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Director's Letter: Health Services Research Must Prove Its Value Now

In the late 1990s, VA was ahead of most health care organizations in incorporating a robust set of quality measures as part of sweeping reforms. Some 15 years later, VA is once again leading—this time in applying health services research to document the limitations of many widely used measures and to develop better patient-centered measures of quality. What has changed? One problem has been the sheer proliferation of measures, which can overwhelm busy clinicians. The second is that the VA of today is a much better performing system: when there is a lot of room for improvement, even imperfect measures can motivate change without risking inappropriate care. Finally, implementation of measures has shifted over time from an initial focus on using them to motivate innovation and local solutions to improve quality—"making the right thing the easy thing to do"—to using measures to enforce compliance with national guidelines. As a recent editorial notes, this change risks "undermining the VA's culture of continuous improvement."¹ The good news is that VA leadership recognizes and is addressing these issues. Even as the new Office of Informatics and Analytics expands our ability to measure practice in real-time for improvement purposes, VA is revising the "one-size" approach to measurement for accountability.

There is plenty of work for researchers in helping create better measures, but it is equally important to learn the best ways to implement them. Should measures be used to motivate individuals or practices? How should incentives be designed when care is the responsibility not of an individual clinician but of a patient-aligned care team? Should we "retire" measures when performance reaches a desired level? Answering these and other questions is an essential task if VA is to continue to meet the IOM's recent vision of the learning health care system.²

David Atkins, M.D., M.P.H., Acting Director, HSR&D

References

1. Kizer K.W. and S.R. Kirsh. "The Double-edged Sword of Performance Measurement," Journal of General Internal Medicine 2012; 27:395-7.
2. National Research Council. 2012. Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. Washington, DC: The National Academies Press.