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VHA facility integration: Changes in operational effectiveness and perceived quality, 1993-1997

Vriesman L, Yano EM, Mittman BS. VHA facility integration: Changes in operational effectiveness and perceived quality, 1993-1997. Paper presented at: VA HSR&D National Meeting; 2001 Feb 15; Washington, DC.


INTRODUCTION: Similar to private market assertions, VA facility integrations were designed so that health care systems would provide the same or higher quality services at significantly reduced costs. By FY1999, 48 VA medical centers had been approved for integration into 23 healthcare systems with the goal of reducing overlapping administrative infrastructure, streamlining potentially redundant clinical services and creating a coordinated delivery model. Only limited information is available on the performance and effectiveness of integrations in the private sector, and early analyses note possible system-wide changes in all facilities, with integrated facilities reporting greater system identification and perceived integration impact. The purpose of this study is to assess the financial and staffing impact of the 14 early facility integrations (FY95-96), adjusting for possible systematic market shifts and matching the comparative non-integrating facilities on structural characteristics.METHODS: We used a pre-test/post-test non-equivalent control group time series design with matched comparisons for selected analyses between the integrated (n = 14 systems) and non-integrated facilities (n = 127 facilities). Operational effectiveness was assessed as a function of direct and indirect costs per bed day of care (CostBDC), clinical to administrative staffing ratios (CAFTE), and direct staff turnover rate (DirTOVR). Perceived quality was measured as the proportion of patients rating fewer problems with access to and coordination of care using the 1995 and 1997 VA National Ambulatory Care Survey. Financial and staffing data (1993, 1997) were obtained from the VA Performance Measurement System. Structural and market variables were used to delineate and match the comparative groups. Frequencies, bivariate comparisons, factor analyses and linear regression were performed to assess early operational effects of facility integration.RESULTS: Compared to all non-integrating facilities (excluding psychiatric VAMCs), integrated VAMCs had less direct staff turnover (p < .10), reduced fewer total beds, and increased their RNs as a percent of total direct FTEs (p < .05). However, when facilities were matched on structural variables such as academic affiliation, urban-rural location, national quadrant, and service size, additional differences were found. Academic, urban, and mid-size integrated VAMCs had less direct staff turnover, were more likely to have higher clinical staffing ratios, but had less improved patient satisfaction scores (p < = .10). Centrally located integrated VAMCs showed slower cost increases and better staffing ratios and turnover; Western integrated facilities clinical staffing ratios actually decreased more than the non-integrating group; and, integrated Southern VAMCs had loess improvement of satisfaction scores. Complex integrated facilities showed the poorest operational performance as costs increased and clinical staffing ratios decreased, but satisfaction with access improved more than the non-integrators.CONCLUSIONS: The greatest impact of facility integration seems to occur among mid-size, mid-western facilities who may benefit from healthcare partners to complement a full range of services and staffing, while already complex facilities that integrated experienced fewer improvements. Because this study measured change rates, some improvements or declines may simply by adjustments from extremes. IMPACT: Facility integration continues to be a principal VHA strategy for streamlining operations at VAMCs. VA planners and policymakers should continue to rely on strong fiscal discipline and proven staffing schemes for operational improvement, while continuing to study the short- and long-term effects of integration on capacity and outcomes.

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