The Veterans Healthcare Administration

Rachel Mayo

November 28, 2006

Outline

• Structure of the VHA

• VistA – the electronic system of the VA

• Quality measurement

• Results of Reengineering

• Current happenings

• How can results be replicated?

Who is the VHA?

• The VHA is the largest healthcare system in the U.S. consisting of:– More than 1400 facilities (hospitals, clinics,

etc.)– 14,800 doctors– 61,000 nurses– 5 million patients

Structure

• Cabinet level head (Secretary of VA)– Creates political pressure– Current Under-Secretary: Kussman

• VISN – regional network– 22 nationwide– VISNs compete for funding from the national

level

Changes Made at the VHA

• Change started under Kenneth Kizer– Appointed during Clinton administration

• Focused on two main areas:– Efficiency of day-to-day operations– Quality enhancement

• Shift from hospital-based → primary care

VistA

• VistA – Veteran’s Health Information and Technology Architecture

• Composed of four main components:– Computerized Patient Record System– VistA Imaging– Bar-Code Medication Administration– My HealtheVet

CPRS• Computerized Patient Record System

– Registration applications– Scheduling– Order tracking system– Patient alerts

VistA Imaging

• Digital imaging system– Allows caregivers to access images in any VA

facility

BCMA

• Bar-Coded Medication Administration

• Prevents Prescription Errors

• Alerts for Missing Doses

My HealtheVet

• Personal Health Record for veterans

• Allows documentation of:– Medical History– Family History– Blood Sugars– Journal Entries

Implementation

• Started 15 years ago

• Eliminated searching for records

• Patients in and out faster

• No problems after Katrina

• End Result: Better Patient Care!

Tracking Performance

• Personnel

• Clinical Care Activities

• Performance Indicators

• Internal Review and Improvement

• External Review and Oversight

Quality Indicators

Index Components

Prevention Immunizations, cancer screening, tobacco consumption, alcohol consumption

Chronic DiseaseCare

Aspirin administration, beta blocker administration, cholesterol management, nutrition/exercise counseling, inhaler observation, regular diabetes and obesity screenings

Palliative Care

Discussion of resuscitation status, pain management, home-based care, management of depression, assessment of nutritional needs

Measured Benefits of Reengineering

• In 3 years, bed days of care reduced 62% per 1000 patients

• Inpatient admissions decreased 32%, ambulatory care visits increased 43%

• Staffing reduction of 11% in 4 years

• 2700 paper forms eliminated

High Quality CarePercent of Recommended Care Given: VA vs. Nation

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

VA Score*

National Sample**

*596 VA Patients **992 patients at non-VA hospitals

Current Happenings

• Kenneth Kizer forced out of job

• Limited veterans’ eligibility to system

• Surge of mental health patients

Governmental Role

• Conservatives worry expanding VHA will cause private sector to tank

• Tom Bock – encourage government to pay VHA instead of Medicare– Is this a concept that could work on a grander

scale?– Government should consider all angles

Replicating Results

• Private sector does not have incentives to create change– Reimbursement “rewards inefficiency”

• No incentive to provide good preventive care

• The VHA gets to do the “right thing all the time”

Keys to Success

• A determined leader

• Functional electronic system

• Good quality measurement

Summary

• VHA – large system, high quality

• Award winning electronic system

• Quality accountability and tracking

• Healthier patients, better care

• Not rewarded by government

• Changes needed for private sector

Final Thought

• “At the VA, you get to do the right thing all the time” – Dr. Peter Woodbridge

• Why is this not the case everywhere else?