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In the 1990s, the Veterans Health
Administration (VHA) underwent a
radical transformation, from a health
system widely derided for its poor quality
to "the best care anywhere."1 Central
to this transformation were efforts to
measure and track quality of care.2 Today,
VHA has the most extensive tracking and
reporting system of any healthcare system
in the country, and perhaps the world.
However, the Veterans Access, Choice,
and Accountability Act of 2014 (also
referred to as the Veterans Choice Act or
VCA) has created substantial challenges
for monitoring quality of care. Indeed, in
the era of VCA, our healthcare system is
undergoing yet another transformation,
this time moving from being a provider of
care to a purchaser of care. As providers of
care, we had access to detailed electronic
health record data and the ability to
leverage these data to assess and promote
quality through a robust performance
management system. But how will we
ensure that Veterans who receive services
from non-VHA providers are getting the
same high-quality care? In this new era, it
is imperative that we develop methods to
identify, prioritize, and track care in both
VHA and non-VHA settings.
Recognizing the impending new
challenges under VCA, HSR&D's Quality
Enhancement Research Initiative (QUERI)
issued a Request for Applications to study
the potential effects of VCA on various
aspects of healthcare delivery. The Center
for Clinical Management Research, a
VA HSR&D Center of Innovation, was
funded to study the implications of VCA
for quality of care. One of the key aims of
this study was to develop a streamlined,
transparent, and reproducible approach
to identify and prioritize performance
measures of underuse and overuse
relevant to VCA.
Adapting the RAND/UCLA method used
for the development of Quality of Care
Assessment Tools, the project proceeded
in three main steps: 1) identification of
clinical areas, 2) an environmental scan,
and 3) rating using modified Delphi
panels.3 We first assembled an expert
council comprising six national VHA
clinical and policy leaders. Council
members were provided with a list
of the most prevalent diagnoses and
procedures for Veterans receiving care
through VHA. Using this information,
they collaboratively identified clinical
areas of potential importance to VCA
participants. Following this initial
meeting, the project team refined the
list of clinical areas. Council members
then individually rated the clinical areas
based on improvement opportunity and
feasibility of measurement. The top eight
clinical areas were prioritized for a formal
environmental scan. These included
diagnosis, treatment, and screening or
surveillance for: back pain, cardiac testing,
diabetes, gastrointestinal procedures,
headaches, hepatitis C, prostate cancer,
and post-traumatic stress disorder.
After the selection of clinical areas,
two team members conducted a rapid
environmental scan to identify measures,
guidelines, and recommendations
related to the clinical areas. Team
members reviewed particular highquality
data sources, such as National
Quality Forum-endorsed performance
measures, American College of Physicians
guidelines, VA guidelines, and Choosing
Wisely recommendations. A collaborative
process was used by the study team to
select approximately five measures or
recommendations per clinical area.
In order to obtain ratings for each of the
recommendations, we first expanded the
expert council from 6 to 10 members
to ensure expertise in each clinical
area. Members of the council were then
provided with information derived
from our environmental scan for each
measure or recommendation, including
the data source, a brief description, and
supporting evidence. After reviewing
these materials, members pre-rated
each measure or recommendation on
validity, feasibility of measurement,
and improvement opportunity. Using a
modified Delphi panel process during a
virtual meeting—facilitated through the
use of a collaborative software platform—expert panel members reviewed, discussed,
and then re-rated each recommendation.
To support future measure development,
we queried the council for suggestions
on: 1) how each recommendation could
be adapted and modified into a formal
performance measure; and 2) whether
quantitative data on improvement
opportunity would be helpful for
prioritizing measures in the future.
The expert council reviewed 35
measures and recommendations. The
council identified 29 measures and
recommendations with high validity
(median panel rating ≥ 7 on a 1-9 scale),
indicating that they should be prioritized
for quality monitoring (see table at: www.
annarbor.hsrd.research.va.gov/vcatable.
asp). Of course, additional work is needed
to implement the recommendations
prioritized by the expert council. In some
cases, the areas identified are important,
but existing measures may fall short
of being ready for implementation.
Nonetheless, we believe that information
obtained from this project will aid
efforts to ensure that Veterans utilizing
community care get the most appropriate
care possible.
In summary, VHA is undergoing yet
another transformation, one that will
create new challenges for monitoring the
quality of care for our Veterans. Using
a methodical and reproducible process,
we convened an expert panel to identify
measures and recommendations that
should be considered for assessing quality
of care received in non-VHA settings.
While implementation of tracking and
monitoring systems from our findings
will require additional work, these efforts
can serve as a starting point for those who
seek to assess and improve quality of care
in this new era. Moreover, the process
used in our work can be adapted to other
contexts where rapidly and systematically
identifying and prioritizing performance
measures is of importance.
1. Jha AK, Perlin JB, Kizer KW, et al. "Effect of the
Transformation of the Veterans Affairs Health
Care System on the Quality of Care," New England
Journal of Medicine 2003; 348(22):2218-27.
2. Kerr EA, Gerzoff RB, Krein SL, et al. "Diabetes
Care Quality in the Veterans Affairs Health Care
System and Commercial Managed Care: the
TRIAD Study," Annals of Internal Medicine 2004;
141(4):272-81.
3. Survey tool available at
http://www.rand.org/health/surveys_tools/qatools.html
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