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As Dr. Kussman points out in his lead
commentary, the VA's performance measurement
system—with over 100 performance
measures in the areas of access,
satisfaction, cost, and quality—has served
VA well. In 1995, VA first incorporated
performance measures in the Executive
Career Field (ECF) performance contract,
an annual plan that establishes standards
against which both central office and VISN
leaders are evaluated. ECF contracts ensure
accountability for both administrative and
clinical performance measures and are
developed collaboratively by central management
and field leaders.
These performance contracts form the
basis for quarterly management reviews,
and incorporate modest management
incentives. Results are also reported broadly
within the VA and externally to key
stakeholders including Congress, the Office
of Management and Budget, and advocacy
groups. Linking performance measures
to these contracts results in personal
accountability throughout the system. The
Performance Management Work Group is
central to this process. The work group has
four key responsibilities:
Engage in regular and systematic planning
for measurement;
Perform annual review of existing network
trends;
Consider non-VA comparator system
trends; and,
Oversee the development of the annual
ECF performance plan.
This last responsibility involves a multi-step
process, which begins with the work
group integrating the priorities it receives
from the Under Secretary for Health and
other central and local VA leaders. The
work group then convenes to identify
measurement priorities and to assure measurement
initiatives are developed, and
approves proof of concept proposals
from subject matter experts. The work
group must also maintain a clear set of
criteria for measurement approval and
retirement, and, ultimately, identify and
incorporate proposed performance
measures into the next year's performance
plan. The 2008 ECF plan emphasizes
greater personal accountability by utilizing
a streamlined set of performance measures,
including new measures aimed at the
efficiency of care provided to veterans,
and also core competencies expected of
senior leaders.
The recent adoption of a new VA national
performance measure for thiazide diuretic
use illustrates the rigorous process by
which new measures are vetted by the
work group. Despite evidence-based guidelines
which favor thiazide diuretics among
patients with uncomplicated hypertension,
use of these drugs remains low. National
hypertension management guidelines such
as the Joint National Committee (JNC) 7
and the VA/DoD Hypertension Clinical
Practice Guidelines recommend thiazide
use for most patients in accordance
with the results of the ALLHAT study.
However, review of published pharmacy
utilization data both in VA and in the private
sector strongly suggests that hypertension
guidelines are not followed for most
patients. The work group approved inclusion
of a pilot measure for diuretic use,
which eventually led to adoption of the
new performance measure for diuretic
use in 2007.
Comprised of central and field leaders,
and including both administrators and
clinicians, the work group is co-chaired by
Barbara Fleming, M.D., Ph.D., and Jim
Roseborough, FACHE. The efforts of the
group result in performance contracts that
are recommended to the Under Secretary
for Health and represent the collaborative
efforts of central and field leadership,
and reflect both administrative and clinical
priorities.
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