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Wednesday, September 11th 2002

Department of Health and Human Services
Office of Strategic Planning (Attn: Vijaya ChannahSorah, PhD)
Hubert H. Humphrey Building, Room 447-D
200 Independence Avenue, SW
Washington, DC 20201

Dear Dr. ChannahSorah:

On behalf of the American Hospital Association's (AHA) nearly 5,000 hospital, health care system, network and other provider members, we appreciate the opportunity to provide written comments on the Department of Health and Human Services (HHS) Strategic Plan for Fiscal Years 2003-2008.  Having participated in the HHS Stakeholders meeting on Thursday, August 29, 2002, we would like to emphasize several of the points that we made during that meeting and recommend some additional changes. 

Our comments are focused on four areas:  workforce; protecting our homeland; improving the quality of health care services; and reducing regulatory burden.

Health care is about people caring for people.  But health care is facing a severe shortage of all types of caregivers and support personnel.  Without help and intervention, this shortage will reach crisis proportions in coming decades, and seriously threaten the public health and safety of the United States.  AHA commends HHS on its plans to help increase the number and diversity of health care workers, but urges a broader-based approach.  We suggest that the department view the growing shortage of personnel in health care as a fundamental, underlying factor that could impede the achievement of all of the department’s goals and objectives unless the issue is appropriately addressed.

We recommend the following changes to the strategic plan related to workforce:

Objective 3.2 - Expand the Health Care Safety Net

  • Under bullet 1 of the section, Underserved rural and urban areas, it should read:  “Expand support for telemedicine and distance learning programs to extend state-of-the-art health care and information, and opportunities to train new health professionals, to the Nation's most isolated communities.”
  • Under bullet 3 of the section, Primary health care services for underserved populations, the section should read:  “Encourage people to enter nursing and allied health professions by supporting educational programs and providing student loan repayment assistance.”

Objective 3.4 - Eliminate racial and ethnic health disparities

  • Add the following bullet:  “Work with community groups and health care providers to recruit minorities and other under-represented populations into health professions.”

Objective 3.6 - Increase access to health services for American Indians and Alaska Natives

  • Add the following bullet:  “Work with tribal organizations to recruit American Indians and Alaska Natives into the health profession.”

Appendix A - Objective 3.2 - External Organizations

  • Under the column “External Organizations” add “community and faith-based groups, higher education system.”

Appendix B - Objective 2.1 - External Factors

  • Under the column “External Factors” add “growing health professions workforce shortages.”

As part of America’s health care infrastructure, hospitals play a key role in national disaster readiness.  The terrorist attacks of September 11th and the subsequent anthrax attacks have changed how Americans view safety and security.  The attacks have also redefined the meaning of disaster readiness for local communities and hospitals.  Over the past 10 months, as the nation has focused on strengthening our national security and emergency readiness, America’s hospitals have been upgrading existing disaster plans.  They continue to tailor their disaster plans to suit the individual needs of their communities in the face of new and more ominous threats of terrorism, particularly terrorist acts involving the use of chemical, biological or radiological agents. 

It is in this context that the AHA is pleased to provide you with the following comments on Goal 2, Protecting our Homeland: 

Goal 2 - Protecting our Homeland

  • Goal 2 should be reworded to address not only response to an attack, but also preparation for and recovery from an attack.  Further, the goal should not focus so narrowly on bioterrorism, as there are other serious, and perhaps more likely, threats facing the nation.  We suggest that Goal 2 read as follows: 

    “Enhance the ability of the Nation’s health care system to effectively prepare for, respond to, and recover from acts of terrorism (including bioterrorism, chemical terrorism and nuclear/radiologic terrorism) and other public health challenges.” 
  • The background information for Goal 2 should define what is meant by the “health care system” and include at minimum, “hospitals, health networks, physicians, nurses, public health officials and others.”

Objective 2.1- Build the Capacity of the Health Care System to respond to public health threats in a more timely and effective manner, especially bioterrorism threats.

  • Objective 2.1 should be reworded to mirror the intent of revised Goal 2.  We suggest the following language:

    “Build the capacity of the health care system to prepare for, respond to, and recover from public health threats in a more timely and effective manner, especially to acts of terrorism such as bioterrorism, chemical terrorism and nuclear/radiologic terrorism.” 
  • Bullet 2 of Objective 2.1 should include the issue of surge capacity.  The following language is recommended: “Upgrade the capacity of federal, state, tribal, and local public health, hospital and other health care facilities, especially community surge capacity, to respond to acts of terrorism and other public health emergencies.”
  • Bullet 4 should specifically identify hospitals and other health care providers as entities that should be included in a national electronic communications system.  For instance, “Create a national electronic communications system to link federal, state, tribal, and local public health, hospitals, physicians, and other health officials so that relevant information regarding public health threats can be rapidly shared.”
  • Add a bullet identifying the need to address workforce shortages:

    “Identify critical health care workforce shortages that would impact the nation’s readiness to respond to acts of terrorism and other public health emergencies and take steps to mitigate those critical shortages.
  • Add a bullet identifying the need to better respond to mental health issues: 

    “Improve the health care system’s capacity to respond to the mental health consequences of acts of terrorism and other public health emergencies.”
  • Add a bullet addressing the need for uniform standards as follows:

    “Cooperate with the private sector to develop standards for responding to acts of terrorism and other public health threats in such areas as personal protective equipment and decontamination.” 
  • Add a bullet addressing the need for education and communication with the public to prepare them to take appropriate steps in situations involving potential acts of terrorism and other public health emergencies.

Appendix A - Objective 2.1 - Crosscutting Activity:

  • Under the column, “Crosscutting Activity” add a provision related to the development of standards for responding to acts of terrorism and other public health threats in such areas as personal protective equipment and decontamination.  The HHS agencies involved should include:  the Centers for Disease Control (CDC), the Food and Drug Administration (FDA), the National Institute on Occupational Safety and Health (NIOSH), the Agency for Toxic Substances and Disease Registry (ATSDR), and the Office of Public Health Emergency Preparedness (OPHP).  Other government and private organizations that should be involved include:  the Occupational Safety and Health Administration (OSHA), the Federal Emergency Medical Agency (FEMA), state and local public health departments, the AHA and the American Medical Association.
  • Under the surveillance and response system activity, add the AHA, the National Organization of City and County Health Officials, and the American Society of State and Territorial Health Officials.

Appendix B - Objective 2.1 - External Factors:

  • Add an external factor under Objective 2.1 that addresses competing economic and other priorities for hospitals and other health care providers.  Hospitals are facing enormous financial pressures as a result of health care cost inflation, workforce shortages, new technologies, new regulations, and more.  All these factors are critical, but costly, priorities.  In an environment in which one in every three hospitals loses money, improving hospital disaster readiness is an additional critical priority that must be seen in the context of other important and competing priorities.  The effect of this external factor on strategies/goals/objectives would be that hospitals and other health care providers are inadequately prepared for public health threats.  HHS can mitigate this external factor by promoting a sustained investment in readiness for hospitals and other health care providers. 
  • The external factor related to lack of communication between the public health sector and the hospital/healthcare sector includes a “HHS Response to Mitigate Factor” item that is simply a restatement of Goal 2.  This is a critical issue that deserves a more thoughtful response by HHS.  Some ideas for ways to mitigate this barrier to communication might include HHS-sponsored meetings to address communications issues, joint training exercises at the state and local levels between the public health and hospital sector, and the development of interoperable communications systems at the state and local level.  

Quality and patient safety are cornerstones of hospitals’ mission.  Reducing and preventing medical errors, and improving the overall safety and quality of the health care system, continue to be top priorities for the AHA and its members.   Addressing these critical issues demands the thoughtful collaboration and participation of all stakeholders – hospital leaders, pharmacists, drug manufacturers, doctors, nurses, government agencies, other organizations and consumers.  We are pleased that the HHS strategic plan embraces improving the quality of health care services as Goal 5 and we offer the following suggestions:

Objective 5.1 - Reduce Medical Errors

  • Objective 5.1 should be restated.  The focus should be on preventing harm to patients.  If attention is focused simply on reducing the number of errors, resources may be directed away from occurrences that are less frequent, but when they occur can cause great harm to patients. 
  • The data collection effort described in bullet 3 is laudable, but needs to be coupled with analysis and efforts to communicate the lessons learned from the data.  We suggest that bullet 3 be revised as follows:  “Improve reporting systems, analytic methods and the diffusion of lessons learned from the data collected.”

Objective 5.2 - Increase the appropriate use of effective health care services

  • Objective 5.2 is too difficult to understand.  Greater specificity is needed, particularly with regard to HHS plans to test payment strategies that would support quality improvement. 

Objective 5.3 - Increase consumer and patient use of health care quality information

  • Objective 5.3 discusses the intent to make data available to the public.  Historically, these types of efforts have not prompted action or even understanding on the part of the public.  The plan should describe efforts to turn data into useful information and to assess whether that has been achieved. 

Objective 5.4 - Improve consumer and patient protections

  • Objective 5.4, improving patient protections, will be brought to fruition largely by improving existing processes that respond to complaints or problems.  As part of this objective, HHS should also promote preventive strategies for patients, such as encouraging patients to inform their clinicians of all medications they are currently taking. 

Objective 5.5 - Accelerate the development and use of the national health information infrastructure

  • Objective 5.5 demonstrates that HHS has a key role in improving information technology that will facilitate improvements in care.   A number of efforts are already underway in the private sector.   Does HHS plan to collaborate in those efforts or develop something on its own?  This should be discussed in the strategic plan.

  • Add a bullet detailing the need for government/private sector collaboration: 

    “Work with existing alliances of information technology vendors, provider organizations, and other interested parties to improve the interoperability of existing technologies.”  

We are heartened that the need to reduce regulatory burden on providers and consumers is in the HHS strategic plan.  Hospitals are drowning in a sea of government rules and regulations.  Confusing and contradictory regulations force caregivers to spend more time on paperwork and less time on patient care.  The AHA has been working tirelessly with Secretary Thompson and his Advisory Committee on Regulatory Reform to identify confusing and conflicting regulations in order to achieve a regulatory environment that puts patients first, not paperwork.  We commend the Secretary for his leadership on this issue and look forward to continuing our work with the Secretary’s Advisory Committee. 

We offer the following comments on Goal 8, Achieving Excellence in Management Practices:

Goal 8 - Achieving Excellence in Management Practice

Appendix A - Objective 8.7 - External Coordination

  • Add the Office of Civil Rights (OCR) to the list of HHS agencies affected by elements of the strategic plan.

Appendix B - Objective 8.7 - External Factors

  • Include the growing workforce shortage in the list of external factors influencing regulatory requirements.  Confusing, conflicting, and often redundant regulations (which generally translate to more time spent doing paperwork than actually providing care) are often cited as among the reasons talented health care professionals leave the field.

Thank you for the opportunity to provide written comments on the HHS strategic plan.  Should you have any questions, please do not hesitate to contact Mary Beth Savary Taylor, vice president for executive branch relations, at (202) 626-2270 or


 Rick Pollack
Executive Vice President


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