Vision
Mission
Environmental Context
Connection to HHS Strategic Plan
Healthy People 2000 and 2010
Strategies To Operationalize the Vision and Mission
Define Customers/Stakeholders and Their Needs for Evidence-based
Information
Establish the Agency's Goals
The Research Pipeline
Identify Issues That Cut Across All Agency Goals and Programs
Implement the Plan
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; be accountable and responsive to consumers and purchasers; and 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 squarely focused 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 in 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.
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 later in this plan:
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 decisionmakers in the health care system. For example:
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.
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 Ensure 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 Systems—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 is found in "Examples of AHCPR's Contributions to the HHS Strategic Plan." 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. Additionally, AHCPR's substantial investment in the development of data bases 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 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.
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 data bases.
The Agency uses a five-step planning framework to prioritize its activities and maximize the use of its resources:
Define the Agency's customers and their needs for evidence-based
information.
Establish the Agency's goals.
Define the nature of the work of the Agency.
Identify issues that cut across all Agency goals and programs.
Implement the plan.
Each of these steps is discussed in detail below.
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 decisionmaking:
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 HHS, a number of agencies are AHCPR customers, including the Health Care Financing Administration (HCFA).
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.
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:
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 (Report of the President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry).
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:
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.(3) 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.
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."(4)
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 (image, 4 KB).
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 which 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 translating research into practice 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.
The Agency has identified two activity areas which 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 make them pertinent to studying issues related to outcomes and quality, as well as access, cost, and use. The first of these activities 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 groups warrant a special focus from health services research: minorities, women, and children (including adolescents). These are 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 underrepresented 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.
2. 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.
1. Planning and Evaluation
This strategic plan will serve as the road map for AHCPR activities for the next 3 to 5 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.
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 (image, 6 KB) describes the processes AHCPR uses to conduct its ongoing activities in order to make the most productive use of its resources.
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.
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 10 years of investment in outcomes and health care research, AHCPR will focus on national priority areas for which much remains unknown.
Translation and Dissemination. Simply producing information is not sufficient; findings must be useful and made widely available to practitioners, patients, and other decisionmakers. 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 decisionmaking. It will then actively disseminate the knowledge, products, and tools to appropriate audiences. Effective dissemination involves forming partnerships with other organizations and leveraging resources.
Evaluation. Knowledge development is a continuous process. It includes a feedback loop that depends on the evaluation of the research's utility to the end user and its 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 the 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's achieving its goals. Partnerships take many forms and contribute to the Agency's achieving its goals at all points of the cycle of research.
Needs Assessment. AHCPR works cooperatively with many public- and private-sector organizations to identify their needs for health services research so that Agency initiatives "begin and end with the user."
Knowledge Creation. 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 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 ensure 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.
1. The Omnibus Budget Reconciliation Act of 1989 (Public Law 101-239), Part A, Section 901(b).
2. Institute of Medicine, 1996.
3. The President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry. Quality First: Better Health Care for All Americans. Final Report to the President of the United States. Washington, DC, U.S. Government Printing Office, March 1998. (GPO stock number 017-012-00396-6)
4. Eisenberg JM. Health Services Research in a Market-Oriented Health Care System. Health Affairs, Vol. 17, No. 1:98-108, 1998.
Current as of March 1999
AHCPR Pub. No. 99-R045
Internet Citation:
AHCPR Strategic Plan. December 1998. Agency for Health Care Policy and Research, Rockville, MD. http://www.ahrq.gov/about/stratpln.htm