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Planning and accountability at AHCPR: applying the quality message at home.

The end of the 1980s witnessed the establishment of a new federal initiative, the Agency for Health Care Policy and Research (AHCPR). Now, ten years later, the end of the 1990s is witness to a still young Agency that has learned from its first decade and is planning its second. When AHCPR was established, most policymakers were concerned about health care costs. Some were focusing on the increasing number of Americans without health insurance, and a few understood the importance of research on the recently discovered geographic variations in utilization of medical services. Even fewer - but notably those who sponsored the birth of AHCPR - were focusing on the need for better information about the outcomes and effectiveness of medical care.

Today, the problems of cost, access, variations, and effectiveness are still with us. The attention of America's health care experts and the American public is now shared by concerns about the risk to the quality of care and the outcomes of care that Americans receive. The need for good information to support decision makers has never been greater, and meeting this need is the goal of the Agency's recently released strategic plan. Publication of the plan in HSR is an important step in furthering our goal of communicating Agency priorities to the research community and in fostering dialogue and input from researchers into our initiatives.

A CUSTOMER-DRIVEN AGENDA

Understanding the need for information on the part of policymakers and others is not new to health services researchers. However, we believe that the emphasis is far greater today than it has been in the past. At the same time, the nature of the end user has changed as new organizational entities in health care create additional opportunities for the application of research findings. AHCPR has recognized that early and frequent input from users can inform the questions that are being asked and thus shape the conduct of the research. Early user input may also be critical to the eventual translation of this research into improved health care.

Therefore, AHCPR's strategic plan clearly spells out whom we see to be the users of research that is supported or conducted by AHCPR. The plan is also being distributed to a broad range of health care organizations and individuals to assure the broadest possible input into our agenda. Finally, a Request for Ideas (RFI) was published in the Federal Register and the NIH guide earlier this year to solicit comments.

A key discussion that occurred within the Agency as the plan was formulated was the role of researchers. Researchers interact with the Agency in a number of important ways. First and foremost, researchers generate the knowledge that enables the Agency to achieve its goals. As such, researchers are partners, or co-producers, of the Agency's work. Researchers also receive services and goods from the Agency. Understanding how to better meet researchers' needs from grant review, grant management, or information dissemination is a priority for the Agency. Finally, researchers are key advisers to the Agency, assisting in shaping the agenda, informing programs and priorities, and keeping us abreast of the cutting-edge opportunities in this dynamic field.

ACCOUNTABILITY: FOR WHAT AND TO WHOM?

There continues to be a spirited debate in this country about the extent to which the research enterprise can and should be held accountable. Beginning in spring 2000, every federal agency will be reporting to Congress on its accomplishments under the Government Performance and Results Act (GPRA). This Act requires the establishment of process, output, and outcome measures that are directly linked to programmatic activities. Fortunately, we were able to develop our strategic plan and GPRA response simultaneously, aligning our commitments under GPRA to the Agency's strategic plan. In drafting this response and our strategic plan, the Agency struggled to find the right balance between accountability for achieving our stated mission while recognizing that a research agency will not alone improve health care. This tension is reflected in the careful wording chosen for each goal statement in the plan. However, we believe that the Agency has a clear responsibility that goes beyond knowledge creation. We cannot emphasize enough that it is not enough to publish. Having an article accepted by a prestigious journal like Health Services Research is just a step along the path to research improvement of health through improved health care. We all have a responsibility to see that research is translated into practice and into policy.

LINKING PLANS AT EVERY LEVEL

The Agency's strategic plan is explicitly linked to other levels in the organization. AHCPR's goals directly support those of the Department of Health and Human Services. Within the Agency, each organizational unit has created individual Office or Center strategic plans that articulate the role that unit plays in achieving the Agency's mission. These plans contain the unit-specific mission and goals as well as annual milestones to be achieved. These annual targets serve as the framework for each employee's annual performance plans within that unit. This nesting of plans promotes each individual's ability to see how her or his job and accomplishments further the respective unit's goals and the Agency's mission. The next step for the Agency is to actually use the strategic plan and its linked Office and Center plans, to help us achieve the promise of health services research for American health care.

In many ways the process that led to the development of the Agency's strategic plan mirrors the changes that health care itself is experiencing. These include a focus on customer and stakeholder responsiveness, a demand for results and accountability, and the need to engage employees at every level in the change process. The publication of this plan is a major milestone for the Agency, but it is only a first step. The challenge is to deliver on the vision it articulates.

The Agency for Health Care Policy and Research Strategic Plan, December 15, 1998

I. AHCPR VISION

The vision of the Agency for Health Care Policy and Research is to foster health care research that helps the American health care system provide access to high-quality, cost-effective services; to be accountable and responsive to consumers and purchasers; and to improve health status and quality of life. This vision incorporates several key concepts. First, it is future-oriented, proposing a concept for what American health care should entail. Second, it is focused squarely on the health care system, which includes patients, providers, plans, purchasers and policymakers, since the majority of the work of the Agency is centered on personal health services. Third, it asserts that the improved knowledge that is provided by health care research about the outcomes and quality of care can enhance the effectiveness of decisions about health care. Fourth, it links the improvement in health care through this evidence-based strategy with its ultimate purpose, that is, improvements of health status and individuals' quality of life.

Wide variations in practice patterns and outcomes continue, and a gap persists between what we know and the care that we deliver. It is clear today that the Agency now has knowledge of what can be improved and can commit to a significant investment in promoting the adoption and use of research findings. This commitment also focuses on being able to demonstrate that the potential benefits demonstrated by the research are actually achieved in daily practice. This must be done while continuing to support new research on priority health issues and the development of new tools, so that in the future this knowledge and the new tools can be translated and implemented to produce improved health care.

II. AHCPR MISSION

The mission of the Agency for Health Care Policy and Research is to support, conduct, and disseminate research that improves access to care and the outcomes, quality, cost, and utilization of health care services. The research sponsored and conducted by the Agency provides better information that enables better decisions about health care.

AHCPR was created specifically to respond to the Nation's need for knowledge about the health care system. The legislation that established the Agency in 1989 states:

The purpose of the Agency is to enhance the quality, appropriateness, and effectiveness of health care services, and access to such services, through the establishment of a broad base of scientific research and through the promotion of improvements in clinical practice and in the organization, financing, and delivery of health care services.(1)

AHCPR accomplishes its mission through three strategic goals, which are described in greater detail beginning on page six of this plan [page 469]:

* Support Improvements in Health Outcomes

* Strengthen Quality Measurement and Improvement

* Identify Strategies to Improve Access, Foster Appropriate Use, and Reduce Unnecessary Expenditures

III. ENVIRONMENTAL CONTEXT

The health environment continues to change rapidly. It is characterized by further consolidation of health plans and movement of patients and providers into managed care settings, efforts to contain rising health care costs coupled with fears that cost-containment measures will lower the quality of care, and persistent problems in access to health care and health insurance coverage for substantial numbers of Americans. Public and private purchasers are experimenting with new, untested financing strategies, organizational arrangements, and delivery approaches. Health plans and providers are seeking to measure and improve the effectiveness and cost-effectiveness of the care they purchase or provide.

This market-driven health care system cannot function efficiently without better information for all decision makers in the health care system. For example:

* Purchasers are looking for value - high quality of care at a reasonable cost;

* Patients and caregivers want to make informed decisions about preventive and other primary care services, treatments, providers, and health care plans;

* Clinicians need information to make the best possible decisions for and with their patients;

* Health plans must assess available information to determine which services to cover;

* Institutional providers (e.g., hospitals, groups, and systems of care) need information to make organizational and management decisions; and

* Policymakers need to understand the ramifications of available policy options.

Health services research addresses the information needs of all of these groups at the clinical, system, and policy decision levels. They represent the core of the Agency's customers and stakeholders. While market-based approaches dominate the delivery of personal health services, public health agencies at the Federal and State levels are adapting their approaches to assure population health. As organized delivery systems take on responsibility for defined populations of "covered lives," the boundaries between clinical service delivery and population-based approaches become less distinct. New opportunities thus exist to integrate these complementary approaches to improve health status.

1. Connection to DHHS Strategic Plan

AHCPR is guided by and supports the strategic plan goals of the Department of Health and Human Services (HHS).

The Agency's activities contribute to five of the six HHS goals.

HHS Goal 2. Improve the Economic and Social Well-Being of Individuals, Families, and Communities in the United States - For example, through the Agency's research on children's health

HHS Goal 3. Improve Access to Health Services and Assure the Integrity of the Nation's Health Entitlement and Safety Net Programs - For example, through the activities of the Agency's Center for Primary Care Research

HHS Goal 4. Improve the Quality of Health Care and Human Services - For example, through numerous Agency activities including quality measurement research and data development

HHS Goal 5. Improve the Public Health System - For example, through the Agency's data development and monitoring activities and investments

HHS Goal 6. Strengthen the Nation's Health Sciences Research Enterprise and Enhance Its Productivity - For example, through the Agency's research, data development, translation, and dissemination activities

A detailed summary of AHCPR's contributions to the HHS strategic plan are summarized in appendix A. However, the Agency's contributions to Goals 4 and 6 are of particular note.

AHCPR is the Department's lead Agency for health care quality activities and is a major contributor to Goal 4. Research on the determinants of health care quality, effective and cost-effective ways to improve health care quality, and how to measure health care quality will be instrumental in achieving success in the goal's objectives. Additionally, the new information developed, and then implemented in the health care system, from research on outcomes and effectiveness of care, as well as access to, cost, and use of health care, will help close the gaps between what we know and what we need to know, on the one hand, and what we know and what we do in health care, on the other hand. AHCPR also supports HHS Goal 4 through leadership of the Secretary's quality initiative, support of the Quality Interagency Task Force, contributions to the HHS Race and Health Disparities Initiative, and close working relationships with other HHS Agencies and the Office of the Secretary.

Within Goal 6, AHCPR's expanding portfolio in outcomes and effectiveness, quality, primary care, and other practice-based research, as well as extramural and intramural studies of issues pertaining to access, cost, organization, and delivery of health care, will contribute to achieving Objective 6.4 [see appendix A for Objectives]. Additionally, AHCPR's substantial investment in the development of databases will enable others to perform research and analyses to answer questions critical to understanding the dynamics of the health care system.

AHCPR maintains its commitment to building the infrastructure needed to continue to conduct high-quality, cutting-edge health care research for the next century through national training programs (the National Research Service Awards program), service fellows and summer intern programs, mentoring programs, and the provision of technical assistance to a variety of its audiences. AHCPR will continue to support efforts to attract trainees from racial and ethnic minorities into the field of health services research. These activities are aligned with Objective 6.6.

For the nation's investment in research to reach its full potential, the results must be widely disseminated (Objective 6.7) and implemented. The AHCPR Cycle of Research presented in section E.2 of this plan illustrates the important role that dissemination will play in all areas of activity within the Agency. This focus aligns with Objective 6.7.

2. Healthy People 2000 and 2010

Finally, the Department of Health and Human Services has a unique responsibility to improve the health of the Nation, which is articulated through the goals of Healthy People 2000: (1) increase the span of healthy life for Americans, (2) reduce health disparities among Americans, and (3) achieve access to preventive services for all Americans. AHCPR will continue to apply these goals to inform priorities of the Agency and to contribute directly to achieving them through its research portfolio and other activities. Additionally, AHCPR will participate fully in the development of the upcoming Healthy People 2010 goals and will contribute data to the monitoring of the goals from its nationally representative and more specialized databases.

IV. STRATEGIES TO OPERATIONALIZE THE VISION AND MISSION

The Agency uses a five-step planning framework to prioritize its activities and maximize the use of its resources:

A. Define the Agency's customers and their needs for evidence-based information;

B. Establish the Agency's goals;

C. Define the nature of the work of the Agency;

D. Identify issues that cut across all Agency goals and programs; and

E. Implement the plan.

Each of these steps is discussed in detail below.

A. DEFINE THE AGENCY'S CUSTOMERS/STAKEHOLDERS AND THEIR NEEDS FOR EVIDENCE-based INFORMATION

Agency activities begin and end with the end-users of Agency research. Through a continuing dialogue with representatives of the end-users, staff identify major issues and decisions for which information on quality, outcomes, cost, access, and use is needed. The research agenda is designed to be responsive to the needs of its customers/stakeholders and what they value in health care. These include consumers and patients; clinicians and other providers; institutions; plans; purchasers; and policymakers in all sectors (e.g., Federal, State, and local governments; voluntary associations; international organizations; and foundations). All of these customers require evidence-based information to inform health policy decisions. Health policy choices in this context represent three general levels of decision making:

1. Clinical Policy Decisions

Information is used every day by clinicians, consumers, patients, and health care institutions to make choices about what works, for whom, when, and at what cost.

2. Health Care System Policy Decisions

Health plan and system administrators and policymakers are confronted daily by choices on how to improve the health care system's ability to provide access to and deliver high-quality, high-value care.

3. Public Policy Decisions

Information is used by policymakers to expand their capability to monitor and evaluate the impact of system changes on outcomes, quality, access, cost, and use of health care and to devise policies designed to improve the performance of the system. These decisions include those made by Federal, State, and local policymakers and those that affect the entire population or certain segments of the public. Within DHHS, a number of agencies are AHCPR customers, including the Health Care Financing Administration.

The development of information and tools for these customers is dependent on a robust partnership between the Agency and the investigator community. Ongoing dialogue with researchers is essential to assuring that the highest-quality and most relevant research is sponsored.

B. ESTABLISH THE AGENCY'S GOALS

* Support Improvements in Health Outcomes

* Strengthen Quality Measurement and Improvement

* Identify Strategies to Improve Access, Foster Appropriate Use, and Reduce Unnecessary Expenditures

Research that promotes the improvement of health care quality will be the Agency's highest priority during the next few years. Accordingly, the Agency has identified three strategic goals, each of which will contribute to improving the quality of health care for all Americans.

1. Support Improvements in Health Outcomes

The field of health outcomes research studies the end results of the structure and processes of health care on the health and well-being of patients and populations.(2) A unique characteristic of this research is the incorporation of the consumer's or patient's perspective in the assessment of effectiveness. Policymakers in the public and private sectors are also concerned with the end results of their investments in health care, whether at the individual, community, or population level.

An important component of AHCPR research is conceptual and methodologic development of tools for measuring outcomes and methods to effectively convey information about outcomes to AHCPR customers.

A high priority for AHCPR's outcomes research will be conditions that are common, expensive, and/or for which significant variations in practice or opportunities for improvement have been demonstrated. Also of importance for research will be the type of delivery system or processes by which care is provided and their effects on outcomes. A focus on the outcomes of health care services reflects a convergence of multiple themes in health care delivery:

* The existence of variations in practice suggests sources of cost without benefit, reflecting differences in access to care, patient preferences, local health care capacity, and insufficient scientific knowledge to guide decision making.

* The prevalence and incidence of chronic diseases is increasing, due in part to the growing elderly population and the successes of preventive and acute care medicine. For individuals with one or more chronic conditions, the traditional measures of outcome are insufficient to measure quality and must be supplemented by reliable measures that incorporate individual and consumer and patient values and preferences.

* Interest in the impact of different approaches to the delivery and financing of health care outcomes is increasing, along with an awareness of organizational, information systems, and other strategies that can stimulate the translation of knowledge into practice in the current environment.

* Continued interest in the evaluation and appropriate use of medical technologies and clinical services (e.g., pharmaceuticals, clinical preventive services, primary care, and specialized services) through technology assessments and other tools requires rigorous and unbiased measurement of the "end results" of care in community settings (i.e., the effectiveness as well as the efficacy of care).

2. Strengthen Quality Measurement and Improvement

At its most basic level, high-quality health care is doing the right thing, at the right time, in the right way, for the right person. The challenge that clinicians and health system managers face every day is knowing what the right thing is, when the right time is, and what the right way is. Patients and their families are also confronted with making choices about treatments and care settings with little information on the relative quality, risks, and benefits of the options available to them. Policymakers, at all levels, also need quality information to support their deliberations.

AHCPR's second research goal will include developing and testing measures of quality, as well as studies of the best ways to collect, compare, and communicate these data. To facilitate the use of this information in the health care system, the Agency will also focus on research that determines the most effective ways to improve health care quality, including promoting the use of information on quality through a variety of strategies, such as information dissemination and assessing the impact on health care organization and financing. Themes evolving in health care quality reflect various foci:

* The development of value-based purchasing strategies within Federal and State (including HCFA) agencies provides the opportunity for AHCPR to provide its public sector customers with evidence-based tools to advance quality of care for public benefit.

* Increased demands for accountability have led to a dramatic shift in emphasis. This shift involves determining what quality is for different populations; what preventive interventions, conditions, treatments, and health care settings are appropriate; how the process and outcomes of care are to be measured; and in what areas improvements can be achieved. Until recently, assessments of structure, using measures such as hospital accreditation and the licensing and board certification of physicians, were assumed to be effective in predicting performance. The emphasis by both public and private sector organizations has changed to documenting actual clinician and organizational performance to assess the quality of care.

* Health care decision makers need to understand how diverse financial incentives, models of care, delivery arrangements, and major changes in market forces and public policy affect quality.

* Advances in information technology and their application to health care settings are enabling significant expansions in the scope and nature of data that can be used for quality measurement, monitoring, and improvement efforts.

* More knowledge is needed regarding the most effective ways to use information on the structure, process, and outcomes of care to improve health care quality results, and to disseminate this information in useful, understandable formats that enhance health care decision making at the clinical, system, and public policy levels.

3. Identify Strategies to Improve Access, Foster Appropriate Use, and Reduce Unnecessary Expenditures

Adequate access to health care services continues to be a challenge for many Americans. This is particularly so for the poor, the uninsured, members of minority groups, rural residents, and other vulnerable populations as defined by the Report of the President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry (Quality First, 1998). The Report recognizes vulnerable population groups as those "made vulnerable by their financial circumstances or place of residence; health, age, or functional or developmental status; or ability to communicate effectively; [and] personal characteristics, such as race, ethnicity, and sex."

In addition, the changing organization and financing of care has raised new questions about access to a range of health services, including emergency and specialty care. At the same time, examples of inappropriate use of care, including overutilization and misuse of services, continue to be documented.

The increasing portion of our Nation's resources devoted to health care expenditures remains a concern, with some indicators suggesting that the rate of increase may accelerate once again. The continued growth in public spending for Medicare and Medicaid, in particular, raises important questions about the care delivered to the elderly, poor, and people with disabilities. Together, these factors require concerted attention to the determinants of access, use, and expenditures as well as effective strategies to improve access, contain costs, and assure appropriate and timely use of effective services.

Through ongoing development of nationally representative and more specialized databases, the production of public use data products, and research and analyses conducted by AHCPR staff and outside researchers, the Agency will address critical policy issues pertaining to the access to, and cost and use of health care.

* It is essential to identify who has access to health care and what type of care it is; the type of health care services Americans use; how frequently they use the services; how much is paid for the services; and who pays what portions of those costs. It is important to collect and examine nationally representative data that provide these answers.

* The organization and delivery of primary care services are changing as capitation, carve-outs, disease management, and other strategies are being adopted with little or no evidence of their impact on quality, outcomes, access, cost, and use.

* Studies of access, health care utilization, and expenditures are needed to identify whether particular approaches to health care delivery and payment alter behaviors in ways that promote, or reduce, access and/or economize, or fail to do so, on health care resource use.

* Information on the access and cost impact of major changes in public policies and health care markets is needed to inform health policy.

C. THE RESEARCH PIPELINE

The Agency achieves its mission through health services research. Health services research addresses issues of "organization, delivery, financing, utilization, patient and provider behavior, quality, outcomes, effectiveness, and cost. It evaluates both clinical services and the system in which these services are provided. It provides information about the cost of care, as well as its effectiveness, outcomes, efficiency, and quality. It includes studies of the structure, process, and effects of health services for individuals and populations. It addresses both basic and applied research questions, including fundamental aspects of both individual and system behavior and the application of interventions in practice settings."(3)

The AHCPR portfolio reflects a "pipeline" of activities that together build the infrastructure, tools, and knowledge for improvements in the American health care system. Biomedical science establishes the foundation for determining which interventions can work under ideal circumstances. The Agency now knows that many additional steps are required to assure that what can work does work for all individuals. The necessary steps include scientific assessment of opportunities for improvement, development of tools to measure and analyze performance, and strategies for improving performance on a broad scale, in partnership with the key change agents in today's health care system: purchasers, health plans, and clinicians. These steps are contained in the Agency's concept of a pipeline [ILLUSTRATION FOR FIGURE 1 OMITTED].

This pipeline begins with the funding of new research that answers important questions about what works in American health care (New Research on Priority Health Issues). This is the essential knowledge base that investigators create that enables us to understand the determinants of the outcomes, quality, and costs of care as well as identify instances when care falls short of achieving its intended outcomes.

The second step in the pipeline is the creation of tools to apply the knowledge gained in the first investment (New Tools and Talent for a New Century). Here, the work of researchers is more applied and translates new knowledge into instruments for measurement, databases, informatics, and other applications that can be used to assess and improve care.

The final step of the pipeline is where these two investments come together with a focus on accelerating the pace of quality improvement through closing the gap between what we know and what we do. AHCPR funds research and demonstrations to translate the knowledge and tools into measurable improvements in the care Americans receive. The Agency also develops partnerships with public and private sector organizations to disseminate the knowledge and tools for use in the health care system.

The three segments of the pipeline represent a comprehensive approach that is successful in yielding important advances.

AHCPR also implements its research agenda by supporting some of the Nation's best health services researchers. A substantial portfolio of investigator-initiated research is particularly important.

AHCPR further promotes the field of health services research by providing an organizational structure and climate that encourages highly qualified and productive research, program, administrative, and support staff to sustain and sharpen their professional expertise. Additionally, the Agency fosters internal and external professional collaboration, and supports research training programs to help develop a diverse cadre of talented individuals in health services research.

D. IDENTIFY ISSUES THAT CUT ACROSS ALL AGENCY GOALS AND PROGRAMS

The Agency has identified two activity areas that require a synergistic strategy that integrates the work under each of the three goals of the Agency. The strong, cross-cutting role that each plays, albeit differently, in Agency programs makes them pertinent to studying issues related to outcomes and quality, as well as access, cost, and use. The first of these is addressing the needs of populations on which the Public Health Service and AHCPR have placed a priority emphasis. The second is assuring that a strong infrastructure for health services research is built through investments in training and the support of young investigators.

1. Priority Populations

Three population groups warrant a special focus from health services research: minorities, women, and children (including adolescents). These are all groups for whom public policy struggles to find effective solutions to improve health care. Health services research has consistently documented the persistent, and at times great, disparities in health status and access to appropriate health care services for certain groups, notably racial and ethnic minorities and low-income families and children. Gender-based differences in access, quality, and outcomes are also widespread; but whether these differences should be eliminated or are appropriate is not well understood. Despite the dramatic changes occurring in the organization and financing of children's health services, the knowledge base for guiding these changes or assessing their impact is less well developed than that for adults. Health care issues that exist for people with disabilities also require attention. Health services research should do a better job of bringing science-based information to bear on these disparities so that the health of minorities, women, and children is enhanced.

In addition, these population groups have been under-represented historically in clinical research studies. Since 1991, policies established throughout the Public Health Service require specific attention to the appropriate inclusion of women and minorities in research. A similar policy has been developed by NIH for the inclusion of children in research that is being adapted by AHCPR for its programs.

Therefore, the Agency recognizes the need for collaborative and integrative work across its Centers and Offices and views this as an opportunity to address issues of access to care, outcomes, quality, and the cost and use of services for each of these priority populations.

1. Health Services Research Infrastructure

For the Agency to succeed in meeting the three research goals discussed earlier, there must be a strong infrastructure for health services research and talented individuals who can contribute to the Agency's successful implementation of its mission. AHCPR will continue to support the personal and professional growth of its staff and the larger health services research community. These individuals include research (both intramural and extramural), program, administrative, and support staff within AHCPR, and both the users and the developers of health services research findings outside AHCPR.

In addition to nurturing the talent that is needed for health services research, AHCPR will foster the infrastructure of this field by sponsoring and facilitating the development of centers of excellence, which focus on high-priority areas in health care delivery. The Agency will also stimulate the development of new methods for health care research and products that facilitate the use of health services research in everyday practice.

E. IMPLEMENT THE PLAN

1. Planning and Evaluation

This strategic plan will serve as the road map for AHCPR activities for the next three-five years. In order to ensure that focus on the plan is maintained, the Agency will assess the progress made toward achieving each of the goals as part of the annual planning and budget development process. To do this, measurable Agency-level evaluation parameters will be developed and used to determine whether AHCPR has achieved its objectives in knowledge development, translation, dissemination, and evaluation. These parameters also will be an integral part of AHCPR's compliance with the Government Performance and Results Act of 1993 (GPRA) and will be detailed in the annual GPRA performance plans submitted with each annual budget request. The results of these efforts will provide the backdrop against which the next year's activities will be planned.

Further, this planning and evaluation process will be employed throughout the Agency at Office/Center and individual levels. All Offices and Centers will establish their own strategic and operating plans and annual measurable objectives that define their responsibilities in carrying out the Agency's strategic plan. Each staff member will have an annual performance plan stemming from the Agency and Office/Center plans that details his or her individual role in implementing the plan and that facilitates personal and professional growth. The evaluation of each component and each individual's performance, based on contributions toward achieving the Agency's strategic plan goals, will place AHCPR at the forefront of government agencies in both accountability and performance management.

2. AHCPR Cycle of Research

Producing meaningful contributions to the Nation and to research on health care requires continuous activity focused on iterative improvement in priority setting, on developing research initiatives, and on research products and processes. The following research cycle describes the processes AHCPR uses to conduct its ongoing activities in order to make the most productive use of its resources.

A. Needs Assessment. AHCPR will conduct needs assessments through a variety of mechanisms including expert meetings, conferences, and consultations with stakeholders and customers of its research, as well as regular meetings with its National Advisory Council and government leaders. The results of these assessments will be used to determine and prioritize information needs.

B. Knowledge Creation. AHCPR will support and conduct research to produce the next generation of knowledge needed to improve the health care system. Building on the last ten years of investment in outcomes and health care research, AHCPR will focus on national priority areas for which much remains unknown.

C. Translation and Dissemination. Simply producing knowledge is not sufficient; findings must be useful and made widely available to practitioners, patients, and other decision makers. The Agency will systematically identify priority areas for improving care through integrating findings into practice and will determine the most effective ways of doing this. Additionally, AHCPR will continue to synthesize and translate knowledge into products and tools that support its customers in problem solving and decision making. It will then actively disseminate the knowledge, products, and tools to appropriate audiences. Effective dissemination involves forming partnerships with other organizations and leveraging resources.

D. Evaluation. Knowledge development is a continuous process. It includes a feedback loop that depends on evaluation of the research's utility to the end-user and impact on health care. In order to assess the ultimate outcomes of AHCPR research, the Agency will place increased emphasis on evaluation of the impact and usefulness of Agency-supported work in health care settings and policymaking. The evaluation activities will include a variety of projects, from smaller, short-term projects that assess process, outputs, and interim outcomes to larger, retrospective projects that assess the ultimate outcomes/impact of AHCPR activities on the health care system.

3. Partnerships

AHCPR is not able to accomplish its mission alone. Partnerships formed with the agencies within Department of Health and Human Services, with other components of the Federal government, and with private sector organizations will continue to play a critical role in the Agency achieving its goals. Partnerships take many forms and contribute to the Agency achieving its goals at all points of the cycle of research.

* Needs Assessment. AHCPR works cooperatively with many public and private organizations to identify their needs for health services research so that Agency initiatives "begin and end with the user."

* Knowledge Development. AHCPR works in partnership with the National Institutes of Health, the Centers for Disease Control and Prevention, and other research organizations to undertake projects of mutual benefit to each and to ensure a balanced investment in the full continuum of health research. Additionally, private sector organizations may also become partners.

* Translation and Dissemination. This is where partnerships are especially critical to the Agency to assure that the knowledge gained through research is used to improve care in America. This strategy has been very effective in bringing AHCPR research into practice in Health Care Financing Administration programs. Private partnerships have also resulted in far wider dissemination and acceptance of the knowledge and tools developed through AHCPR support. AHCPR works with Federal agencies and private sector organizations to adapt research findings for application in practice and other health care settings. Other organizations will also help the Agency disseminate products of interest to their constituencies.

* Evaluation. Increasingly, AHCPR will partner with public and private sector organizations to conduct studies or projects to test implementation strategies; the applicability of research findings in different practice settings; and the quality, usefulness, and ease of use of Agency products.

APPENDIX A

EXAMPLES OF AHCPR'S CONTRIBUTIONS TO THE HHS STRATEGIC PLAN

Goal 2. Improve the Economic and Social Well-Being of Individuals, Families, and Communities in the United States

Objective 2.5: Increase Opportunities for Seniors to Have an Active and Healthy Aging Experience

Objective 2.6: Expand Access to Consumer-Directed, Home and Community-based Long-Term Care and Health Services

AHCPR will conduct research in areas relevant to improving the aging experience in such areas as (1) conditions of particular importance to the Medicaid population; and (2) quality measurement issues and tool development for institutional settings.

Goal 3. Improve Access to Health Services and Assure the Integrity of the Nation's Health Entitlement and Safety Net Programs

Objective 3.2: Increase the Availability of Primary Health Care Services

To test the effectiveness of health care improvement approaches, AHCPR will study such topics as (1) the implementation of evidence-based information in diverse health care settings to determine effective strategies for enhancing practitioner behavior change and improving patient behavior, knowledge, and satisfaction; and (2) the factors that determine the success of quality improvement strategies and to what extent these vary by the nature of the problem addressed and the target population.

Projects to evaluate the impact of managed care will constitute a systematic effort to determine the impact of managed care and other changes in the organization of care on health care quality; outcomes; and cost, use, and access.

Objective 3.3: Improve Access to and the Effectiveness of Health Care Services for Persons with Specific Needs

AHCPR will examine how various clinical and system characteristics affect health outcomes, quality, access, and satisfaction for the elderly and chronically ill.

Objective 3.4: Protect and Improve Beneficiary Health and Satisfaction with Medicare and Medicaid

AHCPR activities supporting Medicare and Medicaid beneficiaries will include (1) research on conditions that are common, costly, and for which there is substantial variation in practice - conditions that represent major Medicare or Medicaid expenditures; (2) providing objective, science-based, timely information to health care decision makers - patients and clinicians, health system leaders, and policymakers; (3) health care surveys, such as CAHPS and MEPS, that provide information supporting health plan choices and coverage decisions; and (4) studying the national impact of the Children's Health Insurance Program on access and cost of care for children.

Goal 4. Improve the Quality of Health Care and Human Services

Objective 4.1: Promote the Appropriate Use of Effective Health Services

AHCPR is implementing a growing portfolio of evaluations that will show over time the outcomes of the investments of Agency funds. The Agency will evaluate the use and usability of the Medical Expenditures Panel Survey (MEPS) databases for their intended purposes. Other evaluations will assess (1) evidence reports and technology assessments of evidence-based practice centers; and (2) products that advance methods to measure and improve healthcare quality, including clinical quality improvement software (CONQUWAR), the Consumer Assessment of Health Plans Survey, and the Expansion of Quality of Care Measures project (Q-SPAN).

Objective 4.2: Reduce Disparities in the Receipt of Quality Health Care Services

AHCPR will expand its commitment to conducting health services research that will help reduce disparities that exist for racial and ethnic minorities. The Agency will also focus on building infrastructure for relevant research by training minority and other investigators to address issues for minority populations.

Objective 4.3: Increase Consumers' Understanding of Their Health Care Options

The Consumer Assessment of Health Plans (CAHPS) is a tool for surveying members of health plans about their experience with and assessment of the quality of health care they receive, and for reporting the results to other consumers who are choosing a plan. AHCPR will continue its efforts to enhance CAHPS and evaluate its use.

Objective 4.5: Promote Research That Improves Quality and Develops Knowledge of Effective Human Services Practice

To test the effectiveness of health care improvement approaches, AHCPR will study such topics as (1) the implementation of evidence-based information in diverse health care settings and (2) identify the factors that determine the success of quality improvement strategies.

Through the Centers for Education and Research on Therapeutics (CERTS) program, AHCPR will fund state-of-the-art clinical and laboratory research that is responsive to the current needs of health plans, providers, and consumers. This research will emphasize the quality of prescribing practices, comparative studies of effectiveness and cost-effectiveness, and the reduction of adverse drug events.

Goal 5. Improve the Public Health System

Objective 5.1: Improve the Public Health System's Capacity to Monitor the Health Status and Identify Threats to the Health of the Nation's Population

AHCPR will begin to increase the capacity of the Medical Expenditure Panel Survey (MEPS) to enable the development of a national capacity to monitor the quality of care, particularly for populations of national interest, including the chronically ill, poor, racial/ethnic minorities, and children.

AHCPR will redesign and expand the Healthcare Cost and Utilization Project (HCUP) to provide state and community decision makers a powerful set of linked databases they can use to monitor the impact of major system changes on access, quality, outcomes, and cost in their states and communities, and to compare these against the progress of other states and communities.

AHCPR will build on past investments in tool development by focusing on expanding the toolbox. These tools will enable purchasers, policymakers, health plans, providers, and patients to improve care.

Goal 6. Strengthen the Nation's Health Sciences Research Enterprise and Enhance Its Productivity

Objective 6.2: Improve the Prevention, Diagnosis, and Treatment of Disease and Disability

To test the effectiveness of health care improvement approaches, AHCPR will (1) study the implementation of evidence-based information in diverse health care settings to determine effective strategies for enhancing practitioner behavior change and improving patient behavior, knowledge, and satisfaction; and (2) identify the factors that determine the success of quality improvement strategies and to what extent these vary by the nature of the problem addressed and the target population.

Objective 6.4: Increase the Understanding of and Response to the Major Issues Related to the Quality, Financing, Cost, and Cost-Effectiveness of Health Care Services

There are many gaps in knowledge in all areas of health care. New questions emerge as new technologies are developed, the population's demographics change, areas of inquiry previously underemphasized take on greater importance, and research previously undertaken identifies further areas that need attention. Therefore, AHCPR will continue to focus on creating new knowledge and assessing the findings that result from completed projects.

Objective 6.6: Improve the Quality of Medical and Health Science Research by Strengthening the Base of Highly Qualified Scientific Investigators

AHCPR will invest in a number of programs to further the training of health services researchers to address the research and analytic needs of the changing health care system. These priorities will build on prior efforts to make both curricula and practical research experiences more relevant to decision makers' concerns about the effectiveness of health care and issues of cost, quality, and access. Further, they will be designed to reflect and incorporate evolving innovations in data systems and research tools so that the researchers of the future not only identify and address significant research questions, but also employ cutting-edge methodological, analytic, and data handling techniques, including appropriate privacy and confidentiality safeguards.

Objective 6.7: Ensure That Research Results Are Effectively Communicated to the Public, Practitioners, and the Scientific Community

Building on the previous ten years of research findings, AHCPR will identify ongoing gaps between what we know now and what we do in health care and will begin to close those gaps through research and demonstrations that develop and test implementation strategies in different settings in the health care system. A major focus within this is identifying existing implementation strategies in use in health care settings and demonstrating their applicability to widespread dissemination in other areas of the system.

AHCPR places considerable focus on developing tools and products that facilitate the transfer of research findings into practice. The Agency has a well-developed dissemination system that includes publications development, the Publications Clearinghouse, and an award-winning Website. This emphasis is critical to the Agency's success. Ongoing plans include incorporating regular customer feedback into our operations to continue to improve our efforts.

NOTES

1. The Omnibus Budget Reconciliation Act of 1989 (Public Law 101-239) Part A, Section 901 (b).

2. Institute of Medicine, 1996.

3. John M. Eisenberg, "Health Services Research in a Market-Oriented Health Care System." Health Affairs 17, No. 1 (1998): 98-108.

Lisa Simpson, M.B., B.Ch., M.P.H., Jane Osborne, M.A.S., and John M. Eisenberg, M.D. are from the Agency for Health Care Policy and Research of the Department of Health and Human Services.
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Title Annotation:Agency for Health Care Policy and Research
Author:Simpson, Lisa; Osborne, Jane; Eisenberg, John M.
Publication:Health Services Research
Date:Jun 1, 1999
Words:7586
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