What Changed the Veterans
Health Administration in 1995?
“All organizations are
perfectly designed to get the
results they get.”
(other than Ken, Jesse, Tom, Jon, Al , Bill, Alan, Lisa,
David, Greg, Jim, Nora, Nancy, Jack, Tom, Jule, Mike,
Ken, Fred, Susan, Fran, Bob, Larry, Carol, Jim, Randy,
Barry, and thousands more…
more…)
David Hanna
Designing Organizations for High Performance
1988
VA Structural Advantages
X
IT focused on Care not Billing
X
108 Medical School Affiliations (10,000
Residency slots): Faculty, Fellows,
Residents, Students
X
Strong Clinical and Health Services
Research
X
Employed physicians
X
Saved $$’s stay in VA
The Environment - 1994
X
President/Vice President
X
X
X
Secretary of VA
X
X
X
X
BUT these were true prepre-1995,
what ELSE changed
21 Veterans Integrated Service Networks
Healthcare agenda
Reinventing Government Initiative
Combat injured war veteran
Demanded change
New Under Secretary from outside
New Congress – “Contract with America”
X
X
Fewer veterans in Congress
Continued calls to privatize VA
VHA’s Performance Contract
Contract Development Cycle|
VISNs are the Funding & Accountability Unit in VA
Public Accountability to Veterans & USA
USH / Policy / Planning => VISION
ƒ Between Under
Secretary for Health and
Administrative & Clinical
Leadership
Ö New Structure
Ö Objective was to
transform from
“Hospital focus”
to a “Population &
Health System”
ƒ Development Involves
Clinicians & Managers,
HQ & Field
Ö From “Safety Net”
to “Health
Promotion &
Disease
Prevention”
ƒ Supports Strategic Plan
(Links Mission, Strategy,
Tactics ) – Patient Care
Focused
ƒ Explicit accountability for
performance
Ö 22 Carefully
selected leaders
for the new VISNs
Ö Half the beds,
twice the access
IN JANUARY 2002
VISNS 13 AND 14
WERE INTEGRATED AND
RENAMED VISN 23
ƒ Supported by
Information & Advanced
Technologies
Internally Identified
Opportunities & Priorities
Past Performance
OMB Accountabilities (GPRA)
Congressional Accountabilities
VA Mission & Goals
VHA Mission => Strategic Goal Areas
(Q, A, S, FS, CE, CH)
Clinical
Recommendations
& Support Tools:
Performance Measure Development
Office of Quality & Perf
Office of Quality & Performance (OQP)
National Clinical Practice
Guideline Council
National Clinical Program
Offices
Measure Alignment, Vetting, Priority
Reconciliation
Creation of Director’s Performance Contract
Performance Mgmt Work Group
Performance Analysis, Measurement and
Reporting
Office of Quality & Performance
Under Secretary for Health’s Performance Accountability Contract
Executed by Office of Under Secretary for Health with VA’s Clinicians & Managers
1. ACCESS: Number of VA Hospitals &
2. TECHNICAL QUALITY:
Clinics Nationally: 19951995-2005
“VHA scored significantly
higher… on 294 quality
metrics”
1400
350 % More Points of
Primary Care Access
1200
1000
800
600
400
200
0
1995
1996
1997
1998
Hospitals
1999
2000
2001
VetCenters
2002
LTC
2003
2004
2005
RAND Study - Asch, McGlynn et al Annals Internal Medicine 2004;141:938-945
Clinics
“ . . . Overall, VHA patients
receive better care than
patients in other settings”
3. SATISFACTION:
X
2000: 79 of 100 on external American Customer Satisfaction
Index (Univ. of Michigan) Outpatient Care
X
2001: 82/100 Inpatient & 83/100 Pharmacy
X
Significantly better than private health sector average of 68
X
X
2002: Repeat Performance – Healthcare Benchmark
X
2003: Repeat Performance – Healthcare Benchmark
X
2004: Repeat Performance – Healthcare Benchmark
X
2005: Repeat Performance – Healthcare Benchmark
VA’s Electronic Health Record
4. FUNCTION: Reduced AgeAge-Adjusted
Amputation Rates in Diabetics
9
ƒ VistA in all
VA’s
Annals of Internal Medicine, August 17, 2004
Amputations per 1,000 patients
8
7
“Overall 2 of 3 intermediate outcomes were
better for patients in the VA system than for
patients in commercial managed care.”
6
5
4
2
1
0
ƒ Computerized
Mail Out
Pharmacies
ƒ Images
ƒ Bedside
Medication
Verification by
barcode in all
VA’s
3
1999
2000
2001
2002
2003
2004
Overall
7.94
6.24
5.42
4.53
4.4
4.04
Major
3.61
2.78
2.4
1.95
1.84
1.72
Minor
4.33
3.46
3.03
2.59
2.55
2.32
Loyalty Score of 90 and Customer Service Score of 87 were healthcare
benchmarks!
ƒ Clinical
reminders
ƒ HSR&D
Summary
X
Right Environment
X
Right Leadership & Support
X
Right Structural Design
X Patient
centered care model
X Evidenced
X QI
based guidelines
Methods (IHI Collaboratives, QUERI)
X Performance
X Aligned
measurement
funding & incentives
X Automation
of the care process