Multilevel Interventions in Health Care Conference: Overview by Arnold Kaluzny, PhD

Uploaded by NIHOD on 05.05.2011

>>>DR. STEVEN CLAUSER: Now there will be more detailed
instructions in terms of how this is going to work,
in terms of the discussions, but right now I'd really like
to move directly into our first substantive presentation and
introduce my close friend, Arnie Kaluzny.
Arnie Kaluzny has served as chairman of Multilevel
Interventions steering committee over the past year
and a half and he has been really been very involved in
contributing his expertise and insight on the structure and
function of healthcare organizations.
Dr. Kaluzny is an emeritus professor of health policy and
management at the UNC Gillings School of Public Health and
also a senior research fellow at the Cecil Shepp Center for
Health Services Research at the University of North Carolina at
Chapel Hill. He is a prolific author of books and book
chapters and journal articles and he's a leader in
the field of health organization and management and also
cancer control and prevention. He is a recipient of numerous
awards and served on numerous advisory committees
here at NCI. Dr. Kaluzny, do you want to start us off?
>>>DR. ARNOLD KALUZNY: Very good.
>>>DR. ARNOLD KALUZNY: Thank you very much, Steve, for your
gracious words, and let me welcome you to our meeting
today, the next two days. What I would like to do
is take about ten minutes and sort of put this into context
and provide some overview of how we are going to be
dealing with some of the issues that Steve had mentioned.
Let me see if this works - there we go.
One of the things that I think we do very well in health
services is develop interventions.
And what we have here is sort of an array of interventions
over the years ranging for various activities within
cancer prevention and control, such as the CCOPS,
such as the ASSIST program, the COMMIT program,
the NCCCP, which we are currently involved in,
as well as the last ten years, a tremendous focus on total
quality management of CQI, DRGs.
Probably the new flavor of the month that is getting a lot of
attention is the electronic medical record and guidelines
and checklists. And all these activities are usually
presented with a great deal of passion because we are
dealing with very, very important kind of activities
focusing on the issues of quality, safety within health
services, the issues of cost, cost containment - that's what
DRGs was all about, continuous quality improvement,
quality and cost as well as the bottom line being health.
The issue really is to step back,
and I think probably the premise of this meeting is how
well are we doing with respect to these kinds of things,
are these things really meeting our expectations.
And in terms of quality and safety, despite efforts, we are
now ten years past the legendary very important study
the Institute of Medicine had on the quality chasm.
This really remains in doubt. One of the things that struck
me very recently was an article in The New England
Journal of Medicine which focused on ten hospitals
in North Carolina -- I don't know whether you have
read that article, but I really suggest that you take a look at
it because I've cited it here - in which they selected ten
hospitals that had, had really committed to the IHI's quality
improvement safety initiative. And then they went back
and did a very, very detailed medical record assessment
looking at trigger events and a follow-up and it was
a world class design and so forth.
And found that despite all of that commitment -- and I
mention North Carolina because we have a very active AHEC
program, very much committed to quality working with these
hospitals -- there was really no significant change in the
quality and safety being provided for these hospitals.
To me, this is a very striking kind of thing.
Now one can always point to all sorts of good things that
happened out there, but I think the bottom line is we need to
go much further with respect to dealing with this
kind of thing. Secondly, there's a whole issue of cost.
The DRGs, you know, guidelines and other kinds of activities
are focusing on cost yet you know, it's out of control.
There is no question about it, in terms of the highest per
capita cost consumption. I think Steve is going to talk
a little bit more about that. And then finally the bottom
line is in terms of health and despite all the claims that
we heard during healthcare reform that this is the best
system in the world and so forth, when you look at
any of the acceptable indicators on a worldwide basis,
folks - as you well know, it's a little bit embarrassing of how
our country ranks to other competitive peer countries
with respect to life expectancy.
And evidence suggests that it is getting worse,
not better. Well, I think that at this point in time,
and perhaps an underlying premise of our effort here over
the next two days is, I think maybe we've run
out of miracles. And as we see in this little cartoon,
I think we need to be a little bit more explicit about the
next step. And as Winston Churchill so nicely captured
it, and I think this demonstrates all of our
approach on interventions, you can always count on
Americans to do the right thing after they have tried
everything else. Well, I think we've just about tried
everything else to really deal with quality, cost and
improvement in health and perhaps it's time to think a
little bit about how we are defining the problem.
I think this little cartoon really makes this point.
This is a tricky runway. It is fifty feet long and five
thousand feet wide. Well, maybe if we approach it
from a slightly different perspective, we might be a
little bit more productive with respect to that.
I think within that spirit, I think the opportunities are
really in the intersection and I personally have been very
impressed with Don Berwick's paper, which appeared in
Health Affairs several years ago where he's talking about
the triple aim -- that the U.S. will not achieve high
value health care unless improvement initiatives,
that is to say interventions, pursue a broader system
of linked goals; the triple aim - looking at improving
individual experience in care, improving the health of the
population and reducing the cost.
Now the reason I mentioned this is that he's no longer just the
head of the IHI, and probably one of the most charismatic,
persuasive people, he is also, at the present time,
the head of the CMS. And so I think, and perhaps the
alignment of the moon and the stars and so forth,
we might be able to move systematically in this
direction. The triple aim, however, to achieve what he is
proposing really requires a little bit of rethinking of how
we are doing things. And my little cartoon - obviously,
I like cartoons - that says first of all,
forget everything you learned in obedience school.
The point being is we need to be rethinking some of these
problems and how we are, in fact, going to address them.
And rethinking requires us, I think,
to do three things which is sort of an underlying dynamic
in the next two days. Number one, we need to think about
the health care as an interactive complex
non-recursive process. I think Jane Zapka has a very
nice paper in which she talks about this continuum of
care - early diagnosis to survivability at the end and
showing all the steps along the way and how at risk
we are of missing these steps and having
a continuous kind of flow as the patient flows through this.
Secondly, which is the major title that we are talking about
here, is the fact that interventions really need to be
involved at multiple levels - the federal,
the state, local, provider, family, individuals and
so forth. And I have one more minute to go.
And the last issue is in terms of intervention with respect to
the translational process. This translational thing I think
I mentioned because it's important, because it's
an integral part of the NCI. Ernie Hawk is sitting
here and I think Ernie chaired the TRWG
which talks about the fact that this needs to process in a very
systematic sort of way. That we need to translate research,
both scientific and many of the interventions we're talking
about in terms of programs arising from laboratory and
clinical population studies into clinical applications to
improve cancer care and reduce morbidity,
mortality and incidence. I am going to have to skip
this because I have got a little note from my colleague
Steve that we are running out of time.
The other thing, I think from my perspective what I see us
doing here over the next two days in this interactive mode
that Steve was talking about is first of all,
we need to determine what we know about multilevel
interventions to arrive at some consensus.
Is there a core here that we can build on?
Secondly, what we think we know about interventions so
that we can develop some workable hypotheses.
And finally what we need to know in terms of identifying
cross-cutting issues, setting an agenda for future
research activity. The organizers of this have nicely
organized, presented this in terms of three segments.
The conceptualization, in which we'll be talking about this
morning, issues of level, issues of continuum.
Secondly, the challenges and opportunities where we are
talking about the issues of synergy and timing and
methodological design, and then finally application,
future directions, giving some illustrations of multilevel
interventions currently in operation.
This is not going to be easy.
I think Machiavelli in his classic The Prince --
"There is nothing more difficult to take in hand,
more perilous to conduct or more uncertain in its success
than to take the lead in the introduction of a new order of
things because the innovator has for enemies all those who
have done very well under the old conditions and lukewarm
defenders for those who may do well under the new."
I think this is something that is a real challenge for us as
we approach this. The challenges we face I think are
going to be very, very difficult in terms of conceptualization,
in terms of research design, in terms of what are the
appropriate levels that we need to be talking out,
the risk of politicalization of some of these things I think
have become very, very important.
Because as you move up to the higher,
more abstract levels, they become political.
We have seen this during the healthcare reform debate where
a very, very important intervention in terms of
dealing with end of life issues became "death panels" and had
significant impacts in terms of what happened in terms
of the legislation. And finally, the whole notion of who
are the relevant stakeholders and can we, in fact,
communicate to each other, not only the various academic
disciplines involved with this, but also communications between
the research community and the practice community?
And these people travel in different worlds and we haven't
had a lot of practice in making these kinds of links.
Which is my last cartoon, which talks about the communications
challenge if this is going to move forward.
And it says "you'll have to rephrase this in another way,
they have no word for fetch." Thank you very much.