I 111th CONGRESS 1st Session H. R. 2948 IN THE HOUSE OF REPRESENTATIVES June 18, 2009 Mr. Levin (for himself, Mr. Higgins, Mr. Doggett, Ms. Hirono, Mr. Pomeroy, and Mr. Etheridge) introduced the following bill; which was referred to the Committee on Energy and Commerce A BILL To amend title IX of the Public Health Service Act to provide for the implementation of best practices in the delivery of health care in the United States, and for other purposes.

1.

Short title

This Act may be cited as the Healthcare Improvements for Generating High Performance (HIGH Performance) Act of 2009.

2.

Findings

The Congress finds the following: (1)The United States has some of the best doctors and hospitals in the world, but, as a whole, the system is not providing the quality of care it has the potential to deliver. (2)On average, patients receive recommended evidence-based therapies only 55 percent of the time. (3)In the United States, it takes an average of 17 years for an established clinical guideline to reach the bedside. (4)More people die from medical errors and hospital-acquired infections in a given year than from AIDS, motor vehicle wrecks, or breast cancer combined. Many of these errors and infections are preventable when best practices are utilized. (5)The United States ranks far behind other countries in many measures of health care quality. (6)The cause of poor quality is not a lack of individual commitment, but a lack of assistance for providers to implement best practices that are proven to work. (7)Experiences in Michigan illustrate the improvement that can be achieved when hospitals and physicians have the tools they need to implement best practices in health care. After Michigan instituted a program to help hospitals implement best practices to prevent hospital-acquired infections in the intensive care unit (ICU), infections went down by 66 percent in the first 3 months. After 18 months, Michigan’s ICUs cut infection rates so low that they outperformed 90 percent of ICUs nationwide. (8)In that time, it is estimated that Michigan hospitals saved $75,000,000 and over 1,500 lives. If these results in reducing infections alone were achieved nationwide, it is estimated that the United States could save $13,000,000,000 over 10 years. (9)There is an urgent need to accelerate the implementation of best practices in health care delivery to improve the quality and value of health care.

3.

Implementation of best practices to improve health care quality

Title IX of the Public Health Service Act (42 U.S.C. 299 et seq.) is amended by adding at the end the following: E

Implementation of Best Practices to Improve Health Care Quality

941.

Establishment of national priorities and goals

(a)

In general

The Secretary shall establish national priorities and goals for quality improvement in the delivery of health care services in the United States. In establishing these priorities and goals, the Secretary shall consult with a multistakeholder group convened for the purposes of reviewing available evidence and recommending national quality improvement targets. Such group shall include representatives of the various interests and organizations needed to enable change, including consumers, physicians, nurses, hospitals and other care delivery organizations, non-Federal purchasers of care, health care oversight or accrediting bodies, research organizations, and entities with successful experience in quality improvement and quality measurement. (b)

Areas for improvement

Priorities and goals may be established in at least the following areas recommended by the Institute of Medicine: safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity. (c)

Periodic updates of national priorities and goals

The Secretary shall update the national priorities and goals established under this section not less frequently than once every 3 years. (d)

Application of national priorities

The Secretary shall use the national priorities established and updated under this section to coordinate, accelerate, and provide for quality improvement activities and initiatives in the delivery of health care services in the United States, including through the work of the Center for Health Extension established under section 942. (e)

Assessment of progress toward national goals

The Secretary shall submit an annual report to the Congress and the public containing an assessment of progress toward the national quality improvement goals. (f)

Interagency coordination

The Secretary shall convene an interagency committee, which shall include representatives from the Agency for Healthcare Research and Quality, including the Center for Health Extension established under section 942, the National Institutes of Health, the Centers for Disease Control and Prevention, the Centers for Medicare and Medicaid Services, the Health Resources and Services Administration, the Indian Health Service, the Department of Defense, the Veterans Health Administration, and other agencies the Secretary deems appropriate, for the purpose of coordinating the quality improvement work of such agencies, including the application of the national priorities.

942.

Establishment of the center for health extension

(a)

Establishment

The Secretary shall establish within the Agency for Healthcare Quality and Research a Center for Health Extension (hereinafter referred to as the Center). (b)

Director

The Center shall be headed by a Director who shall oversee the operations of the Center and of the Regional Health Extension Centers established under section 944.

943.

Mission and functions of the center for health extension

(a)

Mission

The mission of the Center is to improve health care quality by assisting health care providers to implement and improve upon clinical, managerial, and health care delivery best practices, and to evaluate progress in improving patient outcomes. (b)

Functions

(1)

Identify and develop best practices

The Center shall identify and develop clinical, managerial, and health care delivery best practices for implementation in quality improvement activities. (2)

Assist with the implementation of best practices

The Center shall provide voluntary training and technical assistance to hospitals, other health care facilities, and clinician practices to assist with the implementation of best practices. (3)

Measure patient outcomes and satisfaction

The Center shall provide for the measurement of patient outcomes and satisfaction, before, during, and after implementation of quality improvement activities. (4)

Evaluate effectiveness of activities

The Center shall evaluate the effectiveness of quality improvement activities, and progress improving patient outcomes. (c)

Identification of best practices

(1)

In general

The Center shall provide for the identification of highly effective clinical, managerial, and health care delivery practices and innovations that result in excellent patient outcomes and satisfaction, and can be adapted for use by various health care providers. (2)

Sources of best practices

The Center may identify practices and innovations described in paragraph (1) from the following sources. (A)

Providers and other health care entities

The Center may identify practices and innovations employed by hospitals, health care facilities, clinician practices, community cooperatives, and other health care entities. (B)

Empirical studies

The Center may identify practices and innovations from a review of relevant empirical studies. (C)

Public and private entities

The Center may identify practices and innovations developed by public and private entities in the United States and abroad. (D)

Other sources

The Center may identify practices and innovations from other sources as the Secretary deems appropriate. (d)

Development of best practices

(1)

In general

The Center shall provide for the development of highly effective clinical, managerial, and health care delivery practices, taking into account the requirements described in paragraph (2). (2)

Requirements

Practices developed under paragraph (1) shall— (A)be supported by empirical evidence showing that they have a high likelihood of improving patient outcomes and satisfaction; (B)be specified with sufficient detail of the individual processes, steps, training, skills, and knowledge required for implementation and incorporation into workflow of health care practitioners in a variety of settings; (C)be designed to be readily adapted by health care practitioners; (D)where applicable, be designed to be consistent with standards adopted by the Secretary (under section 3004 of the Public Health Service Act) for health information technology used in the collection and reporting of quality information, including for purposes of the demonstration of meaningful use of certified Electronic Medical Record technology by physicians and hospitals under the Medicare program (under sections 1842(o)(2) and 1886(n)(3), respectively, of the Social Security Act (42 U.S.C. 1395w–4(o)(2), 1395ww(n)(3))); and (E)where applicable, assist health care practitioners in working with other health care practitioners across the continuum of care and in engaging patients and their families in improving the care and patient outcomes. (3)

Collaboration with health care providers and other entities

The Center may collaborate with health care providers and other entities to foster the development of highly effective practices and innovations to improve health care quality. (4)

Attention to health care delivery design

The Center shall specifically provide for the development of best practices for health care delivery design as described in section 943(g). (5)

Ongoing review and improvement

The Center shall provide for regular review, updating, and improvement of practices developed under this subsection. (e)

Training and education for health care providers

(1)

In general

Acting through the Regional Health Care Extension Centers established in section 944 (hereinafter referred to as Extension Centers), the Center shall provide for voluntary training activities for hospitals, other facilities, and clinician practices to assist with the implementation of best practices and innovations identified under subsection (c) or developed under subsection (d) that— (A)further the priorities established under section 941, once such priorities have been established; (B)have the greatest impact on patient outcomes and satisfaction; and (C)are determined to be readily employable in health care settings. (2)

Technical assistance

The Center shall work through the Extension Centers to carry out the following functions: (A)

Establishment of participation

The Extension Centers shall seek the voluntary participation of hospitals, health facilities, and clinician practices in a region to enter into arrangements to receive assistance in implementing highly effective practices identified under subsection (c) or developed under subsection (d). Hospitals, health facilities, and clinician practices entering into such arrangements are hereinafter referred to in this subsection as collaborating providers. (B)

Establishment of collaborative team

The Extension Centers may require collaborating providers to designate a group of members from among the professional and administrative staff who are responsible for the implementation of the quality improvement activity or initiative. (C)

Assessment of existing practices

The Extension Centers shall conduct an assessment of the existing practices as compared to the identified highly effective practice at each hospital, facility, or practice that participates in an arrangement under this subsection. (D)

Development of implementation plan

Each collaborating provider shall work with the Extension Center to develop an implementation plan for the incorporation of the highly effective practice into the care of the provider. (E)

Training for collaborating providers

Staff of the Extension Center shall work with the collaborating providers to execute the implementation plan. Such staff shall provide instruction and training through electronic media, in-person training sessions, and data analysis to collaborating providers. Such staff shall work with the collaborating providers to carry out this paragraph. (F)

Measurement of progress

Pursuant to a data protection agreement entered into between the Extension Center and the collaborating provider, the Extension Center shall collect data to measure best practice implementation and patient outcomes before, during, and after implementation of quality improvement activities using, to the extent practicable, data already reported for other purposes by collaborating providers. Where applicable, the Extension Center shall also collect data to measure the culture of safety. (G)

Timely feedback to collaborating providers

The Extension Center shall provide to each collaborating provider— (i)analysis conducted by the Extension Center on the collaborating provider’s progress implementing the highly effective practice and improving patient outcomes, and, where applicable, improving the culture of safety. (ii)information on the collaborating provider’s performance as compared to other like entities participating in similar quality improvement activities, and as available, as compared to other like entities nationally. (H)

Culture change

The Extension Center may incorporate into instruction and training for collaborating providers activities to improve the culture of safety and foster an ethic of continual improvement among collaborating providers. (I)

Meetings

The Extension Center shall provide for meetings of panels of collaborating providers working with Extension Centers on similar quality improvement activities for the purpose of reciprocal learning and information exchange. (J)

Coordination with other quality improvement entities

If an Extension Center is not the organization holding a contract under section 1153 of the Social Security Act or a health information technology regional extension center under section 3012(c) of the Public Health Service Act, the Extension Center shall cooperate with and avoid duplicating the activities of these entities. (K)

Other duties

Such other duties as the Center may specify. (3)

Initial quality improvement activities

The Center shall immediately prioritize assistance for the implementation of best practices that have been shown to be effective with respect to improvement in the following areas: (A)

HAI

Health care-associated infections, including reducing catheter-associated urinary tract infection, ventilator-associated pneumonia, and central line-associated bloodstream infections. (B)

Surgery

Hospital and outpatient perioperative care, including reducing surgical-site infections and surgical errors such as wrong-site surgery and retained foreign bodies. (C)

ER

Hospital emergency rooms, including the development of comprehensive unit-based safety programs, handovers of care when transferring patients from the emergency room to other hospital departments or sites for treatment, early identification and treatment for sepsis, and use of principles of efficiency of design and delivery to improve patient flow. (D)

Obstetrics

Obstetrical and neonatal care, including the appropriate use of cesarean sections, and the implementation of best practices for labor and delivery care. (E)

Care transitions

Transitions of patients between settings, including reduction of unnecessary hospital readmissions and increased coordination between teams of unaffiliated providers. (f)

Assessment of effectiveness of quality improvement activities

(1)

Impact statements

Each Extension Center shall make available to the public and the Center impact statements with respect to its activities to assist health care providers to implement best practices. Such impact statements shall contain de-identified information on progress implementing highly effective practices, the impact of the Extension Center’s activities on patient outcomes and satisfaction, including lives saved, and cost savings attributable to the activities of the Extension Center, and shall include such additional information as the Center may specify. (2)

Aggregate impact statement

The Center shall aggregate the progress reports of the Extension Centers into a national impact statement. The national impact statement shall contain information on the aggregate progress implementing highly effective practices, the aggregate impact of the Extension Centers’ activities on patient outcomes and satisfaction, including lives saved, and aggregate cost savings attributable to the activities of the Extension Centers, including cost savings to Medicare and Medicaid, and shall include such additional information as the Center may specify. (3)

Evaluation of effectiveness

To the extent practicable, the Center shall evaluate the effect of implementing individual best practices on improving patient outcomes and satisfaction. (g)

Health care delivery design

(1)

In general

The Center shall conduct or fund activities to develop superior designs for the delivery of health services. This activity may utilize tools such as operations research, systems engineering, rapid design laboratories, cognitive and social psychology studies, materials sciences, and statistics. (2)

Examples of activities to be conducted

Health care delivery design activities conducted under this paragraph may examine methods to— (A)improve the arrangement of surgical suites to facilitate teamwork among physicians, nurses, and other members of the care team; (B)increase the likelihood that clinical guidelines are followed in care settings; (C)design medication systems to prevent medication errors; (D)improve rounding, handoff, and shift changes to improve coordination of patient care; (E)develop discharge practices that improve coordination and reduce confusion and duplicative care; (F)craft and implement effective patient education procedures; and (G)improve the design and protocols of emergency rooms to reduce unsafe conditions and ambulance diversions. (3)

Solicitation of input

The Center shall solicit input from health care providers on areas in which development of best practices in health care delivery are most needed to improve patient care and satisfaction. (4)

Requirements

The health care delivery design improvement activities conducted under this paragraph shall— (A)be based on identified need for improvement in a specific area of health care delivery; (B)aim to discover or develop designs that can be readily adopted by health care providers and facilities; (C)aim to improve patient outcomes and satisfaction; (D)where applicable, be designed to be consistent with standards adopted by the Director (under section 3004 of the Public Health Service Act) for health information technology used in the collection and reporting of quality information, including for purposes of the demonstration of meaningful use of certified Electronic Medical Record technology by physicians and hospitals under the Medicare program (under sections 1842(o)(2) and 1886(n)(3), respectively, of the Social Security Act (42 U.S.C. 1395w–4(o)(2), 1395ww(n)(3))); and (E)where applicable, assist health care practitioners in working with other health care practitioners across the continuum of care and in engaging patients and their families in improving the care and patient outcomes. (h)

Research and related activities

The Center shall conduct or fund research and other knowledge generation activities on the factors that facilitate behavior change for the sustainable integration of highly effective and innovative practices into medical practice and on the factors that foster an environment of continual improvement. (i)

Public dissemination of information

The Center shall provide for the public dissemination of objective information with respect to activities and research conducted under this Act. Such information shall be made available through multiple media and appropriate formats to reflect the varying needs of consumers and diverse levels of health literacy. (j)

Reports

(1)

Annual reports

Not later than April 1 of each year, beginning in 2011, the Director of the Center shall submit a report to the Secretary on the activities of the Center and the Extension Centers during the preceding year. (2)

Content

Each report submitted under paragraph (1) shall include information on— (A)the number of arrangements established by Extension Centers with collaborating providers; (B)the progress made accelerating the implementation of best practices by the collaborating providers during the year involved and for such other years as the Director determines to be appropriate; (C)the level of implementation of best practices at collaborating providers as compared to other providers; (D)the impact of the work of each Extension Center on patient outcomes and patient safety, including lives saved, and cost savings attributable to the activity or initiatives of the Extension Center; (E)the aggregate national impact of the work of the Center and Extension Centers on patient outcomes and patient safety, including lives saved, and cost savings attributable to the activity or initiatives of the Extension Centers and the Center, including cost savings to Medicare and Medicaid; (F)progress made toward the national goals for health care quality improvement, as established under secton 941; (G)evaluations of the impact of implementing individual best practices on patient outcomes and satisfaction, to the extent such analysis is practicable; (H)research and other related activities conducted or funded by the Center during the year involved and the results of those efforts in improving patient safety and the quality of care in the delivery of health care services or in the science of improvement; and (I)such other matters as the Center, or the Secretary, determines to be appropriate. (3)

Public availability

The Secretary shall transmit each report under this subsection to Congress and shall make each such report available to the public.

944.

Regional health extension centers

(a)

Establishment of regional health extension centers

The Center shall establish, either directly or through contracts with qualified entities (as defined in subsection (b)), Regional Health Extension Centers (referred to in this Act as Extension Centers) to carry out the functions described in section 943(e) within such States or regions as the Center determines to be appropriate: (b)

Definition

In this section, the term qualified entity means an entity that meets all of the following requirements: (1)

Demonstrated experience

The entity has experience— (A)in carrying out the type of functions described in section 942(e); (B)in operating programs on a statewide, regionwide, or nationwide basis to improve patient safety and the quality of health care delivered in health care settings; and (C)in working with a variety of institutional health care providers, physicians and other health care practitioners. (2)

Nonprofit organization

The entity is a nonprofit entity organized for charitable purposes under section 501(c) of the Internal Revenue Code of 1986. (3)

Governance

The entity is governed by a board that includes representatives of multiple health care and nonhealth care stakeholders (including consumers), such that representatives of no single stakeholder group constitute a majority. (4)

Entities with other existing contracts

The performance of services under this act shall be deemed not to create a conflict of interest under other existing Federal contracts for quality improvement, health information technology technical assistance, or data aggregation. (5)

Audits

The Extension Centers shall be subject to periodic audit.

945.

Funding

For the purpose of carrying out this part, there is authorized to be appropriated $200,000,000 for each of the fiscal years 2010 through 2014.

.