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

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


>>>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.>>>[APPLAUSE]>>>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.>>>[APPLAUSE]

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