Data-driven process to improve VA surgical flow.

Purpose During years 2014-2016, Veterans Health Administration National Surgery Office conducted a surgical flow improvement initiative (SFII) to assist low-performing surgery programs to improve their operating room efficiency (ORE). The initiative was co-sponsored by VHA National Surgery Office and VHA Office of Systems Redesign and Improvement. The paper aims to discuss this issue. Design/methodology/approach An SFII algorithm, based on first-time-start (FTS), cancellation rate (CR), lag time (LT) and OR utilization, assigned an ORE performance Level (1-low to 4-high) to each VA Medical Center (VAMC). In total, 15 VAMCs with low-performance surgery programs participated in SFII to assess the current state of their surgical flow processes and used redesign methods to focus on improvement objectives. Findings At the end of the project, 14 VSAs, 40 RPIWs, 45 "90-day projects" and 73 Just-Do-It's were completed with 65 percent (158/243) improvement actions and 86 percent sites improving/sustaining all four ORE metrics. There was a statistically significant difference in improvement across the three stages (baseline, improvement, sustain) for FTS (45.6-68.7 percent; F=44.74; p<0.000); CR (16.1-9.5 percent; F=34.46; p<0.000); LT (63.1-36.3 percent; F=92.00; p<0.000); OR utilization (43.4-57.7 percent; F=6.92; p<0.001) and VAMC level (1.7-3.65; F=80.11; p<0.000). The majority developed "fair to excellent" sustainment (91 percent) and spread (82 percent) plans. The projected annual estimated return-on-investment was $27,949,966. Originality/value The SFII successfully leveraged a small number of faculty, coaches, and industrial engineers to produce significant improvement in ORE across a large national integrated health care network. This strategy can serve healthcare leaders in managing complex healthcare issues in their facilities.

Implementation of a Telephone Postoperative Clinic in an Integrated Health System.

BACKGROUND: Earlier work suggested that telephone follow-up could be used in lieu of in-person follow-up after surgery, saving patients time and travel and maximizing use of scarce surgeon and facility resources. We report our experience implementing and evaluating telephone postoperative follow-up within an integrated health system. STUDY DESIGN: We conducted a pre-post evaluation of a general surgery telephone postoperative clinic at a tertiary care Veterans Affairs facility from April 2015 to February 2016. Patients were offered a telephone postoperative visit from a surgical provider in lieu of an in-person clinic visit. Telephone clinic operating procedures were refined through iterative cycles of change using the Plan-Do-Study-Act method. The study period included 2 months pre-intervention and 9 months post-intervention. The primary end point was mean number of clinic visits per eligible patient before and after telephone clinic implementation. Secondary outcomes were rates of emergency department visits and readmissions before vs after telephone clinic implementation and complication rates in patients scheduled for telephone vs in-person postoperative care. RESULTS: During the study period, 200 patients underwent eligible operations, 29 pre-intervention and 171 post-intervention. In-person clinic use decreased from 0.83 visits per eligible patient pre-intervention to 0.40 after implementation of the telephone clinic (p < 0.01). There was no difference in rates of emergency department presentation or readmission in eligible patients (0.17 visits/patient pre-intervention vs 0.12 post-intervention; p = 0.36). Complication rates were comparable for eligible patients who were and were not scheduled for telephone care (6% vs 8%; p = 0.31). CONCLUSIONS: Telephone postoperative care can be used in select populations as a triage tool to identify patients who require in-person care and decrease overall in-person clinic use.

Characteristics of Postgraduate Year 1 Pharmacy Residency Programs at Veterans Affairs Medical Centers.

PURPOSE: Although the characteristics of pharmacy postgraduate year 1 (PGY1) residency programs have been examined among large academic medical centers, there are no identified studies comparing the attributes of individual programs in the Veterans Affairs (VA) Health Administration System. The primary objective of this study was to describe and contrast characteristics of VA PGY1 residency programs. METHODS: This was a cross-sectional survey of VA pharmacy residency programs. An online survey was distributed electronically to residency program directors of VA PGY1 residencies. RESULTS: Responses from 33 (33%) PGY1 programs were available for the analysis. Programs reported growth over the previous 2 years and expected continued expansion. There was a wide variety of learning opportunities, although experiences were customizable based on residents' interests. Notably, many programs allowed residents to seek rotations at other locations if specific experiences were not available on-site. Additionally, most programs had a mandatory staffing component and required residents to present the results of residency research projects. CONCLUSION: There is a high degree of variability among individual VA facilities with regard to the requirements and opportunities available to PGY1 pharmacy residents. This assessment is able to characterize the currently established residency programs and allows for an active comparison of programs in a nationally integrated health care system.

Polytrauma in veterans: what does it mean for the medical-surgical nurse?

Polytrauma in veterans has increased because improvements in medicine and technology have led to improved survival rates for individuals injured in armed conflicts. Medical-surgical nurses caring for today's veterans are faced with new patient needs. Rehabilitation using a multidimensional approach seems to be most effective in helping patients with polytrauma.

The effect of a regional hepatopancreaticobiliary surgical program on clinical volume, quality of cancer care, and outcomes in the Veterans Affairs system.

IMPORTANCE: Malignant neoplasms of the hepatopancreaticobiliary (HPB) system constitute a significant public health problem worldwide. Treatment coordination for these tumors is challenging and can result in substandard care. Referral centers for HPB disease have been used as a strategy to improve postoperative outcomes, but their effect on accomplishing regionalization of care and improving quality of cancer care is not well known. OBJECTIVE: To evaluate the effect of implementing a multidisciplinary HPB surgical program (HPB-SP) on regionalization of care, the quality of cancer care, and surgical outcomes within an integrated health care system. DESIGN, SETTING, AND PARTICIPANTS: We designed a retrospective cohort study in a tertiary referral Veterans Affairs (VA) medical center within an 8-state designated VA health care region from November 23, 2005, through December 31, 2013. We compared patients with HPB tumors undergoing evaluation by the surgical oncology service before and after implementation of the HPB-SP on November 1, 2008. EXPOSURES: Implementation of the HPB-SP to improve access to specialized, multidisciplinary cancer care for veterans across the region. MAIN OUTCOMES AND MEASURES: Clinical and surgical volume, proportion of patients undergoing a comprehensive multidisciplinary evaluation, and postoperative adverse events included as a composite outcome defined by occurrence of postoperative mortality, severe complications, and/or reoperation. RESULTS: We identified 516 patients referred to the surgical oncology service. Establishment of the HPB-SP resulted in significant increases in regional referrals (17.3% vs 44.4%; P < .001), median monthly clinic visits (5 vs 20; P < .001), and median number of HPB surgical procedures (3 vs 9; P = .003) per quarter. Multidisciplinary assessment increased from 52.6% to 70.0% (P < .001). When we compared patients with hepatocellular carcinoma before (n = 55) and after (n = 131) implementation, more patients received any treatment (35 [63.6%] vs 109 [83.2%]; P = .004) with increased use of liver resection (0 vs 20 [15.3%]; P = .002), percutaneous ablation (0 vs 15 [11.5%]; P = .009), and oncosurgical strategies (0 vs 16 [12.2%]; P = .007) after implementation. Among patients with colorectal liver metastases (29 before vs 76 after implementation), a significant shift occurred from use of ablations (5 [17.2%] vs 3 [3.9]%; P = .02) to resections (6 [20.7%] vs 40 [52.6%]; P = .003), and use of perioperative chemotherapy increased (5 of 11 [45.5%] vs 33 of 43 [76.7%]; P = .01). The HPB-SP was associated with lower odds of postoperative adverse events, even after adjusting for important covariates (odds ratio, 0.29 [95% CI, 0.12-0.68]; P = .005), and a high rate of margin-negative liver (94.6%) and pancreatic (90.0%) resections. CONCLUSIONS AND RELEVANCE: The development of an HPB-SP led to regionalization of care and improved quality of cancer care and surgical outcomes. Establishment of regional programs within the VA system can help improve the quality of care for patients presenting with complex cancers requiring subspecialized care.

Medication-use evaluation with a Web application.

PURPOSE: A Web-based application for coordinating medication-use evaluation (MUE) initiatives within the Veterans Affairs (VA) health care system is described. SUMMARY: The MUE Tracker (MUET) software program was created to improve VA's ability to conduct national medication-related interventions throughout its network of 147 medical centers. MUET initiatives are centrally coordinated by the VA Center for Medication Safety (VAMedSAFE), which monitors the agency's integrated databases for indications of suboptimal prescribing or drug therapy monitoring and adverse treatment outcomes. When a pharmacovigilance signal is detected, VAMedSAFE identifies "trigger groups" of at-risk veterans and uploads patient lists to the secure MUET application, where locally designated personnel (typically pharmacists) can access and use the data to target risk-reduction efforts. Local data on patient-specific interventions are stored in a centralized database and regularly updated to enable tracking and reporting for surveillance and quality-improvement purposes; aggregated data can be further analyzed for provider education and benchmarking. In a three-year pilot project, the MUET program was found effective in promoting improved prescribing of erythropoiesis-stimulating agents (ESAs) and enhanced laboratory monitoring of ESA-treated patients in all specified trigger groups. The MUET initiative has since been expanded to target other high-risk drugs, and efforts are underway to refine the tool for broader utility. CONCLUSION: The MUET application has enabled the increased standardization of medication safety initiatives across the VA system and may serve as a useful model for the development of pharmacovigilance tools by other large integrated health care systems.

Health care delivery restructuring and productivity change: assessing the Veterans Integrated Service Networks (VISNs) using the Malmquist approach.

This study evaluates the productivity changes for the Veterans Integrated Service Networks (VISNs) that the Veterans Health Administration (VHA) created, comparing performance in 1994 with that in 2004. This represents periods before and after the VHA in 1995 reconfigured provider units into 21 regionalized delivery systems and engaged in other important system innovations. Productivity is measured using the Malmquist Index approach (a longitudinal version of the data envelopment analysis [DEA]). Results indicate that the VISN restructuring generally produced improvements in overall productivity (Malmquist scores) and in VISN adaptations to structural/technological change. They also show that the VISNs overall did not produce "changes in efficiency," reflecting challenges they may have faced in making "technical change" through management adaptations. The findings are consistent with what would be expected, given the major changes that did occur within the VHA in recent years as well as the before and after design used in this study.

Families' perceptions of end-of-life care in Veterans Affairs versus non-Veterans Affairs facilities.

BACKGROUND: The Veterans Affairs (VA) has made significant investments in care for veterans. However, it is not known whether these investments have produced improvements in end-of-life care in the VA compared to other settings. Therefore, the goal of this study was to compare families' perceptions of end-of-life care among patients who died in VA and non-VA facilities. DESIGN: Retrospective 32-item telephone surveys were conducted with family members of patients who died in VA and non-VA facilities. SETTING: Five Veterans Affairs medical centers and their affiliated nursing homes and outpatient clinics. PARTICIPANTS: Patients were eligible if they received any care from a participating VA facility in the last month of life and if they died in an inpatient setting. One family member per patient completed the survey. RESULTS: In bivariate analysis, patients who died in VA facilities (n = 520) had higher mean satisfaction scores compared to those who died in non-VA facilities (n = 89; 59 versus 51; rank sum test p = 0.002). After adjusting for medical center, the overall score was still significantly higher for those dying in the VA (beta = 0.07; confidence interval [CI] = 0.02-0.11; p = 0.004), as was the domain measuring care around the time of death (beta = 0.11; CI = 0.04-0.17; p = 0.001). CONCLUSION: Families of patients who died in VA facilities rated care as being better than did families of those who died in non-VA facilities. These results provide preliminary evidence that the VA's investment in end-of-life care has contributed to improvements in care in VA facilities compared to non-VA facilities.

Community planning for pandemic influenza: lessons from the VA health care system.

BACKGROUND: Coordination and communication among community partners-including health departments, emergency management agencies, and hospitals-are essential for effective pandemic influenza planning and response. As the nation's largest integrated health care system, the US Department of Veterans Affairs (VA) could be a key component of community planning. PURPOSE: To identify issues relevant to VA-community pandemic influenza preparedness. METHODS: As part of a VA-community planning process, we developed and pilot-tested a series of tabletop exercises for use throughout the VA system. These included exercises for facilities, regions (Veterans Integrated Service Networks), and the VA Central Office. In each, VA and community participants, including representatives from local health care facilities and public health agencies, were presented with a 3-step scenario about an unfolding pandemic and were required to discuss issues and make decisions about how the situation would be handled. We report the lessons learned from these pilot tests. RESULTS: Existing communication and coordination for pandemic influenza between VA health care system representatives and local and regional emergency planners are limited. Areas identified that would benefit from better collaborative planning include response coordination, resource sharing, uneven resource distribution, surge capacity, standards of care, workforce policies, and communication with the public. CONCLUSIONS: The VA health system and communities throughout the United States have limited understanding of one another's plans and needs in the event of a pandemic. Proactive joint VA-community planning and coordination-including exercises, followed by deliberate actions to address the issues that arise-will likely improve pandemic influenza preparedness and will be mutually beneficial. Most of the issues identified are not unique to VA, but are applicable to all integrated care systems.

Journey of change and back: a case study of a reconstituted social work service.

As a result of Total Quality Management and Reengineering principles during the VA's "Journey of Change" in the mid-1990s many hospital social work departments were re-organized under umbrella-care lines. Outcome studies of this movement have focused primarily on patient services. This study focused on the service providers' (including social workers) point of view and their satisfaction with the change in service structure. Data gathering consisted of a master thesis project by one of the co-authors, an administrative in-house survey of staff satisfaction, a qualitative presentation of staff concerns, and the perspective of the administrator who took the decision.

Federally funded comprehensive women's health centers: leading innovation in women's healthcare delivery.

AIMS: Women's healthcare has historically been fragmented, given the artificial separation of reproductive care from general medical care. Aiming to advance new care models for delivery of comprehensive, integrated clinical care for women, two federal agencies-the U.S. Department of Health and Human Services (DHHS) and Department of Veterans Affairs (VA)-launched specialized women's health centers (WHCs). Exemplars of comprehensive service delivery, these originally federally funded centers have served as foundations for innovations in delivering comprehensive care to women in diverse practice settings. Little is known, however, about details of their organization, staffing, practice arrangements, and service availability that might inform adoption of similar models in the community. METHODS: Using comparable key informant surveys, we collected organizational data from the DHHS National Centers of Excellence (CoE) (n = 13) and the original VA comprehensive WHC's (n = 8). We abstracted supplemental data (e.g., academic affiliation) from the 2001 American Hospital Association (AHA) survey. RESULTS: All DHHS and VA women's health programs served urban areas, and nearly all had academic partnerships. DHHS centers had three times the average caseload as did VA centers. Preventive cancer screening and general reproductive services were uniformly available at all centers, although DHHS centers offered extensive reproductive services on-site more frequently, and VA centers more often had on-site mental healthcare. CONCLUSIONS: The DHHS and VA comprehensive WHCs share similar missions and comparable organization, education, and clinical services, demonstrating their commitment to reducing fragmented service delivery. Their common structural components present opportunities for further advancing women's quality of care across other systems of care.

Adoption of a new technology in a Veterans Affairs national formulary system with local implementation: the insulin glargine example.

A study group gathered by the Pharmacy & Therapeutics Society reviewed data on the Department of Veterans Affairs (VA) health care system's implementation of a new technology (insulin glargine) for patients with diabetes. It examined local implementation of VA criteria for nonformulary use of insulin glargine in 21 VA treatment facilities that were surveyed about the issue. The examination found differences in the use of insulin glargine across the 21 treatment facilities and in the approach to implementing the criteria for nonformulary use of insulin glargine used at the individual VA treatment facility level. Differences were identified regarding the respective roles of endocrinologists and PCPs in prescribing insulins, including insulin glargine. The study group urges further short- and long-term research to better understand the utilization, cost, and health outcome implications of the implementation process for the nonformulary criteria. Lessons learned from such research could benefit other health care systems and formulary committees.

The Veterans Health Administration: an American success story?

The Veterans Health Administration (VHA) provides health care for U.S. military veterans. By the early 1990s, the VHA had a reputation for delivering limited, poor-quality care, which led to health care reforms. By 2000, the VHA had substantially improved in terms of numerous indicators of process quality, and some evidence shows that its overall performance now exceeds that of the rest of U.S. health care. Recently, however, the VHA has started to become a victim of its own success, with increased demands on the system raising concerns from some that access is becoming overly restricted and from others that its annual budget appropriations are becoming excessive. Nonetheless, the apparent turnaround in the VHA's performance offers encouragement that health care that is both financed and provided by the public sector can be an effective organizational form.

Informatics implementation in the Veterans Health Administration (VHA) healthcare system to improve quality of care.

We describe VHA's information technology (IT) implementation from the providers' perspective, and identify factors influencing its effective implementation to improve care. We surveyed a stratified random national sample of 4227 clinicians from three VHA primary care provider groups: 1) physicians; 2) nurse practitioners, physician assistants; and 3) nurses. Facility-level IT support availability was rated across six dimensions: 1) access to literature/evidence, 2) computerized decision support, 3) computerized clinical data, 4) error reduction, 5) provider communication, and 6) patient communication. Factor analysis identified a 5-item scale (IT clinical support, á = 0.76). Generalized estimating equation models identified factors influencing IT clinical support. Complete data from 123 hospitals (1777 providers) were included. IT clinical support was higher in urban hospitals (p<0.05) and those with cooperative cultures (p<0.01). Opportunities exist to enhance effective use of IT to support clinical decision making, electronic communication with patients and access to recommendations while delivering care.

An efficiency analysis of Veterans Health Administration hospitals.

This study evaluates the efficiency of Veterans Health Administration (VHA) hospitals using a variable-returns to scale, input-oriented, data envelopment analysis method. Hospital executives, health care policymakers, taxpayers, and ultimately the veteran patient population benefit from studies that look to improve the efficiency of the VHA. Data for 131 VHA hospitals in 1998 and 121 in 2001 were analyzed by using data envelopment analysis to measure hospital efficiency. The results indicated that efficiency in VHA hospitals improved from 85% in 1998 to 86% in 2001. Although this level of efficiency is commendable, the study documents potential savings through more efficient use of resources. From a management perspective, this study shows opportunities for improved management and the realignment of resources to better meet demand. From a policy perspective, the study highlights the political problems associated with improving efficiency and providing access to critical health care services.

The Veterans Health Administration: quality, value, accountability, and information as transforming strategies for patient-centered care.

The Veterans Health Administration is the United States' largest integrated health system. Once disparaged as a bureaucracy providing mediocre care, the Department of Veterans Affairs (VA) reinvented itself during the past decade through a policy shift mandating structural and organizational change, rationalization of resource allocation, explicit measurement and accountability for quality and value, and development of an information infrastructure supporting the needs of patients, clinicians, and administrators. Today, the VA is recognized for leadership in clinical informatics and performance improvement, cares for more patients with proportionally fewer resources, and sets national benchmarks in patient satisfaction and for 18 indicators of quality in disease prevention and treatment.

The VA advantage: the gold standard in clinical informatics.

How does a healthcare organization undergo such transformation as described in the lead paper in eight short years? Just imagine being part of an organization that achieved the following transformations: (1) reduction in hospital and long-term-care beds from 92,000 to 53,000 and an increase in outpatient clinics from 200 to 850 (2) a 75% increase in the number of patients treated on an annual basis (from 2.8 million to 4.9 million) with only a 32% cumulative increase in budget (from $19 billion to $25 billion) (3) clinicians who have access to complete medical records for almost all patient visits and all care settings (4) clinicians who willingly enter medication orders 94% of the time (5) patients who are increasingly satisfied with their care, ranking the service consistently higher than the competition (6) improved patient outcomes, achieved at costs 25% less than the competition. Such transformation is impossible to achieve without vision, leadership, talent, teamwork and tools. I will restrict my comments to a discussion of the tools, specifically the VA's clinical information system (VistA, HealtheVet, My HealtheVet. However, it is important to note that the results described in this paper would not be possible without the VA's transformational leadership and dedicated teams of professionals capable of executing the vision.