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The "access" crisis that engulfed VA last year spurred significant changes in VA health care. Changes included increases in Veterans' access to care, improvements in clinic scheduling practices, and new leadership. At a recent Congressional budget hearing, Secretary McDonald reported the following outcome measures: 7 million more VA clinic appointments this year, a 44 percent increase in VA care in the community, increases in net staffing by more than 12,000, increases in the number of primary care exam rooms, and increases in provider productivity. These outcomes reflect the traditional structural approach to measuring access. What they also reflect, however, is a missed opportunity to reinforce a multi—dimensional conceptualization that includes both "actual and perceived" access to care as defined in the 2010 VA State of the Art (SOTA) Conference on Access.
Over—reliance on the structure of VA health care, such as wait time metrics, distracts us from measuring patient—perceived access from a broader conceptual foundation that includes geographical, temporal, financial, cultural, and digital dimensions.1 Some, but not all aspects of these access dimensions are addressed by the Survey of Healthcare Experience of Patients (SHEP), the single most important VA program to systematically assess patient perceptions of health care. Questions about the "ease of access to routine and urgent care" form the basis for key agency metrics tied to the Agency Performance Plan. During the early days of the VA access crisis, we observed that results from these standard access questions were already available and indicated wide variability across VA facilities in patient perceptions of access to care. We also observed that lower access scores correlated with longer wait times. We should have been listening to the voice of our Veterans via the SHEP survey results rather than a singular dimensional focus on wait time metrics.
The SHEP program, managed by the Office of Performance Management within the Office of Analytics and Business Intelligence (OABI), was initiated in fiscal year (FY) 2002 in an effort to create standardized survey instruments administered monthly to assess ambulatory and inpatient care. We adopted the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey methodology in FY09 when we launched two flagship surveys: 1) an outpatient survey which was later transitioned to the Patient Centered Medical Home (PCMH) survey that specifically focused on primary care; and 2) a hospital CAHPS survey of inpatient medical and surgical services. These instruments provided a standardized, validated, and tested mechanism for assessing patient experiences with health care that are used to systematically evaluate VA hospital performance. These surveys are supported in the public domain by the CAHPS Consortium, Agency for Healthcare Research and Quality, Centers for Medicare and Medicaid Services, and National Committee for Quality Assurance. Although SHEP deployed the standardized CAHPS surveys, the access questions were limited and did not evaluate the full scope of services used by Veterans.
SHEP was awarded additional resources to
significantly expand the inventory of surveys
to more comprehensively assess Veteran
access to care. Award of these additional resources
was prompted by the widespread recognition
that clinic appointment wait times
were inadequate measures of access to care.
This year we are introducing the following
new surveys, multiple survey modalities, and
new analytic reports designed to measure access
to—and experience with—a wide range
of VA health care services, including VA care
in the community.
PCMH Survey Addition of Specialty
Care Item—Set. For those Veterans who responded
to the PCMH survey and who also
had an encounter with a specialist, they are
asked additional questions about the ease of
getting specialty care appointments and the
Overall Rating of Specialists. Data collection
began in October and facility—level results are
being reported to the field.
VA Specialty Care Survey. Veterans with
visits to high volume specialty care clinics
are sent a specific specialty care survey that
includes questions about ease of access to VA
specialty care clinics, overall rating of VA specialist,
and CAHPS domains such as communication
and coordination of care. The survey
utilizes more timely and effective modes of
survey administration including email invites,
an online survey (mobile device enabled), and
traditional mail—mode administration. Data
collection began in May and results will be
available in late August.
VA Care in the Community. This survey
will address the requirements of the Choice
Act by evaluating Veteran perceptions of
access to—and experiences with—all VA
care in the community. The survey addresses
experience with both choice care and traditional
fee care. Just as with the Specialty Care
Survey, multiple modes of administration will
be utilized in implementing this survey. Extensive
focus group work was completed to
support the development of this survey to be
launched in late FY15.
New Enrollee Survey. This survey will address
Veteran experiences with initial enrollment
and access to first clinic appointments.
Extensive focus group work was recently
completed to support the development of this
survey with an anticipated early fall launch.
Finally, we have established a Veteran Insights
Panel composed of over 3,200 Veterans
that are representative of users of VA
health care. We are engaging panel members
in direct discussions about important themes
and issues. We interact with the panel through
email notification and a special access website
(mobile device enabled). We are engaged in
real time feedback via live chat discussion,
qualitative and quantitative surveys, and survey
development and testing. The panel can
be engaged collaboratively with operational
program offices and researchers to prompt
direct discussions with our Veterans.
Measurement of access is complex because
the understanding and definition of access
mean different things to different people. We
need to embrace a patient—centered view of access that encompasses both the structure of our health care system and the preferences of our Veterans. We need help from the research community to better understand what is most important to our Veterans so that we can systematically assess how well the system is performing to meet those needs. Our commitment of providing accessibility to high quality care for our Veterans deserves no less.
1. Fortney JC, et al. "A Re—conceptualization of Access for 21st Century Healthcare," Journal of General Internal Medicine November 2011; 26 (Suppl 2):639—47.