Advancing High Performance in Veterans Affairs Health Care.

Transparency and accountability are 2 recurring components of efforts to improve the quality and value of US health care. In the June 2017 issue of JAMA Internal Medicine, Blay et al1 compared the performance of US Department of Veterans Affairs (VA) hospitals with non-VA hospitals using Centers for Medicare & Medicaid Services (CMS) Hospital Compare data. VA hospitals (n = 129) were compared with both academic and community hospitals (n = 4010) on a range of clinical outcomes and patient experience measures. VA hospitals performed better than non-VA hospitals for most outcome measures—includinglowerratesof inpatientsafetyeventssuchaspressureulcer, iatrogenicpneumothorax,andcentral line–associatedbloodstream infection—and lower 30-day mortality and readmission rates for acute myocardial infarction (MI), pneumonia, heart failure, and chronic obstructive pulmonary disease. At the same time, VA hospitals scored lower for patient experience and behavioral health. Given the unique mission and heightened visibility of VA as a public-sector institution, these findings raise 2 questions: how does VA ensure the best health care possible for veterans in all aspects of care, and what is the VA doing to address areas that may need further improvement? The finding that VA hospitals perform better on quality when compared with hospitals in the private sector is not novel. A 2017 review of 69 published studies reported that the VA performed as well as, or better than, private health care systems on most clinical quality measures.2 Additionally, the VA has higher screening rates for colon cancer (82% vs a national average within the 60% range),3 has reduced the number of methicillin-resistant staphylococcus infections (infections in the intensive care unit declined 72%, from 1.64 to 0.46/1000 patient-days, 2007-2012),4 and achieves lower 30day mortality than private hospitals for patients older than 65 years hospitalized for acute MI and heart failure.5 What factors explain this better performance? One is likely the VA’s early investment in electronic health records (EHRs). Since the 1970s, the VA has collected system-wide data from EHRs to advance patient care, facilitate research, and enhance patient-physician communication. More recently, the VA has used EHR data to support performance measures and drive improvement. In fact, what began in the 1990s as a small set of measures to encourage improvement efforts by network leaders, today is a sophisticated matrix of 25 measures and measure sets used to assess each VA facility. This matrix—known as Strategic Analytics for Improvement and Learning (SAIL)—includes a comprehensive set of clinical performance metrics, including all veteran-relevant metrics reported to CMS and the National Committee for Quality Assurance, as well as assessments of factors thought to enable quality and safety improvement (eg, employee morale, nursing turnover, leadership vacancies, and selected utilization metrics). An overall improvement index is derived from SAIL to determine whether each facility’s performance has improved in the prior year. In 2016, 82% of 146 VA facilities demonstrated tangible improvements. The SAIL improvement index is now incorporated into performance plans of facility and network leaders. A second factor explaining the VA’s better performance on certain measures than the private sector relates to coordinated programs and clear organizational goals empowering improvement at the local level. Blay et al1 found that VA hospitals performed better than non-VA facilities on surgical patient safety indicators. The VA implemented the National Surgical Quality Improvement Program (NSQIP) in the 1980s. NSQIP collects clinical information about preoperative and postoperative surgical outcomes in the VA system. Local clinical leaders can compare risk-adjusted outcomes between facilities, enabling them to launch quality improvement efforts once they identify where they can improve relative to their peers. A third factor explaining VA’s high quality outcomes is an embedded research program. VA research helped develop the evidence behindnationalprogramssuchasprimarycare–mentalhealthintegration, tele-mental health, and new models to care for women veterans. In an effort to accelerate evidence-based practice in critical clinical areas, in 1998 the VA launched its Quality Enhancement Research Initiative (QUERI),aprogramthatbringstogetherresearchersandprogramleaders to accelerate evidence-based practices in critical clinical areas, including heart disease. The ischemic heart disease QUERI created a national data system for real-time tracking of every procedure performed at VA cardiac catheterization facilities, along with clinical outcomes. Related article at jamainternalmedicine.com JAMA INTERNAL MEDICINE