How to improve the Quality of Care

How does the VA outperform other systems in the delivery of patient care?

In its 2001 report “Crossing the Quality Chasm,” the Institute of Medicine called for systematic reform to close the quality gap in U.S. healthcare. Recommended reforms included the development of a health information technology infrastructure, a performance monitoring system, and methods to ensure accountability of providers and managers.

The Department of Veterans Affairs, the nation's largest healthcare provider, has been identified as a leader in healthcare quality improvement. Since the early 1990s, the Department of Veterans Affairs has implemented system-wide quality improvement initiatives, many of which have been models for change subsequently recommended by the Institute of Medicine.

How does the VA compare with other U.S. health care providers? To answer this question, RAND researchers compared the medical records of veteran patients with data from a national sample to assess the effectiveness of health care provided to both groups. Their conclusions:

• VA patients received about two-thirds of the care recommended in national guidelines, compared with about half in the national sample.
• For patients receiving chronic care, VA patients received approximately 70% of the recommended care, compared with 60% in the national sample.
• For preventive care, the difference was greater: VA patients received about 65% of the recommended treatment, compared with 20% fewer patients in the national sample.
• VA patients consistently received better care in all settings, including screening, diagnosis, treatment, and follow-up.
• Quality of care for acute conditions-which is not measured for the VA-was similar in both populations.
• The largest differences between the VA and national sample were in the indicators for which the VA actively measured performance and in the related indicators for which performance was measured.

VA provides higher quality care

Using indicators from the RAND Quality Assessment Toolkit, RAND researchers analyzed the medical records of 596 veteran and 992 non-veteran patients from across the country. The patients were randomly selected men aged 35 years or older. Based on 294 health outcomes in 15 treatment categories, they found that, overall, VA patients were more likely to receive recommended care than patients in the national sample.

In particular, VA patients received significantly better treatment for depression, diabetes, hyperlipidemia, and hypertension. Similarly, VA patients had better outcomes in all aspects of care, including screening, diagnosis, treatment, and follow-up. The only exception to the better care provided by VA facilities was acute care, for which both samples were similar.

Health Indicator –  VA – National Performance
Sample Score – Difference

• Total: 67 – 51 – 16
• Chronic care: 72 – 59 – 13
• Chronic obstructive pulmonary disease: 69 – 59 – 10
• Coronary artery disease: 73 – 70 – 3
• Depression: 80 – 62 – 18
• Diabetes: 70 – 57 – 13
• Hyperlipidemia: 64 – 53 – 11
• Hypertension: 78 – 65 – 13
• Osteoarthritis: 65 – 57 – 8
• Preventive care: 64 – 44 – 20
• Acute care: 53 – 55 – -2
• Screening: 68 – 46 – 22
• Diagnosis: 73 – 61 – 12
• Treatment: 56 – 41 – 15
• Follow-up: 72 – 58 – 14
• VA-specific performance measures: 67 – 43 – 24
• VA-specific performance indicators: 70 – 58 – 12
• Non-VA-specific performance measures: 55 – 50 – 5

VA changes improve performance

The VA has made significant strides in implementing technologies and systems to improve care. Its advanced electronic health record system allows instant communication among providers across the country and reminds them of patients' clinical needs. VA management has also implemented a quality measurement program that holds regional managers accountable for key processes in preventive care and overall chronic disease management.

Performance measurement was very important

How does performance measurement affect the actual effectiveness of healthcare? To answer this question, the researchers conducted a second analysis that focused exclusively on health indicators that correspond to performance measures used by veteran agencies. They found that veteran patients were significantly more likely than patients in the national sample to receive care for their illness. They also found that performance measures have a “spillover” effect that influences treatment: VA patients were more likely than patients in the national sample to receive the recommended treatment for the conditions for which the outcomes are measured.

For example, VA outperformed the national sample for flu vaccination, a process whose performance the system monitors. However, VA also outperformed the national sample on other processes related to vaccination and preventive care that are not measured. This is a strong indication that when quality is monitored, it improves not only in the monitored area but also overall.

These results have important efforts

The implications of this study extend beyond differences in health care quality between the VA and other health care systems. The study demonstrates that quality of care can be improved and that specific improvement initiatives play an important role. First, health care managers must adopt and implement informatics systems that support coordinated care.

Second, they must adopt tracking systems to measure performance and hold managers accountable for delivering recommended care. If other health care providers were to follow the VA's lead, it would be an important step toward improving the quality of care throughout the U.S. health care system.