Making performance indicators work: experiences of US Veterans Health Administration

Publisher Website
Google Scholar
Abstract
Foundation for changeThe administration made several organisational changes as a foundation for the quality improvements.3 5 Firstly, it reorganised care into regional networks (veterans integrated service networks), which were provided with fixed resources and held accountable for managing all care within their facilities. Secondly, it shifted care to ambulatory settings, opening new outpatient clinics and closing many inpatient beds. Thirdly, the capacity of the administration's automated information system was improved to allow providers to access and enter all patient information within a unified electronic medical record, thus enhancing coordination of care.6A cornerstone of the efforts to transform care was the systematic use of data driven measures to monitor performance across several domains, including technical quality of care, access, functional status, and patient satisfaction.3 Many of the measures paralleled those developed by other US quality assessment organisations, but the administration also included measures to assess care of particular relevance to veterans. Initially, assessment focused primarily on process measures concerning outpatient management of chronic conditions (control of diabetes, use of inhalers for obstructive lung disease, diet and exercise counselling for hypertension and obesity, drug management and cholesterol testing after myocardial infarction) and preventive care (immunisations; screening for breast, colon, cervical, and prostate cancer; and counselling on alcohol and tobacco use). Currently, the administration assesses over 50 measures covering acute and chronic conditions as well as palliative and preventive care (box). An external contractor collects data quarterly by auditing the electronic medical records for a sample of veterans from all the administration's facilities. It also surveys a sample of patients at each facility about their healthcare experiences, satisfaction, and health status.Veterans Health Administration areas of performance measurement, 1997-2006*Chronic and acute care Diabetes Acute myocardial infarction Obstructive lung disease Obesity Hypertension Pain assessment Major depression Smoking cessation Community acquired pneumonia Acute coronary syndrome Substance use disorders Heart failure Preventive care Influenza vaccination Pneumococcal vaccination Prostate cancer education/screening Mammography Cervical cancer screening Colorectal cancer screening Hyperlipidaemia screening Alcohol screening Tobacco screening *Some areas were not covered in all years, and measures within areas also varied by yearIn addition to monitoring quality, the administration instituted mechanisms to make it more likely that performance monitoring would drive quality improvement. Each regional director was held accountable through a performance contract, which included incentives equivalent to roughly 10% of the director's salary, for meeting specified quality standards. The director, in turn, held managers and clinicians accountable for the performance standards, and the performance results of each regional network and facility were widely available within the administration. Consequently, regional networks began to compete with each other on performance, and facilities within each network did the same. Although implementation of quality improvement initiatives was ultimately in the hands of individual networks and facilities, there were also centrally led quality improvement efforts. The administration also drew on researchers from the Department of Veterans Affairs' health services research and development service and from nine disease specific, quality enhancement research initiatives to systematically identify quality gaps and develop and assess interventions to close those gaps.7 8