: Building a Safer Healthcare
System - 1999
Institute of Medicine report documented the
failures in care quality and the enormous loss
of life associated with that
100,000 individuals die each year due to
medical errors - equal to one major airline
crash every day
Doesn’t count the errors that do not kill but
harm – e.g. wrong site surgery
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Quality – is the care the right care and do we
get the desired results. Are we harming
patients?
Access as a complex issue – resources to
access care, availability of services, the
appropriateness of the care.
Reliability – can we be sure all care is equal?
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The Future of Rural Health Care
Details the unique health care challenges of rural
communities or environments, like Vermont.
Calls for enhanced partnership across a variety of
communities to assure quality
Focuses on how to bring evidence to practice in
rural, understaffed, and under-resourced care
environments.
Calls for the development of measurement sets
that are designed to assess the unique care
needs of rural communities
Institute of Medicine, 2005.
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US approach is to incentivize through
payment for care – do the right thing or we
will cut your payments. If you do it well, we
might improve your reimbursement.
Focus on value, outcomes, and accountability
in care delivery.
Never events – what shouldn’t happen will not
be covered.
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“Knowledge translation involves more than
distribution of practical scientific information and
reliance on academic publication as a primary
mechanism for disseminating results.”
Knowledge (or evidence) Translation is primarily an
active and manipulated process that involves “all
steps between the creation of new knowledge and
its application and use to yield beneficial outcomes
for society”
Focus, Technical Brief,
http://www.ncddr.org/kt/products/focus/focus10
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Knowledge explosion means we can never own
the full set of information to be a good
professional
Wikipedia – 40,000 clinical trials in process at
any one time
The knowledge base for our practice doubles
every 3-5 years
Our responsibility is to design partnerships that
seek evidence and explore ways to integrate
new evidence into our care delivery efforts
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Frames a new approach to creating and
applying evidence
Occurs when the clinician finds gaps in
evidence to solve a clinical issue and then
seeks support from researcher for designing
efforts to study and solve the issue
Requires a level of unanimity and
collaboration not often present in researcher
and clinician relationships
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The use of evidence based interventions to
change practice
Investigates whether evidence generated
really has a fit with real world public health
and clinical service interventions – is the
evidence really a fit with reality.
Not just a focus on practice – includes a focus
on policy. Are the policies shaping our health
care delivery efforts – both governmental and
professional - guided by accurate
representations of truth.
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Funded by the Agency for Healthcare
Research and Quality (AHRQ)
National initiative designed to test
mechanisms for improving use of evidence in
practice and to measure quality of evidence
that has emerged.
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Developed out of the awareness, again, that
decades can pass before most evidence is
used on a wide spread basis.
1998 review of published studies on the
quality of care received by Americans, for
example, found that only about three of five
patients with chronic conditions received
recommended care.
◦ Schuster M, McGlynn E, Brook R. How good is the
quality of health care in the United States? Milbank
Quarterly 1998; 76: 517-63.
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Goals:
◦ Help accelerate the impact of health
services research on direct patient
care.
◦ Improve the outcomes, quality,
effectiveness, efficiency, and/or cost
effectiveness of care through
partnerships between health care
organizations and researchers.
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Implementation of TeamSTEPPS in Primary
Care Settings
Description: The overall goal of this project is
to improve patient care by optimizing
teamwork in the primary care setting. Using a
TeamSTEPPS module previously developed
specifically for the primary care setting
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Development and Demonstration of a Surgical
Unit-based Safety Program in Ambulatory
Surgery to Reduce Surgical Site Infections and
Other Surgical Complications
Description: The purpose of this task order is
to measurably reduce surgical site infections
(SSIs) and other major surgical complications
in ambulatory surgery through effective
national implementation of a proven Surgical
Safety Checklist
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Long-term Care Integrated Safety and Risk
Management Program
Project Purpose: The purpose of the project is
to create and pilot test an integrated safety
and risk management program, and
associated facilitator training materials
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Requires a multidisciplinary approach – health
professionals, policy makers, consumers,
social science professionals, etc.
We are never able to act in a unitary or
isolated way and have success – it does take a
village.
Intraprofessional efforts also necessary to
share across a discipline the evidence and its
impact.
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Emphasizes egalitarian collaboration between
stakeholders.
An approach to research endeavors and
application that will result in identifying and
implementing evidence-based clinical practices
more quickly than traditional top-down
approaches.
Clinicians with research ideas can also initiate the
relationship with researchers to collaborate on
projects to either implement evidence or find
new evidence to solve a problem.
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A model of implementation science
Framed by Kurt Lewin and Paulo Freire.
Designed with the primary goal of addressing the
needs of a community with evidence-based
treatment paradigms through collaboration of all
stakeholders. Again, Lloyd Michener
Multiple layers of partners common in CBPR academic researchers, organizational leadership
front-line clinicians, the patients served by
clinicians, and payers (e.g. insurers, Medicare,
Medicaid)
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Study of VA system – revealed that clinicians'
prior research experience was critical to the
quality of efforts to implement evidence.
Revealed that top down efforts of researchers
to implement evidence does not work. Must
have collaborative and co-created processes
for testing the efficacy of the science
Challenges included administrative support
and logistics, and can only work if resources
are available to maintain the collaboration.
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Cochrane Collaboration - summarizes all
randomized controlled trials of healthcare
interventions
Computerized decision support systems that
seek evidence based on decision streams
Requires skill in evaluation of the evidence –
its relevance and quality.
The internet as a source of truth???
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A researcher’s work is inconsequential
without a concurrent effort to disseminate
and translate
A practitioner’s effort to support health care
is futile absent a base of science to shape
that effort
An educator’s interaction with the learner
must focus on evidence and knowledge
seeking as a critical skill for success
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The changes in health care, the political and
economic challenges associated with these, all
have enormous implications for those of us
who are in the business of educating the next
generations of health professionals
New competencies, new practice models, and
new expectations for the clinician’s impact on
health.
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Training and mentoring of researchers and
clinicians to create a new framework for their
individual and collaborative work.
Better understanding of dissemination
efforts, collaborative frameworks, and
mechanisms for shaping policy.
Collaboration to set a research agenda and to
identify implementation science priorities.
Are we separating this learning experience
into silos of distinct differences rather than
co-created learning?
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Transformation as revolution – seeing
dramatic reversals in those earlier trends
Moving away rapidly from an acute care
centric model of delivery
Focusing on the full “health” experience and
how to avoid the illness care
Shaping care delivery to “do the right thing”
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Moving from reactive models of care to
anticipatory exchanges – requires data and
strong comfort level with handling it
Understanding that risk must be anticipated
and managed
Creating an understanding of the system’s role
in change and outcomes
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The tremendous complexity challenges us to
rethink what we have believed in the past about
what is required to be a highly competent
clinician, researcher, or educator.
Have the opportunity to learn from our missed
opportunities and create a preferred future
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This is about our mandate to do no harm and
to do the right thing.
Translating evidence to impact the public’s
health and to improve health in diverse
populations.
Dissemination is more than an article in a
journal – it is the implementation into the real
work of practice – in communities, in acute
care systems, in schools, etc.