Back to Front PageVOLUME 6, NUMBER 4

Quality Is Job One:
VA Zeroes in on Preventive Health Care

Caption: Health care professionals at the Bronx VA Medical Center care for a patient. Over the past five years, the VA has established processes and procedures to emphasize quality and preventive medicine.

"When you think of the VA, do you think of world-class quality?" asks Jonathan Perlin, M.D., Ph.D., chief quality and performance officer with the Department of Veterans Affairs (VA).

While yes might not have been the answer as recently as five years ago, he maintains that it should be now. The VA, Dr. Perlin says, has undergone a sea change in its emphasis on quality and preventive medicine — a transformation that has improved health outcomes and enabled the agency to care for a rapidly growing population on a restricted budget.

"We have made tremendous progress in quality in our day-to-day care," seconds Madhu Agarwal, M.D., associate chief of ambulatory care at the VA Medical Center in Washington, D.C. "Just six years ago preventive medicine wasn’t even on the radar screen."

Evidence supports their claims. For example, more than 80 percent of elderly and high-risk patients at the VA are vaccinated for pneumonia, compared with about half such individuals nationwide. The benefits of the vaccination are clear: A 1999 article in the Archives of Internal Medicine found that it reduces the risk of death from pneumonia by nearly one-third in patients with chronic lung disease.

"Extrapolating nationally, improvement in the VA’s vaccination rate averted nearly 4,000 deaths," Dr. Perlin says. The vaccinations also saved the VA about $300 per recipient in excess health care expenditures over a two-year period.

Pneumococcal vaccinations aren’t the only measure by which the VA has demonstrated effectiveness. The usage rate of beta blockers after heart attacks in VA hospitals is more than 40 percent above that reported by non-governmental hospitals. What’s more, inpatient admissions have dropped by more than one-third, while ambulatory care visits have increased by 50 percent, suggesting that the VA is preventing hospitalizations with more effective outpatient care.

Dr. Perlin traces the new emphasis on quality to the Veteran Health Administration’s 1996 restructuring into 22 regional Veteran Integrated Service Networks. As part of this transformation, the VA implemented a new model of health promotion, disease prevention, and coordination of care with an emphasis on systematizing quality.

The VA also established a goal of "providing consistently reliable, accessible, satisfying, high-quality care that maximizes functional status, is cost-effective, and fosters healthy communities." To achieve that tall order, the agency implemented systems of measurement and accountability, first developing and disseminating national evidence-based clinical practice guidelines for the diseases most prevalent in veterans, including diabetes, hypertension, and heart disease.

Dr. Agarwal explains that these guidelines greatly streamline caregiving. For example, nurses now have a short checklist they can use to assess whether patients should receive a vaccination against pneumonia. If patients meet the criteria, nurses can administer the vaccine immediately without having to seek a doctor’s approval.

Dr. Agarwal also credits the VA’s new electronic medical records system with improving quality and increasing efficiency. Complete records, including lab results, physicians’ notes, and X-ray images, are now only a point-and-click away, she says. Electronic clinical reminders that inform providers when patients need a certain exam or procedure are also part of the system.

And under a comprehensive external review system, reviewers visit VA medical centers every month and examine records to evaluate whether evidence-based standards are met. The reviewers then provide feedback on multiple levels, from that of the individual provider to the network. "It’s extremely helpful to have that feedback," Dr. Agarwal says. "We now know where and how we can improve."

The quality focus has permeated the VA’s graduate medical education programs as well. Stephanie Pincus, M.D., chief academic affiliations officer at the VA, explains that the agency has incorporated preventive medicine into its residency training in which nearly 30,000 residents take part each year.

In an effort to ensure that all residents are trained in preventive medicine, the VA has implemented a primary care specialist program that "gives residents in specialties the education they need to act as primary caregivers for their patients," Dr. Pincus says. "It emphasizes the global needs of patients who may receive much of their care under the aegis of a specialty service."

The VA has also established a National Quality Scholars Fellowship Program. Offered in conjunction with the Center for the Evaluative Clinical Sciences at Dartmouth Medical School, the program provides two-year postresidency fellowships that train physicians in health care quality improvement (QI), including the design and implementation of QI systems.

Gloria Holland, Ph.D., of the VA’s Office of Academic Affiliations, adds that to better meet residents’ needs, the VA is conducting an extensive, nationwide "learners’ perception study," which surveys residents and other trainees on the VA environment, facilities, and education.

But while the VA has made significant progress, there’s always room for improvement, Dr. Perlin says. One of the agency’s most immediate goals is increasing patients’ involvement in medical decision-making. To that end, the VA is developing "Health eVET," a secure Web site that will allow patients to access their medical history and health information online. The VA is also crafting more accessible and extensive clinical decision support and guidelines for physicians.

In the hopes of further improving the VA and sharing its accomplishments, the agency is preparing to apply for the prestigious Malcolm Baldrige National Quality Award in 2002. If the VA wins, it will be the first health care organization to do so. But win or lose the award, Dr. Perlin says, "the real win is improving care and service for veterans."

 

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18 May 2001