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The crisis of the past year for VA over access will likely become
an organizational case study about how not to use performance
measures to drive system performance in a complex system.
The problem of access was not a secret to VA leadership—while
satisfaction with VA care was generally equal or above that of
private systems, many facilities struggled to provide timely care
especially for certain hard-to-recruit specialties, and especially in
places where the growth of the Veteran population had outpaced staffing increases.
In efforts to focus attention on access and improve performance, VA made
numerous errors: it chose the wrong measure (wait times for appointments rather
than a more comprehensive patient-centered measure of access), set a uniform and
unrealistic target (two weeks, without regard to capacity to meet that target), and
tied performance to executive bonuses. The result was that in many facilities, lower
level employees felt pressure to report misleading numbers. The irony was that VA
had actually adopted many innovations over the past five years to improve access
to care, but their success was not necessarily measured in shorter clinic wait times.
Initiatives like video-telehealth, secure messaging, MyHealtheVet, SCAN-ECHO,
and e-consult all improved the means by which patients, especially rural Veterans,
could access their care team or engage the expertise of specialists.
The access crisis was a manifestation of deeper challenges for VA. The series of
outside assessments of VA care that were commissioned as part of the Choice Act
have recently been delivered to VA and a summary report integrating the separate
findings has been made public. 1
Among the many shortcomings it calls out, the report highlights a lack of strategic
vision and systems thinking as a fundamental failing, reflected in a tendency to
tackle each issue as an isolated problem without thinking of its relation to the entire
system. The greatest contribution of research in helping VA respond will be to
examine and test the multiple system effects of different solutions being offered to
improve access. While timely access is essential, it cannot be viewed alone without
considering its relation to other important VA goals: high quality of care; coordination
and communication across sites of care; sustainable costs to both the Veteran and
VA; a robust mission of education, training, and research; and most importantly, an
improved patient experience. There is enough work to keep many researchers busy
while VA continues to address access and works to carry out a new transformation.
David Atkins, MD, MPH, Director, HSR&D
1. CMS Alliance to Modernize Healthcare. Independent Assessment of the Health Care Delivery Systems and Management
Processes of the Department of Veterans Affairs. Volume 1: Integrated Report. September 1, 2015. The
report may be accessed at www.va.gov/opa/choiceact/documents/assessments/Integrated_Report.pdf