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Response to Commentary

Last year's access crisis compelled VHA to rethink how access to care is measured, resulting in new opportunities for HSR&D investigators to work with operational partners. Participants of the VHA 2010 State of the Art (SOTA) Conference on Improving Access to Care envisioned a new conceptualization of access that emphasized patient centeredness and assessing how well the VA health care system fit the needs and preferences of individual Veterans.1 The reconceptualization of access developed at the SOTA Conference also highlighted the importance of measuring how Veterans perceive their access to care. While VHA has traditionally relied on structural measures of access (e.g., number of providers) or objective measures of access (e.g., days to first available appointment), the time has come to track Veterans' perceptions of access to care and use that as the primary yardstick for measuring success.

Shifting the emphasis away from structural and objective measures of access to perceived measures of access has many advantages. First, focusing on patient experiences ensures we measure what matters to Veterans. If VA is going to make structural and process investments in improving access, success should be assessed according to whether Veterans perceive these improvements. Second, research conducted by Drs. Prentice, Davies, and Pizer has shown that Veterans' perceived access to care (e.g., timeliness of care) is highly correlated with actual measures of access (e.g., days to first available appointment).2 Thus, perceived access to care is not too distal an outcome to assess the impact of structural and process improvements in health care delivery. Third, assessing system performance by measuring Veterans' perceptions of care is much less "gameable" than other metrics that are based on data routinely collected by local VHA staff who bear the negative consequences of poor performance. Perceived access is a patientreported measure that can be collected in an unbiased manner by centralized VHA staff who operate independently from the local VHA staff who are responsible for clinical operations.

As described in Dr. Wright's commentary Listening to Veterans about Access to Care, the Survey of Healthcare Experience of Patients (SHEP) represents an ideal mechanism to monitor Veterans' perceptions of access to care, including both care delivered by VHA and private care paid for by VHA. The Consumer Assessment of Healthcare Providers and Systems (CAHPS) instrument is embedded within the SHEP and provides a nice comparison to the private sector. However, the CAHPS does not necessarily measure all the domains of access that are important to Veterans. HSR&D investigators now have an opportunity to contribute to the development of a Veteran-centered survey instrument designed to measure perceived access to care. For example, the objective of Dr. Pyne's HSR&D-funded project is to generate survey items that measure perceived access to VA mental health care based on the conceptual framework for access developed at the SOTA Conference.

Eighty Veterans diagnosed with a mental health disorder living in Veterans Integrated Service Networks 1, 16, and 21 have participated in semi-structured qualitative interviews specifically designed to uncover what dimensions of access are most important to them. Based on qualitative analysis of these interviews with Veterans and in partnership with the VHA Office of Performance Management within the Office of Analytics and Business Intelligence, Dr. Pyne and his colleagues plan to develop and validate a new survey instrument, the Perceived Access Inventory. A key goal of this project is to provide VHA operations with a patient-centered and psychometrically validated survey instrument that can be used to monitor changes in perceived access associated with changes in VA policy or resource allocation. In addition, the project will identify geographic areas or facilities with low perceived access to care and measure changes in perceived access in randomized controlled trials evaluating interventions designed to improve access.

Evidence clearly supports the need for a standardized program designed to improve timely access to outpatient care.3 To this end, VHA is currently embracing the use of an outpatient clinic practice management program. One aim of this program is to incorporate findings about perceived access to care and satisfaction from the SHEP. In addition, facilities will have an opportunity to employ the use of VetLink (kiosks), ICE, and Truthpointe, all products designed to assess Veterans' experience with care in real time. This emerging emphasis on Veterans' experience with care is a high priority of MyVA in the Secretary's Office.

1. Fortney JC, Burgess JF, Bosworth HB, Booth BM, Kaboli PJ. "A Re-conceptualization of Access for 21st Century Healthcare," Journal of General Internal Medicine 26 (Suppl 2): 639-47.

2. Prentice JC, Davies ML, Pizer SD. "Which Outpatient Wait-time Measures are Related to Patient Satisfaction?" American Journal of Medical Quality 29(3): 227-35.

3. Deloitte Report, Phoenix VA Health Care System, Medical Support Assistants Productivity Analysis, Full Version, August 2015.

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