Results of a Regional Effort to Improve Warfarin Management.

BACKGROUND: Improved anticoagulation control with warfarin reduces adverse events and represents a target for quality improvement. No previous study has described an effort to improve anticoagulation control across a health system. OBJECTIVE: To describe the results of an effort to improve anticoagulation control in the New England region of the Veterans Health Administration (VA). METHODS: Our intervention encompassed 8 VA sites managing warfarin for more than 5000 patients in New England (Veterans Integrated Service Network 1 [VISN 1]). We provided sites with a system to measure processes of care, along with targeted audit and feedback. We focused on processes of care associated with site-level anticoagulation control, including prompt follow-up after out-of-range international normalized ratio (INR) values, minimizing loss to follow-up, and use of guideline-concordant INR target ranges. We used a difference-in-differences (DID) model to examine changes in anticoagulation control, measured as percentage time in therapeutic range (TTR), as well as process measures and compared VISN 1 sites with 116 VA sites located outside VISN 1. RESULTS: VISN 1 sites improved on TTR, our main indicator of quality, from 66.4% to 69.2%, whereas sites outside VISN 1 improved from 65.9% to 66.4% (DID 2.3%, P < 0.001). Improvement in TTR correlated strongly with the extent of improvement on process-of-care measures, which varied widely across VISN 1 sites. CONCLUSIONS: A regional quality improvement initiative, using performance measurement with audit and feedback, improved TTR by 2.3% more than control sites, which is a clinically important difference. Improving relevant processes of care can improve outcomes for patients receiving warfarin.

Developing and sustaining quality improvement partnerships in the VA: the Colorectal Cancer Care Collaborative.

OBJECTIVE: The Veterans Affairs (VA) Quality Enhancement Research Initiative (QUERI) seeks to develop partnerships between VA health services researchers and clinical managers, with the goal of designing and evaluating interventions to improve the quality of VA health care. METHODS: In the present report we describe one such initiative aimed at enhancing the continuum of colorectal cancer (CRC) care, including diagnosis, treatment and surveillance-the Colorectal Cancer Care Collaborative (C4). RESULTS: We describe the process and thinking that led to two parallel quality improvement "collaboratives" that addressed (1) CRC screening and diagnostic follow-up and (2) the guideline concordance and timeliness of CRC treatment. Additionally, we discuss ongoing effort to spread lessons learned during the first stages of the project, which initially occurred at only a subset of VA facilities, throughout the VA health care system. The description of this initiative is organized around key questions that must be answered when developing, sustaining and spreading multi-component quality improvement interventions. CONCLUSION: We conclude with a discussion of lessons learned that we believe would apply to similar initiatives elsewhere, even if they address different clinical issues in health care settings with different organizational structures.

Strategies to improve compensation and pension timeliness: lessons learned from high-performing facilities.

The compensation and pension (C&P) process is the mechanism by which injured Veterans are assigned their medical and disability benefits. As part of the documentation and rating process performed by the Veterans Benefits Administration (VBA), many Veterans need supplemental medical examinations performed by the Veterans Health Administration (VHA). Improving C&P examination timeliness is a goal of many VHA facilities. To identify strategies to improve examination timeliness, we used national performance measures to identify high-performing VHA facilities. We then interviewed seven facilities using Donabedian's structure-process-outcome framework to determine characteristics attributed to their high-performance. We developed a list of high-performance characteristics common to all facilities, which relied on a tailored relationship between each VHA facility and VBA office. Additional characteristics were grouped thematically into three management foci - financial incentives, role specialization, and process reliability. Distillation of these characteristics provides guidance to other VHA facilities seeking to improve their C&P timeliness.

Timely follow-up of positive fecal occult blood tests strategies associated with improvement.

BACKGROUND: In light of previous research indicating that many patients fail to receive timely diagnostic follow-up of positive colorectal cancer (CRC) screening tests, the Veterans Health Administration (VA) initiated a national CRC diagnosis quality-improvement (QI) effort. PURPOSE: This article documents the percent of patients receiving follow-up within 60 days of a positive CRC screening fecal occult blood test (FOBT) and identifies improvement strategies that predict timely follow-up. METHODS: In 2007, VA facilities completed a survey in which they indicated the degree to which they had implemented a series of improvement strategies and described barriers to improvement. Three types of strategies were assessed: developing QI infrastructure, improving care delivery processes, and building gastroenterology capacity. Survey data were merged with a measure of 60-day positive-FOBT follow-up. Facility-level predictors of timely follow-up were identified and relationships among categories of improvement strategies were assessed. Data were analyzed in 2008. RESULTS: The median facility-reported 60-day follow-up rate for positive screening FOBTs was 24.5%. Several strategies were associated with timeliness of follow-up. The relationship between the implementation of QI infrastructure strategies and timely follow-up was mediated by the implementation of process-change strategies. Although constraints on gastroenterology capacity were often sited as a key barrier, implementation of strategies to address this issue was unassociated with timely follow-up. CONCLUSIONS: Developing QI infrastructure appears to be an effective strategy for improving FOBT follow-up when this work is followed by process improvements. Increasing gastroenterology capacity may be more difficult than improving processes of care.