VA’s Approach to Value:
Population Health, Performance
Measurement and Quality Improvement
Stephan D Fihn, MD, MPH
Director, Health Services Research & Development
Center of Excellence
VA Puget Sound Health Care System
June 28, 2009
VHA Today
• Largest integrated healthcare system in US:
– Budget ~$42 billion
– 7.8 M enrollees
• >100% more than 2.7 million enrollees in 1995
– 5.5 M patient treated annually
• 62.3 M outpatient visits
• 589K admissions, 4.9 M BDOC
– ~200K FTE employees (~65K health care, including
~17K physicians)
– ~90K health trainees in virtually all disciplines
21 Veterans Integrated Service Networks
IN JANUARY 2002
VISNS 13 AND 14
WERE INTEGRATED AND
RENAMED VISN 23
VHA Sites of Care
o
153 Hospitals
901 Hospital, Community-Based
and Independent Clinics
135 Nursing Homes
225 Readjustment Counseling
Centers
47 Domiciliaries
•
Source: VHA Site Tracking system FY 2008
o
o
o
o
VA Patients
• Older: 49% > age 65
• Compared to age-matched Americans
– 3 additional non-mental health diagnoses
– 1 Additional Mental Health Diagnosis
• Income
– ~ 70% with annual incomes < $26,000
– ~ 40% with annual incomes < 16,000
• Ethnically Diverse
• Changing Demographics
– 4.5% female overall (increasing)
– 22.5% of outpts < 50 y/o
Characteristics of VA Patients
Received Care from VA Med Ctr
Total
Sample (%)
(n=251,570)
Yes (%)
(n=7155)
No (%)
(n=244,415)
Current smoker
18
19
18
Obese (BMI ≥30)
24
28
23
8
22
7
Hypercholesterolemia
36
51
36
Hypertension
30
62
28
9
29
8
Diabetes
Cardiovascular disease
Ross, et al. Arch Intern Med 2008;168:950-958
VHA Quality and Safety Program
• Promote transparency, learning &
accountability
• Support evidence-based, patient-centered
care and improvements in population health
• Manage and mitigate risks to population
health, safety and professionalism
• Support continuing development of a high
performance health care delivery system
Overview of Quality
Overarching Principles
• Quality occurs at the frontline
• Culture more important than programs
• Leadership is paramount
Quality is improved through:
• Informed observation
• Insight and understanding
• Creative collaborations
• Evaluating results
Major Functions & Programs
•
•
•
•
Measurement, Analysis & Reporting
Evidence-based practice
Assessing pts’ experience & satisfaction
Professional functions:
– Accreditation of facilities & programs
– Credentialing and privileging
– Peer review
– Risk management
• Utilization management
Rationale for Performance Measurement
• Accelerate introduction of proven interventions
– e.g., flu vaccine, β-blockers post AMI
• Reduce practice variation
• Transparency: accountability, trust
Origins of PM in VHA
• VA adopted PM in 1994
– Initially manual abstraction of clinical data
from randomly selected records (EPRP)
– Evolved to include data from additional
sources (SHEP, DSS, VISTA)
– Multiple domains
• Reliance largely on audit/feeback,
performance contracts w/ SES
– Performance contracts with sr. leadership
Performance Improvement
Prevention Index
1996:
•Influenza & pneumococcal
vaccination
•Breast, cervical, colorectal,
prostate cancer screening
•Screening for tobacco &
problem alcohol use;
counseling for tobacco
cessation
2004:
•Added hyperlipidemia
screening
•Prostate Ca screening 
education/counseling
100
90
80
70
60
50
40
30
20
10
0
1996
1999
2004
2007
Similar story for most original PMs
VA outpatient performance measures compared with comparable measures from other systems of care.*
INDICATOR
Breast cancer screening
VA
2008
87%
VA
2007
86%
Commercial
2007(1)
69%
Medicare
2007(1)
67%
Medicaid
2007(1)
50%
Colorectal cancer screening
79%
78%
56%
50%
n/a
Hemoglobin A1c < 9.0% in diabetic patients
84%
84%
71%
71%
Cervical cancer screening
LDL-C <100 mg/dl after AMI, PTCA or CABG
LDL-cholesterol <100 in diabetic patients
Retinal examination in diabetic patients
Microalbuminuria screening in diabetic pts
BP <140/90 in patients with diabetes
BP <140/90 in patients with hypertension
Smoking cessation counseling
92%
66%
68%
86%
93%
85%
91%
89%
83%
75%
Influenza vaccination (age ≥65 or high risk)
84%
*VA
64%
77%(2)
84%
Pneumococcal vaccine (all age groups at risk)
62%
78%(2)
Medications offered to smokers
Smokers referred for smoking cessation
91%
92%
94%
76%
n/a
n/a
72%
90%
82%
59%
44%
55%
81%
64%
62%
76%
51%
48%
n/a
49%
n/a
65%
56%
38%
47%
31%
63%
86%
59%
58%
52%
50%
74%
56%
53%
n/a
70%
n/a
39%
n/a
72%
67%
39%
n/a
n/a
Office of Quality and Performance, 2008. VA comparison data obtained by abstracting medical record data using similar methodologies to matched HEDIS
methodologies. Due to population differences, and methodology variations not all HEDIS measures are comparable to VA measures therefore this is not a
comprehensive list of indicators but this comparison does contain those indicators that are closely aligned in content and methodology. N/A = not available
1HEDIS
data were obtained from the 2008 "State of Health Care Quality Report" available (www.ncqa.org)
2Measure
is ≤140/90.
VA Performance Measures and Monitors, 2009
• 120 Performance Measures:
–
–
–
–
81 Clinical
29 Access
7 Functional status
3 Patient satisfaction
• 193 Supporting Indicators
– 177 Clinical
– 11 Access
– 5 Functional
• IPEC
• NSQIP/CSCIP
• CART-CL
More than 5000 measures and monitors related to clinical quality, safety,
patient and employee satisfaction, financial performance, etc.
9 Clinical Composite Measures
Inpatient Composites
• AMI (11)
• CHF (4)
• Pneumonia (9)
• Surgical Quality (SCIP) (8)
Outpatient Composites
• Diabetes (7)
• Ischemic heart disease
(3)
• Prevention (7)
• Behavioral health screening (3)
• Tobacco follow-up (3)
Performance Alerts
Subscriber-driven
Performance Alert System
designed to notify Senior
and Line managers of
possible issues related to
performance measure
groupings, e.g.,. cardiology,
diabetes, surgical infection,
mental health.
.
Evolution toward a knowledge culture
Reliability &
validity of measure
IT
Support
Cost of
measurement
Performance
Measures
Clinical
evidence
Opportunities
for
improvement
Clinical burden
Magnitude
of effect
Relevance to
strategic goals
Future Course
• Developing new meaningful, patient-centered measures
– Clinically linked
– Population-based (cohorts)
• Migration from manual sampling to real-time electronic
measures on all patients
• New approaches to analysis & aggregation
• Emphasis on improving the delivery model:
– Episodic/visit-based  Continuous/ comprehensive
– Cross-sectional  Longitudinal
– Individual  Bundled
Evidence-Based Practice
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Post Deployment Health
Assessment
Uncomplicated Pregnancy
Major Depressive Disorder
PTSD
Psychosis
Substance abuse disorder
Medically Unexplained Symptoms
Opioid Use in Chronic Pain
Mild TBI
Post Operative Pain
Bio/Chem/Rad/Blast Injury
Tobacco Use Cessation
Obesity
Amputation
Disease Prevention
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Heart Failure
Hypertension
Ischemic Heart Disease
Dyslipidemia
Diabetes Mellitus
Pre End Stage Renal Disease
COPD
Stroke Rehabilitation
Acute Stroke
Rehabilitation
Dysuria
Asthma
GERD
Glaucoma
Erectile Dysfunction
Low Back Pain
VA/DoD process compares favorably
with others
Principle
ICSI
Professional
Society
VA/DoD
Kaiser
Diverse,
multidisciplinary body
+
+
+
-
Avoid financial
conflicts of interest
+
+
+
-
Strong evidentiary
standards
+
+
+
-/+
Post near-final draft
for commentary
+
?
?
?
Subject guideline to
peer review
+
?
?
?
Evidence as the Basis
for Clinical Policy
Decision
Support
Performance
Measures
Evidence
Clinical
Guidelines
Appropriateness
Measures
Clinical
Processes & Systems
Formulary
Clinical
Reminders
Vision for Future Guidelines
• Through partnerships with other agencies and
health systems, develop accelerated process for
evidence synthesis and guideline development
• Sharpen focus on deployment health issues
• Incorporate patient preferences*
• Strengthen links between Clinical Practice
Guidelines and Performance Metrics
• Embed the guidelines and the measurement into
clinical work using the EHR
* see Krahn, JAMA 2008;300:436
Survey of Healthcare Experiences of
Patients (SHEP)
• VHA has measured patient satisfaction since 2006
– Initially, Picker-Commonwealth Survey
– 600,000 veteran inpatient & outpatient users
annually
• For 2009, SHEP Consumer Assessment of
Healthcare Providers and Systems (CAHPS) and
HCAHPS
• Will permit direct external benchmarking.
HCAHPS
•
•
CAHPS Hospital Survey for inpatients
HCAHPS Composites:
Communication with nurses
Communication with doctors
Communication about Medications
Responsiveness of Hospital Staff
Cleanliness and Quietness of the Hospital Environment
Pain Management
Discharge Information
 Single Question ratings
– Overall rating of the hospital (SHEP performance measure)
– Willingness to recommend hospital
–
–
–
–
–
–
–
Other Quality Functions
• Utilization management
– integrating criterion-based UM with System Redesign and
Care Coordination
• Quality and Risk Management
– clarify roles of leadership
– triangulation and integration across multiple sources of
observational data (not just performance measures)
• Medical and Professional Staff Processes
• Lesson: Performance measurement alone is not
sufficient