Meeting Minutes, July 26, 2013

Contents

Summary
Call to Order and Approval of April 12, 2013, Summary Report
Director's Update
Update from Subcommittee on Strategic Direction
Update on Centers for Education & Research on Therapeutics (CERTs)
Levers for Change: National Quality Strategy
Patient and Family Engagement
Public Comments
Chairman's Wrap-Up and NAC Input

Summary

NAC Members Present

Bruce Siegel, M.D., M.P.H., America's Essential Hospitals (NAC Chair)
Gregory Baker, R.Ph., Take Care Employer Solutions Group
Mitra Behroozi, J.D., 1199SEIU Benefit and Pension Funds
Francis J. Crosson, M.D., American Medical Association
Jane Durney Crowley, Catholic Health Partners
Andrea Gelzer, M.D., M.S., FACP, The AmeriHealth Mercy Family of Companies
Leon L. Haley, Jr., M.D., M.H.S.A., FACEP, Grady Health System
Michael P. Johnson, P.T., Ph.D., OCS, Bayada Home Health Care
Newell E. McElwee III, Pharm.D., M.S.P.H., Merck Global Medical Affairs (by phone)
Andrea H. McGuire, M.D., M.B.A., Meridian Health Plan
Victor M. Montori, M.D., M.Sc., Mayo Clinic
Henry H. Ng, M.D., M.P.H., FAAP, FACP, MetroHealth Medical Center
David F. Penson, M.D., M.P.H., Vanderbilt University
Christopher Queram, M.A., Wisconsin Collaborative for Healthcare Quality
Jean Rexford, Connecticut Center for Patient Safety
Alan R. Spitzer, M.D., MEDNAX Services/Pediatrix Medical Group/American Anesthesiology
Jeffery Thompson, M.D., M.P.H., Mercer
Janet S. Wyatt, Ph.D., R.N., FAANP, Institute of Pediatric Nursing

Alternates Present

David Atkins, M.D., M.P.H., Veterans Health Administration
Shari M. Ling, M.D., Centers for Medicare & Medicaid Services
Sandra L. Decker, Ph.D., Centers for Disease Control and Prevention

AHRQ Staff Members Present

Carolyn M. Clancy, M.D., Director
Jaime Zimmerman, M.P.H., Designated Management Official
Karen Brooks, CMP, NAC Coordinator

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Call to Order and Approval of April 12, 2013, Summary Report

Bruce Siegel, M.D., M.P.H., Chair of the National Advisory Council (NAC), Agency for Healthcare Research and Quality (AHRQ), called the group to order at 8:30 a.m. and welcomed the NAC members, invited speakers, visitors, and viewers of the Webcast. He noted that he recently became President and Chief Executive Officer of America's Essential Hospitals, based in Washington, D.C.

Dr. Siegel referred to the draft minutes of the previous NAC meeting (April 12, 2013) and asked for changes and approval. The NAC members approved the April 12, 2013, meeting minutes with no changes.

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Director's Update

Carolyn M. Clancy, M.D., AHRQ Director, welcomed the NAC members, speakers, and other attendees and viewers. She began her update on AHRQ activities by discussing the Federal funding picture.

The Big Picture

Dr. Clancy stated that the enacted FY 2013 AHRQ budget was $429.4 million (including $57.5 million from the Patient-Centered Outcomes Research Trust Fund [PCORTF]). The President's proposed AHRQ budget for FY 2014 is $433.7 million. That includes $100 million from the PCORTF. The proposed budget features $62.6 million for patient safety, with $34 million of that focused on healthcare-associated infections (HAIs). The allotment for the Medical Expenditure Panel Survey (MEPS) is $63.8 million, featuring an increase that will maintain the household sample size. The budget features $88.9 million for cross-cutting research, which includes $8.9 million for new investigator-initiated research grants. The area of prevention and care management receives $20.7 million, and the area of health information technology (IT) receives $25.6 million. The budget has $68.8 million for program support.

The Senate developed a FY 2014 budget proposal ($469.7 million) with higher amounts in some areas. In particular, the Senate budget features a greater amount for cross-cutting research ($111.1 million). The House has not yet created its new AHRQ budget proposal.

Recent Accomplishments

Dr. Clancy reviewed the following recent accomplishments:

• An AHRQ-funded study published in the New England Journal of Medicine found success in the use of a universal decolonization strategy in intensive care units to reduce the incidence of methicillin-resistant Staphylococcus aureus (MRSA). The study featured more than 74,000 patients.
• AHRQ produced a new resource guide to help hospitals engage patients and families in care. It features four evidence-based strategies, tools, and real-world examples. [See below.]
• The Maryland Department of Health and Mental Hygiene used Effective Health Care (EHC) Program materials in a Medicaid pharmacy program that established screening for the safe use of antipsychotics in children. As of March 2013, more than 1,000 prescriptions were screened.
• A national network of libraries of medicine in the States of Arkansas, Louisiana, Oklahoma, New Mexico, and Texas employed AHRQ's "Questions Are the Answer" educational materials to train librarians to teach older adults how to locate health information online.
• In the nation of Colombia, a hospital survey of patient safety culture found improvements over a 3-year period—especially improvements in the fostering of nonpunitive culture and levels of safety event and risk reporting.
• The U.S. Department of Veterans Affairs created a program of specialty care access networks for community outcomes, modeled on an AHRQ-funded project, Project Extension for Community Healthcare Outcomes (ECHO). The program offers distance learning for VA clinicians in rural areas and brings specialized care for chronic conditions to local VA offices.
• In Los Angeles, a coalition of agencies and social service providers used the AHRQ-funded Open-Source Electronic Medical Record System to track tuberculosis testing in the Skid Row population during 2009 and 2010.
• Students at the University of Wisconsin School of Pharmacy administered the AHRQ survey "Is Our Pharmacy Meeting Our Patient's Needs?" and used survey data to make presentations to pharmacists and technicians, focusing on the health literacy of patients. One result of this application was a reduction in the use of medical jargon during consultations.
• Virginia Health Information developed a consumer brochure, "C. difficile Prevention:  Dodging a One-Two Punch," based on a statistical brief of AHRQ's Healthcare Cost and Utilization Project (HCUP).  The brochure was distributed to 80 Virginia hospitals.
• Einstein Medical Center used AHRQ pharmacy health literacy resources in a program titled "Medication REACH," which resulted in a significant reduction in readmissions.
• The American Society of Health System Pharmacists created a mentoring program inspired by AHRQ-sponsored research on reducing medication errors in emergency departments.  Titled "Patient Care Impact Program," it stresses the involvement of pharmacists in emergency department use of medications.
• Staten Island University Hospital conducted, in 2011, a survey of safety culture following 2 years of employing the TeamSTEPPS program to improve communication and processes. The survey found improvements in teamwork across units and within units.

AHRQ Program Updates

Dr. Clancy provided the following program updates:

• The National Quality Strategy produced its 2013 annual progress report, citing effective performance measurement, including efforts to identify and adopt uniform measures for the Nation. It noted quality improvement in six priority areas and progress in strategic opportunities, such as development of organizational infrastructure at the community level.(www.ahrq.gov/workingforquality/nqs/nqs2013annlrpt.pdf [561 KB])
• The National Healthcare Quality Report and the National Healthcare Disparities Report were released in May 2013 (tenth anniversary of the reports). AHRQ plans to focus, in the 2013 reports, on patient-centered care, HIV data, people with disabilities, and other priority populations. A decade of reports has shown that data and measurement have increased and improved, quality has improved slowly, and disparities have changed only slightly.
• There are 78 Patient Safety Organizations (PSOs) in 29 States and the District of Columbia. AHRQ recently hosted the 5th Annual Meeting of Patient Safety Organizations and a software developers meeting. Topics included the evolution of a PSO in a large complex organization and using system safety engineering to impact reporting. 
• The TeamSTEPPS annual meeting was held June 12–13 in Dallas. Session topics included the role of TeamSTEPPS in crisis management, the reduction of medical liability, and improving obstetric outcomes. AHRQ, along with the U.S. Department of Defense, presented, to the HHS Secretary's Advisory Committee on Infant Mortality, on projects to reduce maternal and fetal morbidity. The presentation included a description of TeamSTEPPS efforts.
• AHRQ reported success, based on hospital reports, in the use of the Comprehensive Unit-Based Safety Program (CUSP) to reduce catheter-associated urinary tract infections.
• AHRQ is examining the capacity for the MEPS to inform provisions of the Affordable Care Act. MEPS data can help to examine safety trends, insurance coverage, and eligibility for subsidies. They can help to evaluate the health insurance status of young adults and health care use and costs for young adults. They can evaluate the impact of a planned excise tax on expensive employer health plans. The MEPS insurance component is used to determine the small-employer health insurance tax credit. The MEPS Household and Employer Survey may be enhanced to allow assessment of coverage expansion under the Affordable Care Act.
• HHS released data at the beginning of June revealing disparities in outpatient charges from hospital to hospital. HCUP and MEPS were two sources of the data. Also, MEPS data have revealed that annual increases in employer-sponsored health insurance premiums declined from 2000 to 2012. The MEPS program published a statistical brief on attitudes about health insurance and how they have persisted over time.
• The 2013 Subcommittee of the NAC (SNAC) is focusing on retirement of some measures from the core set of child health measures created in 2009. It will provide recommendations following a review process occurring between June and December 2013.
• AHRQ produced The Practice Facilitation Handbook for training health practice facilitators and their trainers.
• AHRQ's MONAHRQ software tool for presenting data on health care quality and utilization was instituted in two more States. The tool is being used in the curriculum at Eastern Virginia Medical School to study disease and care patterns in the community.
• Thirty-two States now offer access to a public report that uses the AHRQ quality indicators. It has been shown that public reporting leads to more rapid improvement in health care quality.
• A funding announcement to support research into disseminating patient-centered outcomes research that can help improve health care delivery was released. The total grant funding is $16 million, and four to eight awards will be made. Applicants must represent existing multi-stakeholder networks. Applications are due September 17.
• An AHRQ-supported study of avoidable hospitalizations for elderly long-stay nursing home residents, published in Medical Care, found that use of nursing home-sensitive conditions nearly doubles the number of hospitalizations characterized as avoidable. It also identifies a diverse set of risk factors.
• AHRQ developed a new infographic series based on the HCUP statistical briefs. The pieces  present data from the briefs using fresh visual styles.
• AHRQ-supported Evidence-Based Practice Centers published more than 25 systematic reviews and more than 25 methods guidance and reports since the last NAC meeting. They completed a set of reviews on adults and children exposed to trauma.
• AHRQ produced a decision aid for women with urinary incontinence. It describes benefits and harms for nonsurgical treatments, pelvic floor exercises, and bladder training. It features videos to help women with low health literacy and is meant to reduce stigma.
• AHRQ supported a supplement in the Journal of Clinical Epidemiology on research methods for comparative effectiveness and patient-centered outcomes research. It distinguished results from randomized clinical trials and observational studies, addressed implementation of patient-centered outcomes research, and much more.
• AHRQ supported a supplement in Medical Care on electronic data methods, including the topics of analytic methods, clinical informatics, governance, and learning health systems. Materials are available at www.edm-forum.org.
• AHRQ is supporting the largest civilian diabetes registry, SUPREME-DM. The registry has published standardized definitions for medication adherence and persistence. It has found that patients excluded from Medicare STAR quality measures for adherence suffer worse control of cardiovascular disease risk factors.
• The U.S. Preventive Services Task Force (USPSTF) posted five draft recommendations and four draft research plans for public comment. It published five final recommendations in the following topics:  screening for HIV, screening and behavioral counseling interventions in primary care to reduce alcohol misuse, primary care interventions to prevent child maltreatment, screening for glaucoma, and screening for hepatitis C.
• AHRQ produced a series of reports on research methods for evaluating patient-centered medical homes.
• AHRQ produced a booklet, Clinical-Community Relationships Measures Atlas, which describes foundational work for primary care improvement. It addresses community relationships, team-based care, and integration of behavioral health and primary care.
• AHRQ developed a how-to guide for performing health assessments in primary care. The Affordable Care Act requires health assessment as part of Medicare's annual wellness visit.
• AHRQ has been working with the Office of the National Coordinator for Health Information Technology to provide input into the development of stage III meaningful use.
• AHRQ funded development of the Health IT Safety Hazard Manager, which is used to monitor and mitigate health IT safety issues and can anticipate problems. Development was completed in 2012. One PSO has begun to use the tool to monitor health IT safety.

Discussion

Michael P. Johnson, P.T., Ph.D., OCS, referred to the effort to retire some core measures and wondered how possible backsliding would be handled. Shari M. Ling, M.D., cited a continuing monitoring process and noted that the process of retiring measures has a number of levels. There will be ongoing discussions about criteria that support wide use of measures. Andrea Gelzer, M.D., M.S., stated that, along with retiring measures, it will be important to identify better measures. Jeffery Thompson, M.D., M.P.H., raised the issue of measures being inserted in contracts and he proposed finer reports, for example quartiles of measures for specific groupings of patients. 

Jane Durney Crowley referred to risk factors for long-stay nursing home residents. She suggested that efforts to have hospitals attempt to change nursing home practices might be unwise. Dr. Clancy noted that HHS is trying to anticipate policy issues in this area and is analyzing data. Jean Rexford suggested that HHS include a consideration of observation status and who is admitted.

Dr. Ling called for strategies to disseminate better the tools developed by AHRQ—bringing them to the point of care. Dr. Clancy suggested that the new subcommittee on AHRQ's strategic direction could address that area, in part by addressing the issue of data capture for measuring quality. The amount of data is rising rapidly. Health care workers need convenience.

Victor M. Montori, M.D., M.Sc., stressed the issues of multiple chronic conditions, legacy measures that are not retired quickly, and the costs of harvesting data. He called for fundamental research and funding to address them. Dr. Clancy cited challenges, asking: What is the best way to support research on fundamental issues? The use of R21 grants? Freeing resources for investigator-initiated work? What will be the best possible contributions? The issue of multiple chronic conditions goes beyond funding research. What is the government's role? What debates will play out in society? What role will the private sector play?

David Atkins, M.D., M.P.H., noted that, as time passes, data will be collected with less expense. How should it be presented to decision-makers, who need the right information presented in the right way? There is a potential for a great deal of noise. Dr. Clancy noted that some hospital leaders say they already have too much project management going on. One solution might be to ask people what they desire in reports. Dr. Siegel noted that many vendors are selling analytics to hospitals now. That could lead eventually to divergence, or a lack of harmony.

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Update from Subcommittee on Strategic Direction

Michael P. Johnson, P.T., Ph.D., OCS, and Helen W. Haskell, Co-chairs

Dr. Johnson stated that the new Subcommittee on Strategic Direction for AHRQ will advise the NAC on leadership, future directions, and research priorities. The group comprises current and past NAC members. In an initial meeting, the group's members discussed a proper niche for AHRQ, AHRQ's audiences, and how to communicate the value of AHRQ's work. They agreed that AHRQ is an essential Agency.

Ms. Haskell, speaking by telephone, noted that the initial meeting had an organizational focus. It served as a basis for moving forward with future regular meetings. The Subcommittee will make a fuller report at the November 2013 NAC meeting.

The NAC members encouraged the Subcommittee to consider interacting with other groups involved in strategic issues.

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Update on Centers for Education & Research on Therapeutics (CERTs)

Anne E. Trontell, M.D., M.P.H., Center for Outcomes and Evidence, AHRQ

Dr. Trontell, Program Director of CERTs, provided an update on the CERTs program, a national initiative to conduct research and provide education to advance the optimal use of therapeutics, including drugs, medical devices, and biological products. She outlined the structure of the program, which uses cooperative agreement grants, AHRQ-supported research centers, and a national steering committee to guide collective policies.

The CERTs Steering Committee advises the program on needs, gaps, and the potential leveraging of opportunities in therapeutics. It comprises the principal investigators (PIs) in the program and representatives from consumer, patient, health care, therapeutics, and Federal sectors. A CERTs Scientific Forum coordinates communications and topical committees, creates agendas for Steering Committee meetings, and facilitates the conduct of one CERTs collaborative project each award year. It currently is led by Stephen Fortmann, M.D., at Kaiser Center for Health Research in Portland, Oregon.

The CERTs Research Centers are required to address at least three of five programmatic interest areas.  The areas are comparative effectiveness research, patient safety, health system interventions, translation of research findings into practice, and development, enhancement, and validation of tools. Each Research Center also proposes an overall research theme for a funding cycle of 4 to 5 years. The six current CERTs Research Centers are as follows:

• Brigham and Women's Hospital—PI David Bates, M.D., M.Sc., theme of health information technology.
• Cincinnati Children's Hospital Medical Center—PI Carol Lannon, M.D., M.P.H., theme of pediatric therapeutics.
• Duke University—PI Eric Peterson, M.D., M.P.H., theme of data-driven cardiovascular care.
• Rutgers, The State University of New Jersey—PI Stephen Crystal, Ph.D., theme of mental health therapeutics.
• University of Alabama at Birmingham—PI Kenneth Saag, M.D., M.Sc., theme of musculoskeletal disorders.
• University of Illinois—PI Bruce Lambert, Ph.D., theme of tools for optimizing medication safety.

Dr. Trontell stated that, since 1999, the CERTs program has produced 2,646 published manuscripts. Attempts, begun in 2007, to quantify productivity of the program produced an estimated healthy "return on investment," in terms of national performance metrics, AHRQ funding, and combined reductions in hospitalizations regarding gastrointestinal bleeding and heart failure readmissions. Dr. Trontell described specific achievements at some of the Research Centers. She noted the program's requirement in recent years that the projects engage in collaborations, including a very recent emphasis on medication adherence. Dr. Trontell encouraged the NAC members to consider the following questions:

• What will help to sustain the vitality and contributions of the CERTs?
• Should the CERTs Centers' thematic foci remain investigator-initiated or should they be determined by AHRQ?
• What perspective is missing from the current CERTs Steering Committee?
• Can collaboration be engineered in the manner currently being attempted?
• What are the merits, if any, of the current initiative on medication adherence?

Discussion

Gregory Baker, R.Ph., addressed medication adherence, wondering how community partners might come together to address patient needs. Dr. Trontell stated that the CERTs would be pleased to tackle that issue. Partnerships would be helpful. The home health industry could be involved.

Dr. Thompson encouraged the program to address differences between care management and pharmacy practice and the need for communication. Dr. Montori noted the "work" of the patient and proposed an emphasis on patient goals rather than disease-oriented goals. We need minimally disruptive medicine. Pharmacy benefit managers should work with care managers. 

Mitra Behroozi, J.D., cited the need to integrate available data in the health care process and the need to obtain the views of the full health care workforce. Andrea H. McGuire, M.D., M.B.A., added the idea of including behavioral health experts in the health care process. Mr. Baker noted that some people making health care decisions are not clinicians (e.g., administrators).

Dr. Siegel wondered how successful strategies, such as the Cincinnati group's lowering of remission rates for pediatric inflammatory bowel disease, could be spread. Ms. Crowley cited a need to disseminate good practices. Dr. Trontell cited the problem of resources. Noting a recent article about "slow medicine" in The New Yorker, Dr. Clancy responded that perhaps a good strategy is to disseminate small clear handbooks with generalized or step-by-step procedures.

Francis J. Crosson, M.D., encouraged the CERTs to consider collaborations with the Choosing Wisely Campaign. Dr. Ling asked about ways to measure potential national performance of the Centers' work. That could help to encourage uptake of the methods and products. Perhaps the program could emphasize a core set of key outcomes. 

Dr. Thompson suggested that the CERTs address the issue of specialty drugs and biologics. Which should be preferred? Dr. Trontell noted that the effective health care program is addressing such issues of effectiveness. Alan R. Spitzer, M.D., suggested that CERTs address fundamental questions in the manner of the neonatal networks supported by the National Institute of Child Health and Human Development. He noted that there are many reasons patients do not take their medications, such as skepticism because of a lack of explanation of purpose.

Henry H. Ng, M.D., M.P.H., FAAP, FACP, noted that his health center has a focus on initiatives that target vulnerable populations. The CERTs might consider such targeting initiatives. For example, they might study how adherence needs are addressed and the environments in which patient populations live.

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Levers for Change: National Quality Strategy

Nancy J. Wilson, M.D., M.P.H., B.S.N., Senior Advisor to the Director, AHRQ

Dr. Wilson reported on history and progress of the National Quality Strategy (NQS), which was established as part of the Affordable Care Act. The NQS is for the Nation and will serve as a catalyst and compass for a nationwide focus. It has been designed by public and private stakeholders and provides an opportunity to align quality measures and quality improvement actions.

The NQS aims to create better care, to create healthy people in healthy communities, and to create affordable care. Dr. Wilson listed the program's six priorities for improvement efforts:  safer care, person- and family-centered care, effective communication and care coordination, prevention and treatment of leading causes of mortality, health and well-being of communities, and more affordable quality care. Implementation activities include meetings of an HHS Quality Work Group, meetings of the Interagency Working Group on Health Care Quality, engagement of stakeholders through the National Priorities Partnership and the Measures Application Partnership, HHS measurement and alignment activities, and the publication of toolkits for communities.

Dr. Wilson referred to the 2013 Annual Progress Report, which features examples of collaborations between public and private payers, updates on national tracking measures, and examples of private sector successes in quality improvement. In the past year, multistakeholder efforts have produced significant achievements in the alignment of health care measures. Private sector businesses have moved forward in areas such as shared decision-making and patient-centered medical homes.

Dr. Wilson noted that the Office of the National Coordinator for Health Information Technology will release a health IT-focused quality improvement strategy for coordinating evidence-based guidelines, clinical decision support tools, and electronic clinical quality measures. To date, 500 hospitals and 30,000 physicians are participating in at least one payment reform model sponsored by the Center for Medicare & Medicaid Innovation. The NQS Working for Quality Web site is at
http://www.ahrq.gov/workingforquality.

Discussion

Dr. Montori applauded NQS efforts in integration, cautioning on the need to define "better off." Dr. Wilson responded, saying the program is considering patient functional outcomes. Dr. Johnson cited a need to address issues of communication and care coordination in a wide range of settings. Dr. Wilson responded that the project is discussing the development of common languages and data to bridge gaps between public health, community health, and other areas. It will seek to leverage hospital community needs assessments. There is a need to bring together the relevant people for discussion. Dr. Clancy cited an opportunity to think creatively and deploy assets in the area of multiple chronic conditions. Dr. Gelzer cited a need for a strategic operating plan that is resourced.

Ms. Rexford raised the issue of bringing the project to the level of individuals and families. Perhaps focus groups could be employed. Dr. Spitzer stressed a need to have more "foot soldiers" involved in quality processes (as opposed to administrators and planners). Quality issues should be part of the training of medical professionals. Dr. Clancy noted that today we have great vision for quality improvement but a lack of excitement in the field.  

Dr. Thompson noted the focus groups that are required by the Centers for Medicare & Medicaid Services for State activities and grants. Perhaps that activity could be used to increase alignment for quality among the States. Dr. Montori stressed that channels and messages are very important.

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Patient and Family Engagement

Jeffrey Brady, M.D., M.P.H., AHRQ, and Marjorie Shofer, M.B.A., B.S.N., AHRQ

Dr. Brady and Ms. Shofer described an AHRQ project to develop a guide for engagement of patients and families in health care processes. Development of the Guide to Patient and Family Engagement (PFE) in Hospital Quality and Safety began in 2009. The guide is a response to an interest in patient- and family-centered care and a lack of tools and training for clinicians and patients working together.

Dr. Brady noted barriers to engagement, including competing priorities, limited hospital resources, the hospital culture, the experiences and attitudes of providers and patients/families, health literacy issues, and a lack of "how-to" resources. A large team of experts representing national organizations helped to develop the guide.  

Ms. Shofer described the processes used to develop the guide, including an environmental scan of literature, documents, existing tools, and results of interviews with individuals. The scan revealed a need for tools that focus on what is important from the patient's perspective and feature concrete action steps for patients and families. The guide developers considered the following principles/goals:

• Highlight meaningful ways in which patients and families can help to improve safety and quality.
• Create partnerships around a set of shared goals.
• Promote hospital culture that values patient- and family-centered care.
• Ensure usefulness for all hospitals.
• Ensure feasibility of implementation.

Following the development of materials, testing with audiences, and revisions, the final guide offered the following four main strategies with associated tools:

• Working with patients and families as advisors.
• Communicating to improve quality.
• The use of nurse bedside change-of-shift reports.
• IDEAL discharge (Include patients and families, Discuss problems to avoid at home, Educate about the condition, Assess the explanation of materials, Listen to patient and family).

The guide has been implemented at three hospitals. Evaluation of the implementations found upward trending HCAHPS scores, positive feedback from patients and families, improved staff time management and accountability, positive views of care, and fewer patient falls and better intravenous pump compliance in one hospital.

Discussion

Dr. Siegel stated that the phrase "person and family engagement" might be more accurate, and he encouraged the group to link with the Partnership for Patients program. Dr. Montori applauded the creators of the guide and noted a project that found that good human connections in the health care arena seem to result when a person goes out of his or her way to help. Ms. Behroozi added the importance of the entire staff of a health care system. Dr. Johnson stressed that connectedness is a key and can lead to competence as well as influence.

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Public Comment

Douglas Kamerow, M.D., RTI International, presented, on behalf of his organization, an appreciation of the work of Dr. Clancy. Dr. Kamerow was with AHRQ years ago, playing an important role in the development of the U.S. Preventive Services Task Force. He noted that this NAC meeting would be Dr. Clancy's last before leaving the position of Director of AHRQ, and he praised her efforts throughout the years, which featured periods of great challenge. In particular, he praised her efforts to improve the dissemination of research findings in the areas of health care quality and safety.

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Chairman's Wrap-Up and Adjournment

Dr. Siegel stated that the next NAC meeting will take place on November 15, 2013. He conveyed the words of Dr. McGuire, who stated that Dr. Clancy will be missed—she has built an Agency that will, to her credit, succeed after her departure. He adjourned the meeting.

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