The VA system: A "Veteran" in Rehab

[NRSKarenRN, BSN, RN]

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A Veteran in Rehab

Brad Cain

May 29, 2002

Healthleaders.com (Free registration required)

http://www.healthleaders.com/magazine/print.php?contentid=34930

Innovation. vision. quality. These words are often used to describe companies at the cutting edge. Rarely, however, are they applied to government agencies, especially ones like the Veterans Administration, which had carried a decades-old reputation of being an uncaring, ineffective and unresponsive bureaucracy. But those days are past.

"There's that old adage that a good reputation is easy to ruin and a bad reputation is almost impossible to change," says Kenneth W. Kizer, M.D., the man observers say put the VA on the path to reform. "But it's still one thing that I don't quite understand. If you compare the VA's performance against essentially anyone else out there, it performs much better than Medicare, and better than most plans across the country. And it does it at a cost of about two-thirds what Medicare pays. Somewhere I would think that this would attract some attention."

Kizer, appointed undersecretary of health for the Department of Veterans Affairs Administration in 1994, is now president and CEO of the National Quality Forum in Washington, D.C. One of his first goals for the VA was organizing the system into a more workable, regional structure.

Under the plan he oversaw, the VA's 173 hospitals, which had been operating as individual facilities reporting to a central office in Washington, D.C., were grouped into 22 Veterans Integrated Service Networks-or VISNs (pronounced "visions" as in a "Vision for Change," the name of Kizer's reorganization plan). These VISNs were organized along geographic lines with regional governance systems. Along with the new structure, Kizer redeployed the system's resources to focus more on outpatient care-a move that ultimately led to the creation of more than 400 community-based clinics.

Now, eight years later, the basic VISN framework is still in place and the enhanced focus on outpatient care can be seen in the VA's dramatically different operational demographics. In 1995, the ratio of outpatient visits to inpatient admissions was 29 to 1. By 1999 the same ratio was 48 to 1. By 2000, outpatient visits reached 36 million-an increase of 9.9 million over five years, according to VA data. During the same period the system eliminated 55 percent of its inpatient beds and cut employment by 28,000.

"People were skeptical that the VISN reorganization could be pulled off. No one believed that the VA could be one of the best places in the country for healthcare. It really is," says Carol Haraden, Ph.D., a vice president with the Institute for Healthcare Improvement in Boston, which worked with the VA on a variety of quality-improvement programs. These included initiatives to reduce medication errors and improve patient safety in high-hazard areas, such as emergency departments, intensive-care units and operating rooms.

Under Kizer's tenure and that of Thomas Garthwaite, M.D. (who was Kizer's deputy starting in 1995, eventually succeeding him in 1999), the VA implemented a number of technological and operational innovations. They were designed to improve the quality of patient care, reduce costs and provide better overall "value"-a term that reached mantra status under their leadership.

"It's been tough to buy healthcare services based on value, because we never measured quality very well," notes Garthwaite. "We knew what we were spending but not a whole lot about what we were getting, so a lot of effort went into measuring quality."

To this end, the system implemented standardized measures to gauge the performance of each region, in terms of reducing patient waiting times and the time it took to get an appointment for a new patient-two notorious problems under the VA of old. It also began measuring patient satisfaction, the cost of administrative overhead and how well facilities were adhering to clinical care guidelines.

"Dr. Kizer put in some very hard performance measures that made us look at how we did business," says Lawrence H. Flesh, M.D., acting network director of the VISN program in upstate New York. "Data is evaluated and then published every quarter so you're compared against the VISNs in the rest of the country," he adds, noting that his program recently won the VA's annual Carey Quality Award based on its performance on these quality measures.

"By having very objective measures of performance we were able to change behavior," says Garthwaite, who left the VA at the end of January to become director of the Los Angeles County Department of Health Services. Before leaving, however, Garthwaite helped initiate two other quality initiatives at the VA: a Web-based online credentialing program for physicians, which earned him a Surgeon General's Medallion, and a systemwide self-assessment program using Baldrige National Quality Award criteria.

"After the changes we made during the VISN reorganization, there's a tendency to maybe rest on your laurels, but Dr. Garthwaite wanted to do something to keep improvement in front of us," says Randy R. Taylor, executive director of the VA's Baldrige program. The initial self-assessment-conducted by the VA's senior leadership-uncovered several areas of weakness, including the way senior managers communicated with the organization as a whole. "Now there is a complete plan for communications up and down and laterally that should improve how the leadership sets the vision for the organization, how they set expectations and how they communicate with folks in the organization," says Taylor.

Since the initial self-assessment, the organization's senior leaders are using that experience and replicating the process in the individual regions, says Taylor. To date, 11 of the VA's 21 networks have completed a self-assessment and four more regions will start the self-assessment process later this year.

The physician credentialing system is another example of how the VA has been quietly leading the private sector in terms of technology adoption, experts say. While the private sector is responding slowly to recommendations from the Institute of Medicine's recent reports on medical errors and the prodding of The LeapFrog Group, the VA had already begun implementing a computerized patient-record system, a bar-code-based medication administration system and a computerized physician order entry system by the mid- to late 1990s, officials say.

"One of the strengths of the VA is that we're an integrated delivery system and that gives us the ability to focus on quality and safety in a way that smaller organizations can't," notes Frances M. Murphy, M.D., the VA's deputy undersecretary for health. "When we wanted to make sure that we administered medication in a way that would reduce errors we went out and piloted the computer programs and software. If we were a single hospital or clinic it would have been difficult."

But even with all of these technological advances, the human element-and resulting opportunities for error- are ever present, say VA officials. With this in mind, the system created the National Center for Patient Safety in 1998 and the following year appointed James Bagian, M.D., a former NASA astronaut and investigator of the Challenger space shuttle disaster, to coordinate the system's new error-reduction programs.

The center established a system to encourage reporting of not just actual medical errors, but also the close calls that don't result in patient harm. "Close calls occur anywhere from 20 to 600 times as often as the event they are the harbinger of, so that gives you at least 20 chances to learn a lesson before you have to have an actual disaster," Bagian says. A key element of the new regime: informing workers up front that they will not be punished for reporting a problem as long as the error or close call didn't stem from an intentionally negligent or unsafe act. Those include, for example, practicing under the influence or not checking a patient's chart for known medication allergies.

Previously, "the fact that people never knew what they were going to get nailed for was certainly not an inducement to report errors or close calls," says Bagian. He says error reporting has increased 30-fold and close call reporting is up 900-fold since the program was introduced three years ago.

In spite of all the transformations that have taken place, however, the VA is still very much a system in transition.

The reorganization reduced the VA's reliance on inpatient care, but now officials believe it must reassess how and where it provides services. The first phase of that reassessment, dubbed Capital Asset Realignment for Enhanced Services or CARES in government-speak, was completed this spring and resulted in calls for inpatient services in Chicago to be consolidated into one facility instead of two. Similar recommendations are expected as the system reviews the rest of its networks this year.

The system also faces the prospect of treating a growing patient population with a budget that may not be able to keep up with demand. Congress expanded eligibility in 1998, but more veterans who have been eligible all along are also now seeking care through the new, improved VA.

"If veterans come in and receive courteous care, and they see good doctors, and they have a computerized record, and they get their medicine from a computerized mail-out pharmacy-the system is suddenly very convenient and efficient and effective," notes Garthwaite. "That word of mouth has spread and more people are coming in."

Brad Cain is associate editor and newsletter editor with HealthLeaders.

© 2002, HealthLeaders, Inc.

I know they've improved as getting concise clinical info when patients referred compared to practically none 6 yrs ago. The outpatient clinics have NP's who manage patients and are great to deal with in Philly area. I refer to VA frequently for eligible patients to get meds covered; Meds are prescribed based on VA formulary and are free if service connected, $5.00 for generic. They must co-manage Veteran's (with pts PCP) to obtain this service. Karen

[traumaRUs, MSN, APRN]

As a vet myself and also for my husband who is a miltary retiree, the VA is an option when we get older if we can't keep health insurance or have financial difficulties.

However, as relative young (in our 40's) and very healthy people - we don't use them now, because of the tremendous wait for services.

[oramar]

I have a couple of retired relatives that lost their medicare supplemental insurance due to their company going bankrupt. One is a WWII vet the other a Korean War vet. Both are now getting their perscriptions through the VA, they are quite pleased with the treatment they are getting. PS Here is an example of a CEO reorganizing without costly consultants. If these people knew how to do their jobs they wouldn't need consultants. The fact that they use them is a monument to their incompetence.

[disher]

Thanks for the article NRSKaren, I don't really know the history of VAs, so can't comment on the "bad reputation".

My experience with spinal cord nurses who work at VAs is limited to those I have met at at the American association of spinal cord injury nurses (AASCIN) conference and through reading their research published in the SCInursing journal. The reasearch coming out of the VAs has been well designed and useful to me in my daily practice. My overall impression of VAs is that if I were ever interested in moving to the US I would be comfortable working in a VA.

[-jt]

In the VA hospital system, the RNs are unionized, even in the right-to-work states, & the union that represents them all is the national RN union - The United American Nurses/AFL-CIO (UAN) - the labor arm of the American Nurses Assoc. The administration may not have had to consult with many costly business consultants but they didnt do it alone either. They certainly had to consult with the UAN VA Council of Nurses which had to be included in the decision making & was instrumental in the development & passage of laws that allowed the changes to be made. Its been well documented by many studies that improved RN staffing improves pt care & pt outcomes, so a focus on making the VA a place where RNs would want to work was tantamount to making the system a success.

-UAN/ANA RN statement to Senate Committee on Veteran's Affairs

on Looming Nurse Shortage: Impact on the Department of Veterans Affairs

June 14, 2001

http://nursingworld.org/gova/federal/legis/testimon/2001/senva.htm

-Economic Equity for Registered Nurses within the Department of Veterans Affairs

http://nursingworld.org/about/summary/flwi.htm

-VA Nurses Win on Two Fronts

http://nursingworld.org/tan/NOVDEC00/VANURSES.HTM

-RNs at Veterans Affairs (VA) health care facilities test-drive a new, electronic system to administer medications to eliminate potentially life-threatening medical errors.

http://nursingworld.org/tan/01marapr/vanurses.htm

-VA raises RN educational standards

http://nursingworld.org/tan/99janfeb/inbrief.htm

-Nursing school, VA partnership benefits vets

http://nursingworld.org/tan/00mayjun/bu/vapart.htm

-Passage of VA Health Care http://nursingworld.org/pressrel/2001/pr1214.htm

-VA Nurse Retention Bill Signed into Law

http://nursingworld.org/gova/federal/news/presign.htm

[oramar]

Dear -jt, I watched a lot of congressional hearings last year on the subject of improving the nurses situation at the VA. Glad to see a lot of it passed. I wonder if they are going to make the alll BSN commitment by 2005?