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Transparency and Public Reporting of Quality and Safety in VA Health Care

VA is committed to transparency as part of our health care delivery. We do this out of respect for Veterans' service and our accountability to the American people. Transparency takes many forms'such as disclosure of errors and adverse events to patients and family members, but is increasingly viewed as a proactive strategy of sharing ongoing performance data in order to improve trust in government. VA's considerable experience in health delivery transformation and quality measurement, if shared widely, can catalyze our internal transformation as well as benefit the wider debate on national health care reform.

VA began sharing comparative performance data in 2005 by transmitting Hospital ORYX measures directly to The Joint Commission for public posting on www.QualityCheck.org. In 2008, we began posting outpatient indicators based on the Healthcare Effectiveness Data and Information Set (HEDIS), and the following year VA released a comprehensive Hospital Quality Report Card that included data on quality of care, waiting times, staffing, nosocomial infections, availability of services, health disparities, and accreditation. We have updated and expanded the Hospital Quality Report Card each year thereafter.1

The next phase of quality and safety transparency involved transmission of VA administrative and clinical data to the Centers for Medicare & Medicaid Services (CMS) to allow direct comparisons of VA and Medicare hospitals on www.hospitalcompare.hhs.gov. Core quality metrics first appeared in March 2010 and have been updated quarterly. Outcome indicators, including risk-adjusted mortality and readmission rates for acute myocardial infarction, chronic heart failure, and community-acquired pneumonia, will appear in early August 2011. In calibrating its risk models, CMS uses VA data that includes subsequent admissions to Medicare hospitals when calculating readmission rates. The combination of VA and Medicare data thus allows a more complete picture of quality for Veterans with dual eligibility. VA also adopted the CMS methodology for measuring patient hospital experiences via the Hospital Consumer Assessment of Health Providers and Systems (HCAHPS) survey tool, and currently, those results are available on our own website, www.hospitalcompare.va.gov. Because these HCAHPS results are now adjusted for patient mix using the risk model provided by CMS, fair comparisons of VA to non-VA patient experiences are now possible.

Although direct comparisons of performance between VA and Medicare hospitals can be compelling, they fall short in several ways. The data on www.hospitalcompare.hhs.gov are delayed by 18 months or more, and the reported quality indicators are limited to those obtained from chart abstraction, billing claims, or patient surveys. Our electronic health record systems actually allow more detailed and timely reporting, which is why we continue to post quality and safety data on VA websites. Our most recent public tools are the web application ASPIRE and the Linking Information Knowledge and Systems (LINKS) dashboards. 2 ASPIRE documents our journey toward high reliability by showing facility and network-level progress toward 'aspirational" goals that represent the highest possible attainment (e.g., the aspirational goal for health care associated infection is zero infections). LINKS provides a quarterly "snapshot" of our outcomes for acute care, ICU, surgery, outpatient, and safety measures.

Now that VA data is available on our websites and those of CMS, as well as through government-wide sites such as www.Data.gov, a variety of secondary users can further analyze our performance and display in ways that may be more accessible for certain readers. These include established and well-known organizations such as Consumer Reports and the Commonwealth Fund (sponsor of reporting site WhyNotTheBest.org), as well as new entities such as FindTheBest.com, which has just released a beta-version for comparing VA hospitals based on proximity to a given Zip code.3

If successful, transparency has the potential to be "game-changing" in the national health care debate. Transparency provides a powerful signal of VA's commitment to transformation and its willingness to compete for clients based on measureable value. Embracing transparency of clinical quality and safety data on the national level offers one hope of countering the "tyranny of the anecdote" that so often besets public institutions. Finally, public transparency reinforces other accountability mechanisms by creating strong incentives to maintain the highest possible reliability.

Important questions remain, however. Health literacy and numeracy remain low in the general U.S. population, and making public reports more "user-friendly" is a challenge. We know very little about how clinicians and administrators respond to these reports. Comparisons among VA and non-VA providers may not always be fair ones; our patients differ, our diagnostic coding practices have evolved in a different payer environment, and current methods of risk adjustment may not fully level the playing field especially for providers with complex populations or safety-net missions. Citizens may not find the data particularly relevant to their own health decisions. We welcome the engagement of the VA health services research community to assist us in exploring these critical questions.

  1. Each annual Hospital Report Card starting with 2008 can be accessed via www.data.gov or directly downloaded from www.va.gov/health/ HospitalReportCard.asp
  2. http://www.hospitalcompare.va.gov/aspire/index.asp
  3. http://va-hospital.findthebest.com

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