Creating a Business Case for Quality Improvement Research: Expert Views: Workshop Summary (2008)

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IMPROVEMENT AND IMPLEMENTATION CREATING A BUSINESS CASE FOR QUALITY IMPROVEMENT RESEARCH EXPERT VIEWS W O R K S H O P S U M M A RY Samantha Chao, Rapporteur Forum on the Science of Health Care Quality Improvement and Implementation Board on Health Care Services THE NATIONAL ACADEMIES PRESS Washington, D.C. www.nap.edu 

THE NATIONAL ACADEMIES PRESS   500 Fifth Street, N.W.  Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Gov- erning Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engi- neering, and the Institute of Medicine. This project was supported by a grant from the Robert Wood Johnson Foundation and Award No. HHSP233200700506P between the National Academy of Sciences and the Department of Health and Human Services. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project. International Standard Book Number-13:  978-0-309-11652-7 International Standard Book Number-10:  0-309-11652-X Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2008 by the National Academy of Sciences. All rights reserved. Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin. IOM (Institute of Medicine). 2008. Creating a business case for quality improvement research: Expert views, workshop summary. Washington, DC: The National Acad- emies Press. 



The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal govern- ment on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the char- ter of the National Academy of Sciences, as a parallel organization of outstand- ing engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in pro- viding services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council. www.national-academies.org 

PLANNING COMMITTEE FOR THE WORKSHOP ON CREATING A BUSINESS CASE FOR QUALITY IMPROVEMENT RESEARCH THOMAS F. BOAT, Department of Pediatrics, University of Cincinnati College of Medicine JEROME H. GROSSMAN, Senior Fellow, John F. Kennedy School of Government, Harvard University, Cambridge, MA SCOTT J. HAMLIN, Senior Vice President of Finance and Chief Financial Officer, Cincinnati Children’s Hospital Medical Center JOEL KUPERSMITH, Chief Research and Development Officer, Veterans Health Administration, Washington, DC LAURA C. LEVITON, Special Advisor for Evaluation, The Robert Wood Johnson Foundation, Princeton, NJ LORI MELICHAR, Senior Program Officer, The Robert Wood Johnson Foundation, Princeton, NJ PAUL H. O’NEILL, Former U.S. Secretary of the Treasury, Pittsburgh, PA  



FORUM ON THE SCIENCE OF HEALTH CARE QUALITY IMPROVEMENT AND IMPLEMENTATION THOMAS F. BOAT (Co-Chair), Department of Pediatrics, University of Cincinnati College of Medicine PAUL H. O’NEILL (Co-Chair), Former U.S. Secretary of the Treasury, Pittsburgh, PA PAUL B. BATALDEN, Director, Health Care Improvement Leadership Development, Dartmouth Medical School, Hanover, NH IGNATIUS BAU, Program Director, The California Endowment, San Francisco, CA JAY E. BERKELHAMER, Senior Vice President of Medical Affairs, Children’s Healthcare of Atlanta MARSHALL H. CHIN, Associate Professor of Medicine and Co-Director, General Internal Medicine Research, University of Chicago CAROLYN M. CLANCY,* Director, Agency for Healthcare Research and Quality, Rockville, MD CATHERINE D. DEANGELIS, Editor-in-Chief, Journal of the American Medical Association Scientific Publications and Multimedia Applications, Chicago, IL JULIE L. GERBERDING,* Director, Centers for Disease Control and Prevention, Atlanta, GA JEREMY GRIMSHAW, Director, Clinical Epidemiology Program, Ottawa Health Research Institute, Ontario, Canada JEROME H. GROSSMAN, Senior Fellow, John F. Kennedy School of Government, Harvard University, Cambridge, MA JUDITH GUERON, Scholar-in-Residence, MDRC, New York ANDREA KABCENELL, Executive Director for Pursuing Perfection, Institute for Healthcare Improvement, Cambridge, MA RICHARD KAHN, Chief Scientific and Medical Officer, American Diabetes Association, Alexandria, VA RAYNARD S. KINGTON,* Deputy Director, Office of the Director, National Institutes of Health, Bethesda, MD JOEL KUPERSMITH,* Chief Research and Development Officer, Veterans Health Administration, Washington, DC LAURA C. LEVITON, Special Advisor for Evaluation, The Robert Wood Johnson Foundation, Princeton, NJ BRIAN S. MITTMAN, Co-Editor-in-Chief, Implementation Science, and VA Greater Los Angeles Healthcare System, Sepulveda, CA *Denotes ex-officio members. vii 

STEPHEN M. SHORTELL, Blue Cross of California Distinguished Professor of Health Policy and Management, University of California, Berkeley MARITA G. TITLER, Director, Institute for Translational Practice, University of Iowa City Health Care System and University of Iowa, Department of Nursing Services and Patient Care, Iowa City KERRY WEEMS,* Acting Administrator, Centers for Medicare & Medicaid Services, Washington, DC IOM Forum Staff Samantha Chao, Forum Director Michelle Bazemore, Senior Program Assistant Cassandra Cacace, Senior Program Assistant Roger Herdman, Board Director, Board on Health Care Services Michele Orza, Acting Board Director, Board on Health Care Services1   Served through November 2007. viii 

Reviewers T his report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: DONALD GOLDMANN, Institute for Healthcare Improvement, Cambridge, MA STUART GUTERMAN, Program on Medicare’s Future, The Commonwealth Fund, Washington, DC SCOTT J. HAMLIN, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH LAURA C. LEVITON, The Robert Wood Johnson Foundation, Princeton, NJ SUSAN C. ROSSI, Office of Medical Applications of Research, National Institutes of Health, Bethesda, MD ix 

 REVIEWERS Although the reviewers listed above have provided many con- structive comments and suggestions, they were not asked to endorse the final draft of the report before its release. The review of this report was overseen by coordinator DONALD M. STEINWACHS, of Health Services Research and Development Center, Bloomberg School of Public Health, Johns Hopkins University. Appointed by the Institute of Medicine, he was responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review com- ments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution. 

in memoriam This workshop summary is dedicated to Dr. Jerome Grossman, a pioneer in health informatics and health care quality, a valued member of the forum, and an irreplaceable colleague and friend. 



Contents OVERVIEW 1 1 THE BUSINESS CASE FOR QUALITY IMPROVEMENT 5 Managed Care, 6 Department of Veterans Affairs, 7 Systems, 11 Integrated Health Care System, 13 Nursing Perspective, 17 Discussion, 19 2 THE ROLE OF FEDERAL FUNDERS 24 Agency for Healthcare Research and Quality, 25 National Institutes of Health, 27 Discussion, 28 3 RESEARCH AS A DRIVING FORCE FOR CHANGE 32 Overview, 33 Examples of Quality Improvement Research, 34 Department of Veterans Affairs Initiatives, 37 Discussion, 39 4 BREAKOUT GROUPS 40 Value Proposition, 40 Intraorganizational Quality Improvement Gains, 41 Industrywide Quality Improvement, 42 xiii 

xiv CONTENTS 5 COMMUNICATING A VALUE PROPOSITION 44 Integrating the Business Language, 44 The Need for Research, 45 Other Audiences and Areas, 46 REFERENCES 48 APPENDIXES A Workshop Agenda 49 B Workshop Participants 53